Dermatology > Test 2 > Flashcards

Test 2 Flashcards

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1
Q

basal cell carcinoma pop

A
  • men
  • Caucasian
  • closer to the equator
  • Tucson
  • Finland
  • Australia
  • 55-75
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2
Q

basal cell carcinoma pathophysiology

A

sun exposure low vegetable and fruit intake

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3
Q

Basal Cell Carcinoma RF

A
  • history of BCC
  • Caucasians
  • Chronic UV radiation
  • childhood sun exposure
  • number of past sunburns
  • SAD diet
  • arsenic exposure
  • smoking
  • immunosuppressive drugs or organ transplant
  • tanning beds
  • farmers, outdoor jobs
  • psoralen plus ultraviolet A light (PUVA)
  • Broad band and narrow band ultraviolet (UVB) phototherapy
  • ionizing radiation therapy
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4
Q

Basal cell carcinoma location

A
  • ears
  • face
  • neck
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5
Q

what is the most common BCC?

A

nodular

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6
Q

round shinny, pearly, flesh-colored papule, telangiectasia, translucent when stretched, can have center ulcerates/bleeding, accumulates crusts/scales and will heal then grow again

A

nodular BCC

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7
Q

brown, black, or blue; elevated, pearly white, translucent border; papule

A

pigmented BCC

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8
Q

appear yellow-white when stretched, firm to touch, seemingly well-defined border, doesn’t ulcerate

A

micronodular BCC

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9
Q

white or yellow, waxy sclerotic plaque, rarely ulcerate, flat or slightly depressed, fibrotic, and firm, borders are indistinct

A

morpheaform BCC

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10
Q

upper trunk or shoulders, extremities, face; red, round-to-oval, well-circumscribed patch or scaling plaque, whitish scale; thin, raised, pearly white; least aggressive

A

superficial BBC

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11
Q

BCC complication

A
  • death
  • hemorrhage of eroded large vessels
  • meningitis
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12
Q

TX nodular BCC

A

Electrodesiccation and curettage or by simple excision
Mohs surgery
solasodine Rhamnosyl glycosides (SRG’s) (Zycure, Curaderm-nightshade extract) and black salve
Radiation therapy
Anti-inflammatory diet

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13
Q

superficial BCC tx

A

topical tazarotene
photodynamic therapy
topical 5-Fluorouracil and imiquimod

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14
Q

Tx Morpheaform BCC

A

wide excision
Mohs micrographic surgery
Curaderm
black salves

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15
Q

Squamous Cell Carcinoma pop

A

older, white

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16
Q

SCC RF

A
  • Chronic sun exposure
  • Fair complexion
  • Chronic skin ulcers or sinus tracts
  • Long term-exposure to hydrocarbons, arsenic, burns, radiation
  • Immunosuppression
  • Other radiation exposures
  • Chronic inflammation
  • Genetics or inherited disorders
  • Smoking
  • Inflammatory diet
  • HPV infection
  • Xeroderma pigmentosum
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17
Q

SSC sx

A
  • Hyperpigmented nodular mass which commonly ulcerates
  • Papules, plaques, nodules that can be smooth, hyperkeratotic, or ulcerative
  • Head and neck (55 %)
  • Dorsum of hands/forearms (18 %)
  • Legs (13 %)
  • Arms (3 %)
  • Shoulder or back (4 %)
  • Chest or abdomen (4 %)
  • Other sites (3 %)
  • areas of chronic inflammation
  • areas of chronic scarring
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18
Q

Bowen’s disease SCC

A
  • Patch or plaque
  • Erythematous
  • Slow growing
  • Asymptomatic
  • lower legs, neck and head.
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19
Q

Erythroplasia of Queyrat

A
  • Well-defined, velvety, red plaque
  • Pain
  • Bleeding
  • Pruritus
  • penis
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20
Q
  • Asymptomatic
  • Painful or pruritic
A

Invasive SCC

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21
Q
  • indurated or firm, hyperkeratotic papules, plaques, or nodules
  • 0.5-1.5 cm
  • ulceration
A

Well differentiated SSC

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22
Q
  • fleshy, soft, granulomatous papules or nodule
  • ulceration
  • hemorrhage
  • areas of necrosis
A

Poorly differentiated SCC

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23
Q

Tx Localized SCC

A
  • Cryotherapy
  • Electrosurgery (e.g. ED & C)
  • Topical (5-fluorouracil, imiquimod)
  • Radiation therapy
  • Surgical excision
  • Mohs surgery
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24
Q

Prevention SCC

A
  • anti-inflammatory diet
  • sunscreen
  • oral and topical green tea
  • grape seed extract
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25
SCC
26
BCC
27
Keratoacanthoma pop
50-69, men, with Fitzpatrick I-III classification
28
Keratoacanthoma Pathophysiology
ultraviolet (UV) radiation, exposure to chemical carcinogens, viral exposure including human papillomavirus (HPV)
29
Keratoacanthoma sx
- Rapidly growing, dome-shaped nodules with a central keratin-filled crater - cheeks, nose, ears, hands (post), but can be any location
30
Keratoacanthoma tx
surgical excision
31
Keratoacanthoma
32
Melanoma pop
- men - whites
33
Melanoma cause
increased UVA exposure and decreased cutaneous Vitamin D3 levels
34
Melanoma RF
- sun exposure and sunburns - inflammatory diet - family history of atypical nevi or melanoma - light colored skin and red hair - immunosuppression - previous history of melanoma - airline pilots
35
Melanoma growth pattern
- growth phase - horizontal phase - spread out horizontally and can be confined to the epidermis - vertical - infiltrate deep into the dermis quickly
36
- from atypical nevi 30-50% - most common - 30-50 yo - grows slowly (5-10 y) and horizontal then will grow vertical - lower extremities (F), trunk (M), upper back (both) - brown to black macule, color variation, irregular, notched borders - less than 1 mm in thickness
superficial spreading melanoma
37
superficial spreading melanoma
38
- aggressive, highest risk of spreading, difficult to diagnose - greater than 2 mm in thickness at diagnosis - pedunculated or polypoid black nodules - blue, gray, white, brown, tan, red, or skin tone - trunk, legs, arms, scalp (M) - elderly
nodular melanoma
39
nodular melanoma
40
Lentigo maligna melanoma
41
Acral lentiginous melanoma
42
- aggressive - most common among Asian and African-American - on palmar, plantar, subungual surface, between the toes - lesion raised, develops ulceration, >5 mm in diameter need to look at lymph nodes - dark brown to black, irregularly pigmented macules to patches
acral lentiginous melanoma
43
- most common in geriatric pop - remain close to skin surface for years to decades - elderly, chronically sun-exposure, damaged skin - on the face, ears, arms, upper trunks, - flat or mildly elevated mottled tan, brown, or dark brown - nodule or papule indicate invasion - asymmetric foci, color variegation - most common melanoma in Hawaii - slow growing and grows outward - multiple colors
lentigo maligna melanoma
44
hutchinson's sign
acral lentiginous
45
melanoma dx
- Excisional Biopsy- 1-3 mm margins of normal skin and a layer of subcutaneous fat - Punch biopsy - DON’T DO Shave - scoop shave biopsy- scoop out the lesion with 1-3 mm margins
46
melanoma complication
- death - metastasis
47
melanoma tx
- wide local excision, surgical removal - Mohs micrographic surgery - interferon - cytotoxic chemotherapy - radiation therapies - Vit C, A and E, carotenoids, dietary antioxidants, fruits, vegetables, Med diet - curcumin, green tea, - pre-surgery: modified citrus pectin and bioflavonoid - Silymarin, curcumin, polysaccharide krestin, Vit E, melatonin - quercetin, betulinic acid, ginseng, licorice, cordyceps, viscum - vit D, azelaic acid, genistein, astragalus - black salves - fasting before chemo: low protein,
48
Most SSCs that occur in sun-exposed areas of the skin have a very _____ rate of metastasis.
low
49
In dark-skinned people, SCCs tends to arise on non sun-exposed areas (e.g. the legs and anus) and are frequently associated with chronic inflammation, chronic wounds, or scarring. T or F
T
50
Cumulative UVB sun exposure in the past ________ years of a person’s life increases the likelihood of SCC in the presence of other risk factors.
5-10
51
A lesion on the vermillion border is ___ until prove
SCC
52
which is more likely to metastasize? SCC or BCC
SCC
53
Why do basal cell carcinomas have a limited capacity to metastasize?
absence of necessary growth factors derived from the stroma of the original tumor site.
54
Persons aged 55-75 have a ______ -fold higher incidence of BCCs than those younger than 20.
100
55
About ____ % of patients who have had one BCC will develop another lesion within five years.
40
56
What is the most important environmental risk factor for developing BCCs?
sun
57
intermittent, intense sun exposure decrease BCC T or F
F
58
rodent ulcer
BCC Center ulcerates/bleeds, accumulates crust/scale then heal with scarring
59
morpheaform BCC have borders that are easily localized T or F
F
60
BCCs must be treated early on to avoid the locally invasive, aggressive, and destructive effects on skin and surrounding tissues t or f
t
61
ED&C are the most effective treatment of BCC t or f
f
62
Why would one chose radiation therapy to treat a BCC?
not candidates for surgery
63
List three features of BCCs that account for a high likelihood for recurrence after initial treatment.
size, depth, and irregular border
64
Although there is no uniform agreed upon screening protocol for malignant melanomas in the US a skin survey to identify suspicious lesions is considered the best option! T or F
T
65
Individuals with atypical nevi have a _________ fold elevated risk of developing malignant melanoma.
6
66
There is a strong association between high nevus counts (more than ____) and malignant melanoma.
>50
67
Case studies found the strongest association for malignant melanoma for ____________ sun exposure and ___________ in adolescence or childhood.
intermittent exposure sunburn
68
During the ___________ growth phase a malignant melanoma is almost always curable by surgical excision alone.
horizontal phase
69
Nodular melanomas have no identifiable __________ growth phase and enter the _____________ growth phase almost from their inception.
horizontal; vertical
70
Over 60% of superficial spreading malignant melanomas are diagnosed as thin, highly curable tumors of less than _ mm thickness.
1
71
Nodular malignant melanomas are the most difficult to diagnose at an early stage – at least half are greater than ____ mm in thickness when diagnosed!
2
72
The great majority of lentigo maligna melanomas are diagnosed at less than ___ mm of thickness!
1
73
The most common type of malignant melanoma among Asians and in African-Americans is the ______________ _____________ ____________ which arise most commonly on palmar, plantar, and subungual surfaces.
acral lentiginous Melanoma
74
______________ _______________ is the single most important determinant of prognosis for a malignant melanoma.
sun exposure
75
Stage T1: ≤1 mm malignant melanomas have a ten year survival of ____ percent.
92%
76
The definitive “initial” surgical treatment for primary cutaneous melanoma is a ________ ________ __________ down to the deep fascia.
excision
77
Because of the potential of metastasis and possible death, any biopsy that comes back positive for malignant melanoma needs to be referred for additional surgery via ______________ procedure.
mohs
78
SCC TX
oral vitamin A
79
oral SCC
Present as an ulcer, nodule, or indurated plaque involving the oral cavity Floor of the mouth and lateral or ventral tongue most common sites. Lesions arise in sites of: erythroplakia (premalignant persistent red patches) leukoplakia (persistent white plaques
80
Verrucous carcinoma SCC
exophytic, cauliflower-like growths that resemble large warts. Lesions are sub classified according to site: Oral – florid mucosal verrucous papillomatosis Anogenital – giant condyloma acuminatum or verrucous carcinoma involving the penis, scrotum, or perianal region Epithelioma cuniculatum – verrucous carcinoma on the plantar foot surface
81
SCC on lip
Primarily occurs on the lower lip Lesions may present as nodules, ulcers, or indurated white plaques
82
ELECTRODESICCATION & CURETTAGE advantage
Cost effective Relatively quick, single visit Relatively easy wound care Well suited for multiple lesions Usually good to excellent cosmetic results No sedation or general anesthesia required
83
Disadvantages of ED & C
Not margin-controlled Recurrence rate unacceptably high with larger (>5 mm) lesions located in high risk sites! Need special equipment and user experience to get higher cure rates Poor choice in most BCCs of the head Must be cautious in patients with pacemakers
84
surgical excision advantages
Margin-controlled Resultant scar is optimized both cosmetically and functionally.
85
Disadvantages of Surgical Excision
Invasive have to use general anesthesia not as good results as Mohs micrographic surgery
86
Advantages of Mohs
Cost effective No sedation or general anesthesia required. high cure rates great cosmetic outcome Allows for histological evaluation of 100% of the peripheral margin
87
Disadvantages of Mohs
expensive long time to get done Requires special training in the technique.
88
Advantages of Cryotherapy
Cost effective Relatively quick – no sedation or general anesthesia required Relatively easy wound care Well suited for multiple lesions Usually affords good to excellent cosmetic results Low recurrence rates in small primary BCCs that lack "high risk" features
89
Disadvantages of Cryotherapy
Not margin-controlled. May require multiple visits Requires considerable clinical judgment/experience Potential hyper- and hypo-pigmentation Possible permanent damage to underlying nerves, vessels, etc.
90
TOPICAL 5-FLUOROURACIL AND IMIQUIMOD advantages
Noninvasive; avoids operative risks. Rarely causes scarring. Good for patients who are otherwise not candidates for surgery.
91
TOPICAL 5-FLUOROURACIL AND IMIQUIMOD disadvantages
Limited to treating only superficial BCCs located in low-risk areas. Brisk inflammatory reaction - poorly tolerated in some individuals. Requires prolonged application (weeks to months!)
92
radiation therapy advantages
Noninvasive – relative sparing of critical structures Relatively painless Good for patients who are not otherwise candidates for surgery High cure rate for selected lesions
93
digit block or nerve block
- Cleanse the toe/finger and paint the area with povidone-iodine (Betadine®) solution. - Using a 27 gauge needle, slowly inject 1% lidocaine (or lidocaine 1%:Marcaine 0.25% 1:1 mix) midway between the dorsal and palmar surfaces of the finger at the midpoint of the middle phalanx. - Advance the needle and inject lidocaine in the vicinity of the neurovascular bundle. - Then pull back without removing the needle and fan the needle toward the dorsal  surface – repeat injection
94
alteratives
Nourishing, restorative tonics with effects focused on digestion, absorption, and elimination
95
Alterative, Nutritive, high in phytoestrogens, lymphagogue, Antitussive, Antispasmodic, Vulnerary
Trifolium pratense actions
96
menopausal climacteric symptoms, vaginal dryness, chronic skin conditions, Breast cancer estrogen positive Lots of heat Cancer, gout, arthritis, acne, spasmodic cough, cachexia, burns with poor healing, ulcers of the skin or mucous membranes, TB or inflammation of the lungs
Trifolium pratense indications
97
better subjective improvement of scalp hair and skin status, libido, mood, sleep, and tiredness inhibition of 5-α-reductase activity, reduction of inflammatory reactions, and stimulation of ECM protein synthesis in the vicinity of the hair follicle
Trifolium pratense MOA
98
Root: alterative, mild digestive bitter, antitumor, antimutagenic, nutritive, antirheumatic, phytoestrogenic, liver tonic Leaves: used topically as a antimicrobial, anti-inflammatory poultice Seeds: alterative, diuretic, urinary tonic, vulnerary Cholagogue
Rumex spp actions
99
ALBE inhibits the expression of IL-4 and IL-5 by downregulating MAPKs and NF-κB activation in ConA-treated splenocytes
Rumex spp MOA
100
**Root:** dry and scaly skin conditions – psoriasis, eczema, dandruff, rheumatic/arthritic conditions, anorexia nervosa, cystitis, wounds and ulcers (poultice). **Leaves:** mastitis, joint sprains (poultice), alleviate nettle stings **Seeds:** cystitis, skin conditions including exanthems
Rumex spp indications
101
Oxalate kidney stones, kidney disease, iron overload, pregnancy Don’t eat the leaves - very high in oxalic acid and can cause poisoning – oxalic acid chelates calcium in the blood.
Rumex spp CI
102
Alterative, digestive bitter, anticatarrhal, antimicrobial, cholagogue, mild laxative.
Mahonia spp actions
103
lipoxygenase inhibition and lipid antioxidant properties
Mahonia spp moa
104
**Skin conditions**: Psoriasis, eczema, herpes, pityriasis, acne, syphilis. **Poor gallbladder function**: Nausea, fat malabsorption, digestive upset **Infections**: Skin, eye, and intestinal tract (bacterial, fungal and protozoal)
Mahonia spp indication
105
Mahonia spp CI
pregnancy
106
Antioxidant, inhibit tumor cell proliferation and induce apoptosis, pro-oxidant, promotes weight loss, decreases LDL, modulates inflammation, decreases sebum production, antimicrobial
Camelia sinensis action
107
inhibition of MAP kinase signaling, inhibition of growth factor signaling, inhibition of matrix metalloproteinases, inhibit angiogenesis, decrease invasiveness of cancer cells, augments hormonal therapies, decreases free testosterone, increases SHBG, decreases insulin resistance and improves other glucose-related markers
Camelia sinensis moa
108
Cancer, PCOS, androgenic alopecia, anti-aging, acne, wound and scar healing, sun protection
Camelia sinensis indication
109
Camelia sinensis CI
Take away from iron supplementation
110
Berries – antioxidant, modulates inflammation. Rhizome and root – also modulate inflammation, effects glucose metabolism, antimicrobial
Berberis vulgaris action
111
Berries – effective in the treatment of acne as well as other inflammatory conditions. Rhizome and root – source of berberine and uses relate to that constituent.
Berberis vulgaris indication
112
hepatoprotective, hepatotonic, antihepatotoxic (particularly against *aminita phalloides), nephroprotective, bitter, galactagogue,* antifibrotic effect, Increase glutathione
Silybum marianum action
113
increased GSH levels, decreased MDA and IL-8
Silybum marianum MOA
114
Liver diseases , jaundice, hepatitis, cirrhosis, alcoholism, fatty liver degeneration, hepatitis, cirrhosis, alcoholism with fatty liver, diabetic nephropathy Acne
Silybum marianum indication
115
Silybum marianum CI
Speculative - asteraceae family allergy
116
Warm, stimulating or calm depending on physiologic state, dispels wind dampness
Eleutherococcus senticosis Energetics
117
Adaptogen, immunomodulating, mild CNS stimulant Nonspecific ant stress effects Ergogenic Anabolic/anticatabolic Antitoxic Radioprotective Chemoprotective Immunoprotected Immunoregulatory Antiviral Gonadotrophic Insulin-trophic/antidiabetic Neuroprotective
Eleutherococcus senticosis action
118
reduced frequency of HSV,
Eleutherococcus senticosis moa
119
Build vitality, increase resistance to infection, stress, and toxicity, improve physical performance, and improve mood
Eleutherococcus senticosis indication
120
Adulteration is common in the marketplace. Monitor blood glucose in diabetics and hypoglycemics when introducing this herb.
Eleutherococcus senticosis CI
121
Anti-allergic action of triterpenes, anti-hypertensive, oleic acid inhibits histamine release, hypotensive, decreases platelet aggregation/LDL/arrhythmia/insomnia/angina, protects against ionizing radiation
Ganoderma lucidum action
122
Used in cancer treatment to increase immune function and help treat fatigue, hypertension, immune deficiency, insomnia, hepatitis
Ganoderma lucidum indication
123
Potential allergy to spores
Ganoderma lucidum ci
124
Seborrheic keratosis
125
Seborrheic keratosis
126
Seborrheic keratosis
127
milia
128
Localized atypia of the epidermis – a precursor to SCC in situ Gross morphology: Tan-brown, red or skin-colored Rough like sandpaper On face, arms, dorsal hands, lips Hyperkeratosis What is this?
Actinic keratosis
129
Meibomian cyst/Chalazion
130
Digital mucous cyst
131
Painful lesions Early Central crust Apex -mc Long standing Dense rolled edge
Chrondrodermatitis nodularis helicis
132
Painful lesions Early Central crust Apex -mc Long standing Dense rolled edge
Chrondrodermatitis nodularis helicis
133
Painful lesions Early Central crust Apex -mc Long standing Dense rolled edge
Chrondrodermatitis nodularis helicis
134
Most common tumor of the intraepidermal eccrine sweat glands Women>Men Autosomal dominant Usually symmetrical distribution
Syringoma
135
Very common, button-like dermal nodule pink, brown, tan, darker at center leg>arms>trunk few mm to 1 cm ‘dimple sign’ with lateral compression Tx-leave alone, excision, cryotherapy
Dermatofibroma
136
Seborrheic keratosis
137
Ganglion cyst
138
Lipoma
139
Basal cell carcinoma
140
Seborrheic keratosis
141
Sebaceous hyperplasia
142
actinic keratosis
143
Actinic keratosis
144
Chrondrodermatitis nodularis helicis
145
Basal cell carcinoma
146
Dermatosis Papulosa Nigra
147
Skin tag acrochordon
148
Skin tag acrochordon
149
Skin tag acrochordon
150
Epidermal inclusion cyst
151
Epidermal inclusion cyst
152
Present in 5-20% of white population skin surface of whites-can occur anywhere acral and mucosal surface of other races potential precursors to Superficial Spreading melanoma (SSM), increase risk for developing primary melanoma
Atypical or dysplastic nevi
153
Present in 5-20% of white population skin surface of whites-can occur anywhere acral and mucosal surface of other races potential precursors to Superficial Spreading melanoma (SSM), increase risk for developing primary melanoma
Atypical or dysplastic nevi
154
Dermatofibroma
155
Dermatofibroma
156
Junctional nevi
157
Solitary lesions are: infrequent inconsequential represent spontaneous mutations These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.
Neurofibroma type 1
158
Solitary lesions are: infrequent inconsequential represent spontaneous mutations These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.
Neurofibroma type 1
159
BCC
160
BCC
161
BCC
162
Dermal nevi
163
Dermal nevi
164
Ganglion cyst
165
Usually deeper than an epidermal inclusion cyst May feel rubbery but is usually not malleable. If uncertain diagnosis, particularly if the lesion feels quite firm, a malignant tumor must be considered
Lipoma
166
Abnormal scarring in susceptible individuals More common in darker skin types 1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery) Age 10-30 years
Hypertrophic scar or keloid
167
Abnormal scarring in susceptible individuals More common in darker skin types 1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery) Age 10-30 years
Hypertrophic scar or keloid
168
Abnormal scarring in susceptible individuals More common in darker skin types 1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery) Age 10-30 years
Hypertrophic scar or keloid
169
Abnormal scarring in susceptible individuals More common in darker skin types 1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery) Age 10-30 years
Hypertrophic scar or keloid
170
Abnormal scarring in susceptible individuals More common in darker skin types 1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery) Age 10-30 years
Hypertrophic scar or keloid
171
Skin tag
172
Digital mucous cyst
173
Alopecia areata cause
autoimmune disease hashimoto’s thyroiditis vitiligo myasthenia gravis
174
Alopecia areata sx
loss of hair that is asymptomatic exclamation point hairs
175
Alopecia areata TX
stress reduction topical onion juice x2 topical steroids injection of steroids topical minoxidil wig topical immunotherapy
176
Acquired loss of pigmentation Pathogenesis is not known Theories: autoimmune, neurogenic, self-destruct, genetic background (30%) Age of onset: any, 10-30yrs (50%) Incidence: common up to 1% All races, equal in both sexes Skin lesions: white macules, sharply marginated, 5mm-5cm Can affect any area; most common on face and extremities. Accentuated with sun exposure.
Vitiligo
177
Acquired loss of pigmentation Pathogenesis is not known Theories: autoimmune, neurogenic, self-destruct, genetic background (30%) Age of onset: any, 10-30yrs (50%) Incidence: common up to 1% All races, equal in both sexes Skin lesions: white macules, sharply marginated, 5mm-5cm Can affect any area; most common on face and extremities. Accentuated with sun exposure.
Vitiligo
178
Sun exposed areas of skin male> females pre-malignant 1 out of 1000 lesions develop into SCC annually 5-10% over a lifetime
actinic keratosis
179
Acquired light or dark-brown hyperpigmentation Age of onset: young adults Female>male(10%) Race: brown or black skin type Incidence/etiology: hyperinsulinemia, pregnancy (mask of pregnancy), combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti seizure medication
melasma
180
Acquired light or dark-brown hyperpigmentation Age of onset: young adults Female>male(10%) Race: brown or black skin type Incidence/etiology: hyperinsulinemia, pregnancy (mask of pregnancy), combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti seizure medication
melasma
181
Nodular mass of dilated vessels 80-90% resolves spontaneously within 5-8 years
hemangiomas
182
Nodular mass of dilated vessels 80-90% resolves spontaneously within 5-8 years
hemangiomas
183
Nodular mass of dilated vessels 80-90% resolves spontaneously within 5-8 years
hemangiomas
184
Fair-skinned individuals with excessive sun exposure in childhood at highest risk Exposure to chemical carcinogens (pitch, tar, crude paraffin oil, fuel oil, creosote, lubricating oil) arsenic (Flower’s soln. for psoriasis) other etiologies (HPV, immunosuppression)
SCC
185
Fair-skinned individuals with excessive sun exposure in childhood at highest risk Exposure to chemical carcinogens (pitch, tar, crude paraffin oil, fuel oil, creosote, lubricating oil) arsenic (Flower’s soln. for psoriasis) other etiologies (HPV, immunosuppression)
SCC
186
nodular melanoma
187
Single or scattered discrete lesions Adherent hyperkeratotic scales – “rough texture”
actinic keratosis
188
punch biopsy was malignant 20 years history grows nodule after several years means its spread
lentigo maligna melanoma
189
Hutchinson’s sign Periungual spread from nail
acral lentiginous melanomas
190
Scaling to ulcer elevated nodule to tumor Indurated, eroded nodule that ulcerates and bleeds easily Common on lower lip, top of ears, tongue, head, neck, back of hands
SSC
191
Scaling to ulcer elevated nodule to tumor Indurated, eroded nodule that ulcerates and bleeds easily Common on lower lip, top of ears, tongue, head, neck, back of hands
SSC
192
Autoimmune disease causing localized hair loss w/o signs of inflammation (asymptomatic) about 2% of population have at least one episode Etiology-autoimmune, can be assoc. with Hashimoto’s thyroiditis, vitiligo, myasthenia gravis
alopecia areata
193
Autoimmune disease causing localized hair loss w/o signs of inflammation (asymptomatic) about 2% of population have at least one episode Etiology-autoimmune, can be assoc. with Hashimoto’s thyroiditis, vitiligo, myasthenia gravis
alopecia areata
194
Exclamation point hairs Course: remission is common (80%) Management: stress reduction, topical onion juice, topical, intralesional, or systemic glucocorticoids, can add topical minoxidil, wig in severe cases, or refer for topical immunotherapy
alopecia areata
195
pre-malignant (1 out of 1000 lesion annually) develop into SCC, 10% over lifetime
actinic keratosis
196
5-Fluorouracil- applied bid for 2-4 weeks – very irritating Acetaminophen with codeine often given to control pain Petrolatum often used between applications to soothe skin
actinic keratosis
197
management: gluten free diet, dipsone,
Dermatitis herpetiformis
198
Dermatitis herpetiformis
199
Storke bite lesion
200
nodular BCC
201
Course and Prognosis: May spontaneously disappear after delivery or stopping hormones Management: can be difficult to treat. Use sun blocks and/or reduce UV exposure, hypopigmenting agents (i.e. hydroquinone 2-4% bid), topical tretinoin, azelaic acid, chemical peels (glycolic acid, salicylic acid and TCA), laser cryotherapy, dermabrasion
Melasma
202
Course and Prognosis: May spontaneously disappear after delivery or stopping hormones Management: can be difficult to treat. Use sun blocks and/or reduce UV exposure, hypopigmenting agents (i.e. hydroquinone 2-4% bid), topical tretinoin, azelaic acid, chemical peels (glycolic acid, salicylic acid and TCA), laser cryotherapy, dermabrasion
Melasma
203
most common in 6th decade of life no radial growth, so early metastasis
nodular melanoma
204
most common in 6th decade of life no radial growth, so early metastasis
nodular melanoma
205
photodynamic therapy
actinic keratosis
206
rapid growth within few weeks- can self-resolve within a month-year
Keratoacanthoma
207
Treated 5-FU or Curaderm identify
superficial BCC
208
Dilated vessels deep in dermis and subcutaneous tissue Spontaneous resolution, surgery, interferon, propranolol, intralesional and topical corticosteroids, vincristine and cyclophosphamide
hemangioma deep cavernous
209
Dilated vessels deep in dermis and subcutaneous tissue Spontaneous resolution, surgery, interferon, propranolol, intralesional and topical corticosteroids, vincristine and cyclophosphamide
hemangioma deep cavernous
210
Vascular malformation/port wine stain
211
Vascular malformation/port wine stain
212
Vascular malformation/port wine stain
213
asymptomatic, soft benign papule, from dilated venule
venous lake
214
Develops after a minor trauma Bleeds easily <30 years old
pyogenic granuloma
215
Develops after a minor trauma Bleeds easily <30 years old
pyogenic granuloma
216
spider angioma
217
spider angioma
218
25% remit with decrease sun exposure Antioxidants, fruit, vegetables, green tea, etc 5-Fluorouracil Black salve (iris, red clover, sanguinaria) Vitamin A Curaderm Cryotherapy (3-10 seconds max/3) w/ 5FU Sunscreen Type I & II skin excision for large lesions
actinic keratosis
219
25% remit with decrease sun exposure Antioxidants, fruit, vegetables, green tea, etc 5-Fluorouracil Black salve (iris, red clover, sanguinaria) Vitamin A Curaderm Cryotherapy (3-10 seconds max/3) w/ 5FU Sunscreen Type I & II skin excision for large lesions
actinic keratosis
220
most common skin disorder in adolescents Typical age range:12-25 years 79% to 95% of adolescents aged 16-18 years-reference
acne
221
most common skin disorder in adolescents Typical age range:12-25 years 79% to 95% of adolescents aged 16-18 years-reference
acne
222
A reactive hypermelanosis of the skin that occurs as a sequela of cutaneous inflammation EPIDEMIOLOGY A common disorder that can occur at any age and has an equivalent incidence in males and females. may occur regardless of skin color, but is clinically more significant with darker skin pigmentation.
hyperpigmentation syndrome
223
Wheals –transient edematous papules and plaques Usually pruritic 15-25% of pop will have at least one episode at during their lifetime Duration: hours-months Histamine is the most important mediator
urticaria
224
Wheals –transient edematous papules and plaques Usually pruritic 15-25% of pop will have at least one episode at during their lifetime Duration: hours-months Histamine is the most important mediator
urticaria
225
Chronic, recurrent, intensely pruritic vesicles, papules, and urticarial plaques that are arranged in groups Can resembles herpes; therefore the designation of herpetiformis Almost universally associated with celiac disease (1% of pop) Age of onset: 20-60 years Prevalence in Caucasians, M:F 2:1, 10-39 per 100,000 persons
dermatitis herpetiformis
226
Thickened, hyperpigmented skin in the axillae and groin Often associated with obesity and hyperinsulinemia Can be congenital Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)
Acanthosis Nigricans
227
Thickened, hyperpigmented skin in the axillae and groin Often associated with obesity and hyperinsulinemia Can be congenital Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)
acanthosis nigricans
228
Thickened, hyperpigmented skin in the axillae and groin Often associated with obesity and hyperinsulinemia Can be congenital Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)
Acanthosis Nigricans
229
Localized proliferation of melanocytes due to chronic sun exposure (esp. sunburns) 1-3 cm macules >40 years old esp. Type I to III skin Roughly 75% of white people over 60 have one or more
solar lentigo
230
Dermatitis Heprtiformis pathophysiology
celiac disease
231
Dermatitis Heprtiformis population
20-60 yo Caucasians M
232
Dermatitis Heprtiformis Sx
Chronic, recurrent, intensely pruritic vesicles, papules, and urticarial plaques that are arranged in groups
233
Dermatitis Heprtiformis TX
gluten free diet dapsone sulfapyridine
234
Acanthosis Nigrican cause
hyperinsulinemia causes melanocytes, dermal fibroblast and keratinocyte to proliferation diabetes, metabolic syndrome internal malignancy Insulin and insulin-like growth factor-1, and their receptors on keratinocytes are obviously involved in the complex regulations leading to the peculiar epidermal hyperplasia
235
Acanthosis Nigrican sx
symmetric velvety hyperpigmented plaques on intertriginous areas like axilla, neck, inframammary, and groin associated with skin
236
Acanthosis Nigrican Tx
berberine, metformin, rosiglitazone remove meds that cause hyperinsulinemia: glucocorticoids, injected insulin, niacin, oral contraceptives topical retinoids: keratinolytic effects on the skin vitamin D analogs: reducing keratinocyte proliferation keratolytics topical urea, salicylic acid, glycolic acid peels, and laser therapy
237
Melasma pop
young age, female, darker skin types
238
Melasma cause
oral contraceptive use, pregnancy hyperinsulinemia, combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti-seizure medication
239
Melasma sx
Irregular blotchy patches of hyperpigmentation on the face
240
Melasma DX
insulin glucose
241
Melasma TX
sunscreen hydroquinone 2-4% bid topical tretinoin azelaic acid chemical peels (glycolic acid, salicylic acid and TCA) laser cryotherapy dermabrasion
242
Postinflammatory hyperpigmentation cause
reactive hypermelanosis of the skin that occurs as a sequela of cutaneous inflammation acne vulgaris, atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, psoriasis, and lichen planus. Accidental burns, nonionizing radiation therapy, phototoxicity, chemical peels, and laser procedures when inflammation leads to a disruption of the basal layer of the epidermis, causing the release of melanin into the papillary dermis. Macrophages in the papillary dermis then phagocytize the released melanin.
243
Postinflammatory hyperpigmentation TX
avoid sun treat underlying cause Topical hydroquinone (2-4%): cytotoxic effect topical retinoids, azeliac acid, and chemical peels (Glycolic acid-Alpha hydroxy acids (AHAs) and salicylic acid-Beta hydroxy acid (BHA laser lignin peroxidase mequinol, niacinamide, ascorbic acid, kojic acid, and licorice
244
Solar Lenitgo cause
Localized proliferation of melanocytes due to chronic sun exposure
245
Solar Lenitgo pop
>40, Type I to III skin
246
Solar Lenitgo sx
1-3 cm macules, brown
247
Solar Lenitgo dx
punch biopsy shave
248
Solar Lenitgo tx
hydroquinone solution tretinoin azeliac acid cream glycolic acid peels and creams Light cryotherapy
249
Vitiligo pop
any race, 10-30
250
Vitiligo cause
unknown, autoimmune, family history neurogenic, self-destruct, associated with thyroid disease (30%), alopecia, Addison’s disease, pernicious anemia, type 1 diabetes, chronic candida, melanoma
251
Vitiligo sx
Irregular, completely depigmented patches area devoid of melanocytes white macules, sharply marginated, 5mm-5cm face and extremities accentuated by sun exposure
252
Vitiligo tx
sunscreen oral and/or topical psoralens with UVA (6-24 month course), UVB(6-12 months) oral/topical steroids tacrolimus B12 (2,000mcg/day) plus folic acid (10mg/day) L-Phenylalanine 50mg/kg/day orally and a 10% gel topically, plus 30 min of sun per day Ginkgo biloba - 40 mg orally 3 times daily
253
urticaria cause
histamine is the most important mediator Inhalants: pollens, animal danders, mold spores, feather down, aerosols, smoke, dust and volatile chemicals Injectants: drugs, diagnostic agents, vaccines, insects stings Ingestants: drugs, food, food additives (dyes, preservatives, etc.) Infections: bacterial, fungal, viral, parasitic Contactants: plants, cosmetics, plastic, chemicals dermographism cold solar exercise-induced pressure
254
urticaria sx
wheals pruritic hours to months angioedema of glottis leading to air flow obstruction
255
urticaria dx
CBC with differential: normal or elevated eosinophil or neutrophil ESR, CRP: elevated or normal C4 level: decreased Chronic utricaria - TSH, antibodies - ANA - skin prick testing - specific IgE blood test to allergen - allergen elemination diet - serum tryptase - C1 esterase inhibitor - C1-inhibitor
256
urticaria tx
antihistamines: benadryl, claritin, zyrtex, hydroxyzine, diphenhydramine, cetirizin, prednisone epinephrine for severe cases ID the causse stop all nonessential drugs/supplement/herbs elimination diet low histamine diet Vit C: 1 g tid, Vit D: 1,000-10,000IU D3-test blood levels Vitamin B12, 1,000 mcg intramuscularly, once a week for 4 weeks, has been reported to provide relief in >50% (Gaby) Quercetin: 250 mg 20 minutes before meal Check and evaluate for HCL deficiency Eradication of H pylori resulted in clinical improvement in 73% of patients with chronic urticaria (Helicobacter 2001;6(1):60-65 Relaxation, homeopathy, acupuncture For cholinergic urticaria: hot shower depletes histamine store – 24 hour refractory period Baking soda, starch or oatmeal bath Botanicals: comfrey, euphoria, yerba sante, feverfew, ephedra address histamine detox via diamine oxidase - Gluten intolerance, leaky gut, SIBO, DAO blocking foods (alcohol, energy drinks, tea), genetic mutations, inflammation from Crohn’s ulcerative colitis, and IBD - Medications such as: Non-steroidal anti-inflammatory drugs (ibuprofen, aspirin) - Antidepressants (Cymbalta, Effexor, Prozac, Zoloft) - Immune modulators (Humira, Enbrel, Plaquenil) - Antiarrhythmics (propanolol, metaprolol, Cardizem, Norvasc) - Antihistamines (Allegra, Zyrtec, Benadryl) - Histamine (H2) blockers (Tagamet, Pepcid, Zantac)
257
Hemangiomas pop
most common tumor in infancy
258
Hemangiomas sx
deep and superficial nodular mass of dilated vessels Dilated vessels deep in dermis and subcutaneous tissue
259
Hemangiomas TX
Spontaneous resolution surgery interferon propranolol intralesional and topical corticosteroids vincristine cyclophosphamide
260
Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus sx
Flat, unilateral patches of irregular reddish-blue color. Face and neck are most common
261
Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus dx
10% of face send for MRA to rule out CNS problems
262
Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus tx
Refer to dermatologist, an ophthalmologist and a neurologist if large Pulsed dye laser
263
Cherry Angioma pop
male and females begin around 30 years old
264
Cherry Angioma cause
family history
265
Cherry Angioma sx
bright red, blue, purple, black dome-shaped to polypoid, firm papule chest and back
266
Cherry Angioma tx
radiosurgery shave excision laser electrodesiccation cryotherapy no treatment necessary
267
Spider angioma pop
women
268
Spider angioma cause
oral contraceptive, pregnancy and liver disease
269
Spider angioma sx
Central arteriole w/ radiating telangiectasia face, arms, and upper trunk abdomen is liver congestion
270
Spider angioma dx
diascopy
271
Spider angioma tx
optional radio/electrosurgery laser pulsed dye laser
272
Venous Lake pop
over 50 yo
273
Venous Lake sx
Dark blue to violet - dilated venule face, lips, and ear 2-10mm soft papule that blanches with pressure Asymptomatic, if unsure, R/O melanoma
274
Venous Lake dx
put slide and the blood drains out
275
Venous Lake tx
cosmetic electrosurgery laser excision
276
Pyogenic Granuloma pop
277
Pyogenic Granuloma pop
any age
278
Pyogenic Granuloma cause
site of minor trauma
279
Pyogenic Granuloma sx
recurrent bleeding red, dusky red, violaceous, brown/black head, neck, upper trunk and hands and feet
280
Pyogenic Granuloma dx
rule out melanoma excision/biopsy
281
Pyogenic Granuloma TX
electrodesiccation of base to prevent recurrence Curettage and Cauterization surgical Excision Electrocautery Excision Cryosurgery sometimes possible Laser Surgery Sclerotherapy Injections of Corticosteroids into the Lesion
282
Benefits of epinephrine
- decreases bleeding - prolongs the duration of the anesthesia - minimize the amount of anesthesia
283
Issues of epinephrine
- goes through breast milk - reduce uterine blood flow - induce premature labor - can cause gangrene or reduced blood flow
284
Benefits of Sodium Bicarbonate
- reduction in infiltration - faster onset of action
285
Cons of sodium bicarbonate
- chemically unstable - decrease the overall activity of epinephrine
286
Drug interactions to epinephrine
- MAO inhibitors: hypertensive crisis - Carbamazepine and Cyclobenzaprine: potentiate effects - tricyclics and tetracycline antidepressants: hypertensive crisis and dysrhythmia - phenothiazines: profound hypotension
287
allergy to anesthetics cause, sx, management
- uncommon to amide - allergy to methylparaben preservatives Sx - delayed appearance of skin rashes - acute onset of localized or general urticaria - onset of asthma Management - maintain airway - legs up - administer epinephrine, Benadryl, ER
288
topical anesthetics use and type
- mucous membranes - cocaine, tetracaine, lidocaine, phenylephrine +lidocaine or tetracaine
289
local infiltration steps
- injection of local anesthetic directly into tissue without considering the course of cutaneous nerve - clean the skin with alcohol or use betadine - Insert a 25-30 g. needle attached to a syringe into the skin at a 15-20o angle and inject the anesthesia around or within the skin in the area to be removed or treated. - Pull back or tighten the skin before inserting a 25-30 g needle ¼ inch back from wound edge or lesion - Push the needle attached to a syringe into the skin at a 15-20 angle - Advance the needle as far as it will go - Draw back on the syringe to make sure the needle is not sitting in a vessel - Slowly inject the anesthetic as you withdraw the needle - Retain needle and advance to the opposite side of the “V” - Repeat on other side of lesion - May need to inject into the Sub-Q tissue and around the base of deep structures, i.e. a cyst, for good effect. - Another injection can be done over future incision
290
field block
Injection of a combination of intradermal and subcutaneous local anesthetic solution in an inverted V just proximal to and to each side of the lesion (not into the lesion) with no attempt to locate specific nerves anesthetizing the region distal to the site of injection
291
field block procedure
- Clean the skin with alcohol. - Use Betadine if needs to be sterile. - Pull back or tighten the skin before inserting a 25-30 g needle ¼ inch back from wound edge or lesion - Push the needle attached to a syringe into the skin at a 15-20 angle - Advance the needle as far as it will go - Draw back on the syringe to make sure the needle is not sitting in a vessel - Slowly inject the anesthetic as you withdraw the needle - Retain needle and advance to the opposite side of the “V” - Repeat on other side of lesion - May need to inject into the Sub-Q tissue and around the base of deep structures, i.e. a cyst, for good effect. - Another injection can be done over future incision
292
anesthetics except cocaine are vasodilators T or F
T
293
What is the purpose of adding sodium bicarbonate to local anesthetics?
reduce the burning
294
Can sodium bicarbonate be safely added to local anesthetic products containing epinephrine? Why/why not? What are the effects?
yes
295
field block definitions
Injection of a combination of intradermal and subcutaneous local anesthetic solution in an inverted V just proximal to and to each side of the lesion (not into the lesion) with no attempt to locate specific nerves  anesthetizing the region distal to the site of injection. Injection of a combination of intradermal and subcutaneous local anesthetic solution completely around the boundaries of the lesion, with no attempt to locate specific nerves  an anesthetized “field” inside of the boundaries of the anesthesia.
296
What are the 2 advantages of a field block over an infiltration anesthesia?
rapid onset less drug can be used
297
What are the considerations when choosing an infiltration anesthetic?
the location allergy
298
What are the maximum allowable safe single doses of plain 1 % lidocaine and 0.25 % bupivacaine alone and with epinephrine?
lidocaine: 4.5 mg/kg (30 ml per average adult) lidocaine w/ epi: 7 mg/kg (50ml per average adult) bupivacaine: 3 mg/kg 70 ml per average adult bupivacaine w/ epi: 3.5 mg/kg 90 ml per average adult
299
What are “two” advantages of using langer's lines when doing minor surgery?
minimize wound tension heal faster produce less scarring than those cut across
300
Langer's lines
direction in which the skin of a human cadaver will split when stuck with an ice pick. Correspond to the natural orientation of collagen fibers in the dermis and parallel to the orientation of the underlying muscle fibers
301
What are the “problem areas” of the body for increased risk of scarring/keloids?
upper chest and back shoulders
302
How do Kraissl's lines compare to Langer’s Lines?
Langer's lines were defined in cadavers, Kraissl's lines were based on observations in living people.
303
When a wound occurs what, essentially, is the body’s only interest?
survival
304
What is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?
5-6%
305
inflammatory phase
constriction of the blood supply leukocytes break down cellular debris and foreign material macrophages ingest the remaining debris platelets start to clot formation of a scab opening of the blood supply cleansing of the wound
306
proliferative phase
fibroblasts new collagen tissue is laid down new capillaries fills in defect wound edges pull together cells cross over the moist surface cells travel about 3 cm from point of origin
307
maturation phase
collagen forms which increases tensile strength to wounds scar tissue is only 80 precent as strong as original tissue 3 weeks to 2 years
308
clean wound
free from microorganisms
309
clean-contaminated wound
non-significant contamination and less than 6h elaspsing until medical care
310
dirty/contaminated wound
without local infection and more than 6 h elapsing until medical care
311
infected wounds
intense inflammatory reaction and frank infectious process
312
Is there a “Golden Period” of time for closing lacerations?
no
313
What are the four “Goals of Surgery”?
Close the wound efficiently Have no infection occurring during the healing process. End up with a small scar that is as inconspicuous as possible Have no loss of function.
314
What factors involving the surgeon affect wound repair?
length/direction of the incision/wound dissection technique careful tissue handling removal of necrotic tissue/foreign materials good hemostasis choice of closure materials elimination of dead space in the wound closing with sufficient and proper tension anticipation of post-op wound stressors immobilization of the wound if needed
315
What factors involving the patient affect wound repair?
patient’s age patient’s weight nutritional status degree of hydration inadequate blood supply to the wound site (e.g. DM) patient’s immune response presence of chronic disease malignancies debilitating injuries localized/systemic infection patient corticosteroids use immunosuppressive or antineoplastic drugs hormone use prior radiation therapy
316
Understand the concept of “Healing by First (Primary) Intention”. What are the goals and outcomes of this method?
a clean wound to start prompt closer minimal edema no local infection no serious discharge normal healing time good skin edge approximation and eversion minimal scar formation
317
What are advantages and disadvantages of “Healing by Secondary Intention"?
Advantages: its simplicity relatively low risk of infection Disadvantages: may take forever to heal tends to cause larger scars
318
What are the two possibilities that lead to a wound “Healing by Secondary Intention”? Can it be a reasonable choice made by the patient or surgeon?
1. Wound is left open on purpose, e.g. a “paper cut”, abrasion, or a draining abscess: 2. Wound fails to heal via primary (first) intention due to: excessive tissue trauma and/or loss, imprecise tissue approximation, or wound infection
319
Describe the steps in “Delayed Primary Closure (DPC)”. When should it be used? What are its advantages?
Steps: Debride the wound of non-vital tissues Leave the wound open Pack the wound with sterile dressing Cover with supporting bandage REPEAT PROCESS DAILY. uses: heavily contaminated wounds (combat wounds/major trauma) where there is extensive tissue loss and high risk of infection even with proper cleansing and primary closure. Advantages uncomplicated closure low risk of infection a “reasonable” scar better overall than an infected wound!
320
Name the several different ways to deal with “bleeders” that may appear in a surgical wound or traumatic laceration.
small -wait for them to stop on their own -apply pressure with a sterile gauze clamp with hemostat; then twist around several times -cauterize with a battery powered high temp cautery pen (“hot wire loop”) -cauterize with the hyfrecator -radiosurgery tip directly to the tissue large bleeding -clamp with hemostat and tie off with dissolvable suture -touching the hyfrecator tip to the hemostat -tie off with a “figure-of-8” suture
321
What are the other steps in laceration evaluation and treatment?
Assess for wound contamination and tissue damage. Check flexion/extension of all joints against resistance for underlying nerve and tendon damage – PRIOR TO INJECTING ANESTHESIA. R/O fractures In relatively “clean” wounds – first inject anesthesia In “contaminated” wounds – clean skin first! Then, if needed, inject anesthesia in a fan-like pattern through the skin surface around the laceration. REMEMBER – no anesthetics with epinephrine in areas of limited blood supply! Clean and debride as needed. Culture if risk of infection – decide about prophylactic antibiotic coverage. Carefully close wound and bandage appropriately – apply minor surgery tincture, honey, antibiotic, or Vaseline.
322
Contrast the treatment of an area of skin loss up to 1 cm2 in a fingertip vs. a larger wound or avulsion of the fingertip.
Areas of skin loss up to 1 cm2: Treat only with dressings changed regularly Heal with good return of sensation Skin loss greater than 1 cm2: Refer for plastic surgical opinion & treatment May need skin graft &/or re-attachment of severed part!
323
What are particular concerns about palm wounds?
deep structures could be involved fracture
324
tetanus immune globulin administration guidelines
If not certain that the patient has had the last dose of a primary series or a booster within the past 5 years, give tetanus toxoid. If patient has received fewer than two doses of tetanus toxoid in her/his lifetime and the wound is heavily contaminated, give both tetanus toxoid and tetanus immune globulin (derived from vaccinated patients and confers immediate passive immunity!)
325
When a wound has a Foreign bodies?
need to look for them but can be hard to identify because of wound type, location, timing, and mechanism of injury need x-ray
326
What are the controllable and the uncontrollable issues that affect wound healing?
Uncontrollable factors : Mechanism of injury Location of the wound Age and race of the patient Patient's inherent ability to heal Patient’s tendency toward abnormal scar formation Patient’s nutritional status Controllable factors: Tissue handling – use gentle, meticulous tissue handling, especially on the face. Do careful, thorough cleaning of the injured tissue. Splint/cast wounds located near joints to help prevent dehiscence &  less scarring
327
BEFORE APPLYING ANESTHESIA assess the wound site for tissue damage, contamination and possible underlying nerve, tendon, muscle and boney damage. T or F
T
328
Cleaning wound steps
1. assessing function, inject anesthesia 2. Remove embedded materials with a forceps or hypodermic needle to prevent skin "tattooing”. 3. Wear face shield, gloves, and impermeable gown to prevent contamination of the physician and others nearby. 4. Minimize operator and room contamination – use splash guard with a 30- or 60-ml syringe and sterile normal saline. 5. Use an 18-gauge needle or angiocatheter attached to a syringe to increase irrigation pressure. 6. For better disinfection add diluted Betadine or HIBICLENS (chlorhexidine gluconate) to the saline irrigating solution. 7. Irrigate until clean with a minimum of 500 ml of solution 8. If needed scrub out the wound with a gauze, cloth, or scrub brush. 9. Warn the patient about pain in case you may not have obtained good anesthesia. 10. Clean thoroughly but try to accomplish the task as quickly as possible. 11. Scrubbing/irrigation will often cause a wound to begin bleeding again as blood clots are dislodged. 12. Stop this bleeding by one or more of the methods described earlier –the goal is to avoid hematoma formation! 13. Remember to rinse the wound thoroughly with sterile saline when finished
329
Anesthetic usually should be administered by injecting from the inside or center of the laceration out through the side of the wound (unless it is significantly contaminated) into the tissue rather than through the skin surface because it will be less painful. T or F
T
330
All wounds should be considered contaminated, especially human bite wounds, which generally should not be closed, at least not initially. T or F
T
331
To prevent wound "tattooing," embedded foreign material must be removed with a forceps and scissors/scalpel or hypodermic needle and the wound copiously irrigated with sterile saline preferably under pressure. T or F
T
332
As part of debridement, all debris and devitalized and necrotic tissue should be removed from the wound. However, if there is any question concerning a tissue’s viability, it’s usually best to minimize the debridement at that time and opt for delayed primary closure.. T or F
T
333
Wound care steps
1. assessing function, inject anesthesia 2. Remove embedded materials with a forceps or hypodermic needle to prevent skin "tattooing”. 3. Wear face shield, gloves, and impermeable gown to prevent contamination of the physician and others nearby. 4. Minimize operator and room contamination – use splash guard with a 30- or 60-ml syringe and sterile normal saline. 5. Use an 18-gauge needle or angiocatheter attached to a syringe to increase irrigation pressure. 6. For better disinfection add diluted Betadine or HIBICLENS (chlorhexidine gluconate) to the saline irrigating solution. 7. Irrigate until clean with a minimum of 500 ml of solution 8. If needed scrub out the wound with a gauze, cloth, or scrub brush. 9. Warn the patient about pain in case you may not have obtained good anesthesia. 10. Clean thoroughly but try to accomplish the task as quickly as possible. 11. Scrubbing/irrigation will often cause a wound to begin bleeding again as blood clots are dislodged. 12. Stop this bleeding by one or more of the methods described earlier –the goal is to avoid hematoma formation! 13. Remember to rinse the wound thoroughly with sterile saline when finished
334
Skin and hair preparation
avoid shaving clippers and scissors are okay
335
When trimming a wound edge the goal is to produce an opening smaller at the base than the surface, which helps produce eversion of the wound edges. T or F
F
336
What are the alternatives to consider if a wound can’t be closed by primary intention?
secondary intention or delayed closure
337
Excessive scar formation can be minimized through gentle handling and careful cleaning of the injured tissue T or F
T
338
Name the 7 “Wound Closure Technique Basics”.
Handle tissues gently with forceps Ensure hemostasis Use as fine a suture as feasible Enter needle at 90° to the skin surface Evert the wound edges Keep the skin edges relaxed but well opposed Remove sutures as early as reasonably possible to reduce scarring
339
Excision advantages
- Margin-controlled - Usually performed under local anesthesia - Area of tissue removed can be more precisely controlled than with cryosurgery, radiation therapy, or electrosurgery → limiting damage to critical structures - Resultant scar is optimized both cosmetically and functionally
340
Excision Disadvantages
- Invasive - Occasionally needs to be performed under conscious sedation or general anesthesia with their inherent risks. - Uncertain “clear” margin → a poorer cure rate compared to Mohs micrographic surgery
341
Lift and Snip procedure
1. Apply alcohol to skin 2. Clean anesthesia bottle top with alcohol 3. Draw up anesthesia with an 18-22 g needle (controversial whether or not to inject air into the bottle!) 4. Switch to a ½-1 inch 27-30g needle 5. Inject Anesthesia: 0.2-0.4cc 1% lidocaine or 1% lido w/epi to create a cutaneous bleb (or use optional field block) 6. Grasp lesion with forceps and elevate a moderate amount 7. Snip off lesion with sterile iris scissors 8. Apply direct pressure and/or cautery (electro, silver nitrate, styptic) to oozing wound/bleeders 9. Dress with minor surgery tincture on Band-Aid
342
excision types
- Shave, Scoop, Punch Biopsy - Electrodesiccation (hyfrecation or radiosurgery) & Curettage - Elliptical (fusiform)Tissue Resection Lift and Snip
343
Conditions used for excision
SK Nevi Skin tags Small lesions Malignancy
344
Shave biopsy
1. Apply alcohol to skin 2. Clean anesthesia bottle top with alcohol 3. Draw up anesthesia with an 18-22 g needle (controversial whether or not to inject air into the bottle!) 4. Switch to a ½-1 inch 27-30g needle 5. Inject Anesthesia: 0.2-0.4cc 1% lidocaine or 1% lido w/epi to create a cutaneous bleb (or use optional field block) under the skin lesions at an angle, pull back on syringe then push it in as pull out 6. Test it they are numb 7. Put on gloves 8. 3 iodine swabs from center outward 9. Open towel away from you, open up, place on patient and press down 10. Dab off iodine 11. Open up scalpel and forceps 12. If possible, grasp lesion with forceps and elevate 13. Shave off lesion with #15 or #10 scalpel or dermablade 14. Apply direct pressure and/or cautery (electro, silver nitrate, styptic) to oozing wound/bleeders from the outside to center, put pressure and see if oozes 15. Dress with minor surgery tincture and/or Vaseline on Band-Aid
345
Punch biopsy
1. Prep area with alcohol. 2. Apply local anesthesia in the skin. 3. Prep with Betadine®. 4. Stabilize the skin surface with your thumb and index finger. 5. Firmly press the punch tip, perpendicular to the skin surface 6. Rotate back-and-forth until you feel the punch drop through the skin. 7. Grasp specimen with tissue forceps, and snip through the with iris scissors., sub-Q layer 8. Deposit in specimen container. 9. When doing a 2-3 mm punch, control bleeding with direct pressure and/or cautery or styptic solution, e.g. silver nitrate stick. 10. For larger punches close wound with appropriate number of sutures. 11. Dress with minor surgery tincture and/or Vaseline on a Band-Aid.
346
Scoop
1. Prep and anesthetize skin 2. If possible, grasp lesion with forceps and elevate 3. carefully shave it off with a scalpel or Dermablade 4. Apply direct pressure and/or electrocautery and/or silver nitrate and/or styptic to control oozing wound or bleeders 5. Dress with Vaseline and/or minor surgery tincture on a Band-Aid
347
1. Draw an ellipse around the lesion parallel to skin lines with an indelible marker. 2. This orientation reduces wound edge tension and improves the cosmetic effect. 3. Ellipses should be 3:1 length to width ratio with 30o angles at the ends. 4. Hold the scalpel at a 90 degree angle to the skin to produce perpendicular skin edges to allow for better eversion on closure. 5. If sending for biopsy, use atraumatic (no teeth) forceps to avoid tissue damage! 6. Undermine as needed and if needed/possible close sub-Q layer with simple stitches 7. Appose and align the wound edges using the “Rule of Halves”. 8. Carefully suture using a combo of mattress and simple sutures to evert the skin edges and reduce tension
348
elliptical excision complications
dog ear created can't close wound wound dehiscence
349
Steri strips benefits
- **Rapid, effortless application** - **Less pain and anxiety in kids** - **Less scarring** and **less infection** than sutures and staples - **Easy to care for – just keep dry!** - Trim loose ends as needed. - **Leave on until they fall off!**
350
Steri strips
- Thin paper strips with a pressure-sensitive, hypoallergenic adhesive, Reinforced with polyester filaments for added strength - Apply across a small wound to pull the skin edges together. - Good for the face, contoured areas, joints, areas of swelling, edema, and hematomas. - Use to provide wound support after early suture/staple removal.
351
Surgical glue
Cyanoacetate and formaldehyde combine in a heat vacuum along with a base →liquid monomer. When this monomer combines with moisture on the skin's surface, it chemically changes into a polymer that binds to the top epithelial layer. This polymer → cyanoacrylate bridge that strongly binds the two wound edges together and allows normal healing.
352
surgical glue use
Best suited for small, superficial lacerations May be used with confidence on larger wounds AFTER first applying subcutaneous sutures. low tension not bleeding low infection risk not over a joint high friction areas
353
surgical glue advantages
Maximum bonding strength at 2 ½ minutes Only topical or no anesthetic Usually need no additional injectable anesthesia no needles! Faster repair time than sutures Better patient acceptance Flexible, water-resistant covering No sutures to remove – adhesive peels off in five to 10 days.
354
surgical glue caution
wounds must be dry. use in wounds that have low risk of infection. don’t use over joints or high friction areas.
355
surgical glue results
Long-term cosmetic outcome is comparable to that of traditional repair methods.
356
when can't you use steri strips or surgical glue
Lacerations into the deeper dermal layers and Sub-Q Wounds missing tissue Wounds with increased wound tension Eliminate dead space Reduce the chance of infection and hematoma formation To reduce the likelihood of dehiscence
357
Staples advantages
quick placement fewer infections lower tissue reaction
358
staples cons
scarring
359
Electrosurgery use
to destroy benign and malignant lesions control bleeding incise or excise tissue Superficial lesions – e.g. skin tags Tiny lesions (may not need anesthesia) Vascular lesions Basal cell carcinoma - (only in experienced hands combined with curettage)
360
Electrodessication
Touching or inserting the active electrode into the skin → tissue destruction
361
Electrofulgeration
Holding the electrode a short distance from the skin → in “sparking” and a more shallow level of tissue destruction than directly touching the lesion with the tip
362
Epilation
Inserting a fine-wire electrode into a hair follicle destroys the follicle
363
Electrocoagulation
Stops bleeding in deep and superficial surgery
364
Electrosection
The electrode is used to cut tissue
365
thermal cautery pen
- Disposable – battery powered (1300 and 2200 degree F units) - Low cost – $15-20 - Individual sterile packaging - Safe around eyes - Safe with pacemakers - Drain subungual hematomas! - Control bleeding; “cut” off lesions
366
Hyfrecator unit
- Performs both electrofulguration and electrodessication - Available accessories: - blunt/sharp disposable/reusable tips - epilator needle
367
Radiosurgery
- Surgitron radio-frequency unit by Ellman - Available accessories: - non-disposable and disposable loop & ball electrodes - epilator needle tip)
368
Pros of electrosurgery
Simple to master Rapid technique Controls bleeding while cutting/destroying tissue Compact equipment Affordable – available “used” Sterile conditions and sutures are not needed. Infection rarely develops in wounds left open.
369
cons of electrosurgery
Safety risk (electric shocks, burns, or fires) – e.g. may ignite alcohol on the skin Risk of hypertrophic scars Risk of “channeling” of current down vessels and nerves Risk of smoke plume carrying viruses (e.g. from wart) into respiratory tract. Delayed hemorrhage while healing Unsightly wound (initially) Slow healing vs. scalpel shave excisions = essentially is a “burn” Biopsies - Hyfrecator (not radiosurgery): Produces electrosurgical artifact at margins → obliteration of histology Do shave biopsy first if needed
370
Cryotherapy over Electrosurgery
Often the treatment of choice for actinic keratosis and simple warts Faster and easier to perform Needs no anesthesia Tends to cause less scarring than electrosurgery No smoke plume: - No need for a smoke evacuator - No risk of developing HPV, HIV or other viral respiratory tract infections
371
Electrosurgery over Cryotherapy
More likely to cause hypopigmentation due to the cold killing melanocytes – varies with degree of skin pigmentation Less effective than electrosurgery for large pedunculated lesions, e.g. condylomata. Final result not immediately visible: - More guesswork in treating the lesion for the inexperienced physician - May need to be repeated several times Causes more postoperative swelling Does cause transient discomfort
372
Scalpel over Electrosurgery
Best for shave biopsies and excisions Inexpensive vs. electrosurgery and radiosurgery devices Disposable “Cleaner” edge on the biopsy specimen No heat-induced tissue damage to obscure borders of the biopsy specimen
373
Electrosurgery over Scalpel
Does not control bleeding by itself Small risk of accidentally cutting yourself
374
Electrosurgery over Lasers
less expensive easier to use
375
Laser over Electrosurgery
Very good for treating large hemangiomas Ideal for treating port-wine stains Efficiently cut, coagulate and destroy lesions Good for “resurfacing” (removing wrinkles Less scarring when treating angiomas and telangiectasias better cosmetic results
376
electrosurgery CI
pacemakers metal plates, pins, or prosthetic joints suspected melanoma or BCC- need to biopsy don't use around nose, eye, body folds
377
Cautions electrosurgery
alcohol fire and burns bowel gas use three pronged plug Do not make or break contact with the patient with your free hand while the electrode is activated no metal
378
Reduce problems with elctrogsurgery
Always wear gloves. Use disposable electrodes (OR remove the charred tissue from the electrode after use and sterilize properly). Use disposable safety needles with Luer Lok syringes. Use smoke evacuator – hold intake nozzle 2 cm from the operative site Surgeon and treatment team should wear eye protection (and ideally, surgical masks) Consider using a different treatment modality – weigh risk vs. benefits
379
Radiosurgery
Uses a high frequency AM radio spectrum current Uses an antenna as the “indifferent” electrode applied to the skin on opposite side of the body part Three to four times the initial cost of the hyfrecator More efficient cutting than the hyfrecator with less tissue damage (due to less “lateral heat”*). The unit has 4 different waveforms - Fully filtered and rectified current - for cutting. - Fully rectified current - for simultaneous cutting/coagulation. - Partially rectified current - for coagulation - Fulgurating current - for destruction of large lesions, similar to the Hyfrecator
380
Radiosurgery uses
Hemangiomas Xanthelasma Spider Veins Dermatofibromas Congenital Compound Melanocystic Nevi Resistant Deep Verruca Sebaceous Hyperplasia Thick Seborrheic Keratosis Porokeratosis
381
How radiosurgery works?
The intercellular water molecules in the cells are vaporized. The affected cells explode with little or no damage to the adjacent cells, there is only a 10-20 µ of heat spread. As it cuts, it coagulates saving operation time.
382
Radiosurgery benefits
hemorrhage Control reduced post-operative discomfort minimal scar tissue formation readability of histological specimen enhanced healing good cosmetic results
383
Medications to stop before surgery
- aspirin - Alka-Seltzer - ibuprofen - clopidogrel - warfarin - fish oil - gingko biloba - garlic - ginseng - ginger - feverfew - Vit E - Saw palmetto
384
Ecchymoses
blood leaks into the skin and often into the subcutaneous fat swollen bluish black discoloration of the skin in and around or dependent to the wound or hematoma develop during surgery or at the time of trauma or over hours to days later
385
Ecchymoses treatment/prevention
- Carefully surgery and repair - Don't use too much local anesthesia - Apply proper pressure bandaging f - ice packs for 2-3 days - Spontaneously resolve
386
Hematomas
localized collection of blood outside of the blood vessels, typically in dead space deep purple, grape jelly-like nodule
387
hematomas cause
- post-op sustained capillary bed leakage - or venous/arterial bleeding from the raw surface of a surgical site or within a traumatic lesion
388
hematomas timing
- develop hours to days after surgery or trauma - typically resolve naturally in days to weeks
389
Hematomas prevention
- Assess each patient’s general health status and history of coagulopathies - Identify any history of significant bleeding during prior low-risk surgical or dental procedures. - Identify common medical problems that may affect healing – renal dysfunction, hypertension, liver disease, and abnormal coagulation - Screen for alcohol abuse – impairs coagulation of platelets and decreases vasoconstriction - Identify all daily and prn medications and the last date taken.
390
Hematomas management
Intraoperative steps - use figure-of-8 sutures or suture ligation - quilting sutures (interrupted deep stitches) Post-op management - Pressure bandaging – for 24 hours post-op/repair hold in place 2 twice-folded 4x4s with a pressure bandage of hypo-allergenic paper tape or elastic wrap such as Coban. - Apply ice packs over the dressing for 20 minutes every hour for six hours Patient instruction - Examine wound frequently - Monitor for a warm, expanding, painful mass: possible collection of blood and/or tissue fluid &/or sign of an infection. - If such a swelling appears apply an ice pack and pressure to the area continuously for 20 minutes. - Re-examine in 30-60 minutes and re-apply if needed. - If problem lasts more than 12 hours call or return to clinic – follow up visits are FREE - The physician will examine the wound site to determine if there is a collection of blood or tissue fluid that needs to be removed/drained.
391
Hematomas treatment
- Partially or completely re-open the surgical wound - Identify any oozing vessels - Stop bleeding by suture ligation or electrosurgery - Insert a drain/suction if indicated - Do a full-layer re-closure - If there is a high risk of more bleeding or the wound is contaminated the best choice may be to let the wound heal by secondary intention! - Aspirate with sterile procedure – use large needle directly through the wound - Repeat every 1–2 days until hematoma stops forming - Continue using pressure bandaging - Get C & S of aspirate - Begin empiric antibiotic treatment and adjust based on C & S reports
392
Seromas
a mass caused by accumulation of serous fluid within tissue or an organ as a complication of surgery or after other traumatic injuries to soft tissues, low infection risk,
393
Seroma formation
- small blood vessels rupture → blood plasma seeps out - trauma causes tissue fluid leakage that does not fully subside - inflammation caused by dying injured cells - particularly common after major surgeries – breast, abdominal and reconstructive surgeries
394
Seromas prevention
- Careful tissue handling to reduce trauma - Thorough wound irrigation and debridement - Quilting (interrupted deep stitches) in a large wound to reduce dead space → reduced seroma formation. - Pressure bandaging to reduce fluid collection
395
Seromas management
- Most resolve spontaneously within days to weeks. - Avoid blood-thinning analgesics! - Consider homeopathic Bryonia, Silica and Sepia to reduce pain/itching and speed healing. - Rest/elevate affected part. - Intermittent ice packs - In a few days use alternating hot/cold to help speed resorption. - If persists consider fine-needle aspiration
396
Does prophylaxis with antibiotics for routine or elective MS generally lower the risk of infection?
no
397
Prophylactic antibiotics are indicated in patients with traumatic wounds in what three situations?
- prosthetic cardiac valve - history of infectious endocardiits - congenital heart disease
398
What are the arguments against using antibiotics in traumatic wounds?
- Limited indications for the routine use of antibiotics in lacerations. - A single reliable study showing an advantage to prophylactic oral penicillin for intraoral wounds. - Clean, properly debrided early traumatic wounds in patients that are not immune compromised do not require prophylactic antibiotics.
399
Seroma treatment
fine needle aspiration -Consider aspiration only for excessive amounts of fluid collection because even an aspiration carried out under aseptic conditions carries a certain risk of infection!
400
Wound dehiscence cause
- Too much tension on newly sutured tissue – damages the tissue, and interferes with circulation and healing - Too little tension – wound edges too loosely apposed to allow proper healing - Inappropriate suture material (wrong size or material) → breakage and/or a tissue reaction. - Poor tissue quality (poor nutritional status, chronic disease, chemotherapy, etc.) → tissue failure and poor healing.
401
Wound dehiscence tx
- leave it alone - re-closure - retention sutures
402
Nerve and Vascular Damage prevention
always use a blunt undermining tools always assess sensation and vascular integrity in traumatic wounds - two-point discrimination - capillary refill
403
tendon and bone damage
test active and passive ROMs If there is anything more than a simple laceration and if you suspect a lacerated tendon and/or fracture, apply an appropriate splint and immediately refer to a hand specialist or orthopedist!
404
Hyper/Hypopigmentation
caused by hyfrecation, radiosurgery, lift and snips, shaves, or cryotherapy 1-6 month will be pink then gradually go back to facial color Treatment: hydroquinone
405
Hypertrophic scarring
enlargement of the scar within the boundary of the original scar
406
Keloid scaring
enlargement of the scar beyond the original scar boundary
407
Hypertrophic and Keloid scarring cause
genetics body site (esp. upper chest, back, shoulders) quality of the surgery skin tension (worse with more tension) skin types the patient’s health status at the time
408
Informed consent implies that the patient completely understands what issues?
make them aware of risks The nature of the treatment All material risks for the treatment The possibility of risk(s) Alternative treatment(s) available and associated risks of those treatments Consequences of going untreated
409
Know the meaning of PARQ and how to use it for “informed consent”.
Procedure Alternatives Risks Questions
410
Know what/what not to include in the Procedure Note portion of the MS Report.
history vitals description of lesion what procedure anesthetic used and lot Describe the skin prep used, record the amounts of anesthesia and bicarbonate mixed & used. Describe the suture type(s) , size(s), location, and number. List the duration of the procedure and the amount of blood lost.
411
Understand the concept of “free margin” on a Pathology report.
means the edges around the biopsied portion are clear of pathology?
412
Vertical mattress advantages
better than other stitches helps to close a large area of dead space in a wound strong stich use as a stay suture
413
Horizontal mattress uses
wound under tension fill up dead space
414
run and run locking stich
convenient good approximation of wound edges good eversion proper tension faster valuable on eyelids and neck and other aras where loose skin is found watertight seal gathering loose skin
415
Vertical mattress suture disadvantage
proper placement is time consuming can cause railroad tracking
416
acne vulgaris pop
12-25
417
acne vulgaris pathophysiology
Outlet narrows due to proliferation and accumulation of keratinocytes and skin edema Sebum (composed of lipids and cell fragments) builds up in blocked follicle Cutibacterium acnes (formerly Propionibacterium acnes) lives off sebum and proliferates in comedone Inflammation of comedone results from leakage of sebum into the dermis and secretion of proinflammatory mediators, chemokines, and degradative enzymes by C. acnes
418
acne sx
papules or pustules or nodules or cysts red and central core face, trunk, arms, back, upper chest, shoulders
419
acne tx standard of car based on severity
420
acne tx ND
Diet: 100% grass fed pastured or wild meats, fish and eggs, vegetables, fruit, nuts, seeds, and tubers Eliminate/reduce processed foods, diary, grain fed meat, chocolate, sunflower seeds, salt Anti-inflammatory/elimination diet Detox: fasting, sauna, chelation Botanical (Topicals): azelaic acid, green tea, tea tree oil, Calendula succus Botanical (Internal): Berberine (barbarry, coptis, oregon grape, goldenseal), Chasteberry, Indian Gooseberry Physical medicine: sun (start with 5 minutes a day), hot/cold contrast bath with green tea, calendula Supplements to consider zinc/copper, chromium, selenium, omega 3 fatty acids, vitamin D
421
alteratives
An herb that alters the body in a non-specific but broadly beneficial way Nourishing, restorative tonics with effects focused on digestion, absorption, and elimination
422
alteratives herbs
arctium lappa curcma longa mahonia spp rumex spp smilax spp taraxacum officinale trifolium pratense urtica dioica
423
Mahonia part used
Root bark and stem bark
424
mahonia action
Alterative, digestive bitter, anticatarrhal, antimicrobial, cholagogue, mild laxative.
425
mahonia indications
**Skin conditions**: Psoriasis, eczema, herpes, pityriasis, acne, syphilis. **Poor gallbladder function**: Nausea, fat malabsorption, digestive upset **Infections**: Skin, eye, and intestinal tract (bacterial, fungal and protozoal)
426
mahonia CI
pregnancy
427
rumex part used
Root (primarily) also the seed and leaf
428
rumex actions
**Root:** alterative, mild digestive bitter, antitumor, antimutagenic, nutritive, antirheumatic, phytoestrogenic, liver tonic **Leaves:** used topically as a antimicrobial, anti-inflammatory poultice **Seeds:** alterative, diuretic, urinary tonic, vulnerary Cholagogue
429
rumex indications
**Root:** dry and scaly skin conditions – psoriasis, eczema, dandruff, rheumatic/arthritic conditions, anorexia nervosa, cystitis, wounds and ulcers (poultice). **Leaves:** mastitis, joint sprains (poultice), alleviate nettle stings **Seeds:** cystitis, skin conditions including exanthems Chronic skin conditions - psoriasis, eczema, acne Lax bowels, constipation – regulates the GI (Bitter! Enhance digestion, pro motility, tonifying/astringent) Liver congestion
430
rumex CI
Oxalate kidney stones, kidney disease, iron overload, pregnancy
431
trifolum part used
blossom
432
trifolium actions
Alterative, Nutritive, high in phytoestrogens, lymphagogue, Antitussive, Antispasmodic, Vulnerary
433
trifolum indications
menopausal climacteric symptoms, vaginal dryness, chronic skin conditions, Breast cancer estrogen positive Lots of heat Cancer, gout, arthritis, acne, spasmodic cough, cachexia, burns with poor healing, ulcers of the skin or mucous membranes, TB or inflammation of the lungs
434
trifolium CI
Caution with blood thinning medications and oral contraceptives
435
anti-inflammatory/antioxidant herbs
berberis vulgaris camelia sinensis silybum marianum
436
berberis part used
Berries, Rhizome and Root
437
berberis actions
Berries – antioxidant, modulates inflammation. Rhizome and root – also modulate inflammation, effects glucose metabolism, antimicrobial
438
berberis indications
Berries – effective in the treatment of acne as well as other inflammatory conditions. Rhizome and root – source of berberine and uses relate to that constituent.
439
camelia part used
leaf
440
camelia actions
Antioxidant, inhibit tumor cell proliferation and induce apoptosis, pro-oxidant, promotes weight loss, decreases LDL, modulates inflammation, decreases sebum production, antimicrobial resistance
441
camelia MOA
inhibition of MAP kinase signaling, inhibition of growth factor signaling, inhibition of matrix metalloproteinases, inhibit angiogenesis, decrease invasiveness of cancer cells, augments hormonal therapies, decreases free testosterone, increases SHBG, decreases insulin resistance and improves other glucose-related markers
442
camelia indications
Cancer, PCOS (particularly in overweight individuals), androgenic alopecia, anti-aging - Used topically in the treatment of acne vulgaris and rosacea - UV protection and decreased photocarcinogenesis - Decrease age-related damage/changes - Used topically for Condyloma accuminata - Atopic dermatitis – baths decreased pruritis and area of lesions. - Decrease hypertrophic scar formation - vulnerary action in wound healing - Topical antimicrobial
443
camelia CI
Take away from iron supplementation green tea block the activity of boronic acid proteasome inhibitors
444
silybum part
seed
445
silybum actions
hepatoprotective, hepatotonic, antihepatotoxic (particularly against *aminita phalloides), nephroprotective, bitter, galactagogue,* antifibrotic effect, Increase glutathione
446
silybum indications
Liver diseases, jaundice, hepatitis, cirrhosis, alcoholism, fatty liver degeneration, hepatitis, cirrhosis, alcoholism with fatty liver, diabetic nephropathy Acne
447
silybum CI
asteraceae family allergy
448
astringents herbs
arctostaphylos uva-ursi black tea
449
arctostaphylos part
leaves
450
arctostaphylos actions
Antimicrobial, astringent, tonify
451
arctostaphylos indications
UTIs Relaxed urinary tract (tissue laxity), with pain and bloody or mucous secretions; weight and dragging in the loins and perineum not due to prostatic enlargement; chronic irritation of the bladder, with pain, tenesmus, and catarrhal discharge. Oozing tissues
452
arctostaphylos CI
Pregnancy Not recommended for long term use (due to high tannins) anti-nutrient Toxicity is proportional to the conversion of arbutin to hydroquinone as hydroquinone is potentially toxic and mutagenic Caution when combining with herbs high in alkaloids as the tannin may precipitate out of solution. The precipitate is active, but it settles to the bottom of the bottle – shake well!
453
immunostimulants
agents that increase the activity of immune system, used to fortify the body’s response to invasion by a pathogen MOA: increased phagocytosis, increased production of WBC, and modulation of various cytokines
454
immunostimulants herbs
allium sativum baptisia tinctora echinacea eupatorium perfoliatum sambucus nigra scutellaria bicalensis spilanthes acmlla usnea barbata
455
immunomodulators
agents that have a tonifying effect on immune system
456
eleuthrococcus part used
Root (most researched), stem bark and leaf
457
eleuthrococcus actions
Adaptogen, immunomodulating, mild CNS stimulant Nonspecific ant stress effects Ergogenic Anabolic/anticatabolic Antitoxic Radioprotective Chemoprotective Immunoprotected Immunoregulatory Antiviral Gonadotrophic Insulin-trophic/antidiabetic Neuroprotective
458
eleuthrococcus indications
Build vitality, increase resistance to infection, stress, and toxicity, improve physical performance, and improve mood
459
eleuthrococcus CI
Adulteration is common in the marketplace. Monitor blood glucose in diabetics and hypoglycemics when introducing this herb.
460
ganoderma part
fruiting body
461
ganoderma action
Anti-allergic action of triterpenes, anti-hypertensive, oleic acid inhibits histamine release, hypotensive, decreases platelet aggregation/LDL/arrhythmia/insomnia/angina, protects against ionizing radiation
462
ganoderma indications
Used in cancer treatment to increase immune function and help treat fatigue, hypertension, immune deficiency, insomnia, hepatitis
463
ganoderma CI
Potential allergy to spores
Dermatology
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