Charlotte Jane Sumner, M.D.

• Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0015714/charlotte-sumner

No longer commonly used for this indication; may require a longer duration of treatment erectile dysfunction injection device order cheap viagra line. Clinical manifestations include burning impotence at 19 order viagra now, stinging impotence at 80 cheap viagra 100mg free shipping, pruritus erectile dysfunction medications cost buy viagra in india, erythema impotence for erectile dysfunction causes buy 100 mg viagra otc, edema erectile dysfunction mental generic viagra 25 mg with amex, peeling, blistering, and allergic contact dermatitis. Oral terbinafine may cause a morbilliform eruption and, less commonly, urticaria, pruritus, alopecia, or dermatitis. Non-cutaneous side effects of terbinafine include gastrointestinal disturbances, elevated liver enzymes, headaches, taste and visual disturbances, transient decreases in absolute lymphocyte count, and, rarely, neutropenia in immunosuppressed patients. It is recommended that liver enzyme tests be performed at baseline and, for courses lasting >6 weeks or in patients at risk for hepatic disease, during treatment. Griseofulvin has been used for over 50 years with infrequent adverse effects, most commonly headache and gastrointestinal disturbances. Less often, it leads to cutaneous side effects such as fixed drug eruptions, photosensitivity, petechiae, pruritus, exfoliative dermatitis, urticaria/angioedema, and serum sickness-like reactions. Griseofulvin has occasionally been associated with enuresis, proteinuria, increased urinary frequency, arthralgias, fever, neurologic side effects. Caspofungin acetate may cause headaches, nausea, vomiting, fever, infusion reactions, phlebitis, flushing, facial swelling, urticaria, other rashes, and pruritus. Laboratory abnormalities that have been observed include increased alkaline phosphatase, hypokalemia, eosinophilia, proteinuria, and hematuria. Micafungin may uncommonly cause anaphylaxis, liver or kidney dysfunction, thrombophlebitis, and hemolytic anemia. Anidulafungin may cause liver toxicity, diarrhea, hypokalemia, and infusion reactions. Terbinafine increases cyclosporine clearance by 15% and decreases caffeine clearance by 19%. Whereas cimetidine increases terbinafine levels, rifampin decreases terbinafine levels by doubling its rate of clearance. Azole antifungal drugs exert their therapeutic effect by inhibiting cytochrome P450 enzymes (see above). Cytochrome P450 enzymes play a major role in transforming lipophilic drugs to more easily excreted metabolites72. Griseofulvin potentiates the effect of alcohol or may induce a disulfiram-like reaction72. It also increases estrogenmetabolizing liver enzymes, which may make oral contraceptives less effective or cause menstrual irregularities. Systemic corticosteroids, loop diuretics, and thiazide diuretics increase the risk of developing hypokalemia due to amphotericin B. Nephrotoxic drugs such as cisplatin, flucytosine, gentamicin, and vancomycin can compound the Interactions hypertension, tachycardia, dyspnea, headache and skin eruptions, including exanthems, exfoliative dermatitis, fixed drug eruptions, flushing, urticaria, and infusion site reactions. Flucytosine can cause a number of neurologic side effects, including headaches, fatigue, vertigo, ataxia, paresthesias, confusion, and hallucinations. Serious potential side effects include cardiac and respiratory arrest, renal failure, aplastic anemia, agranulocytosis, thrombocytopenia, gastrointestinal bleeding, and colitis. K, ketoconazole; I, itraconazole; F, fluconazole; V, voriconazole, P, posaconazole. Cisplatin used in conjunction with flucytosine increases the risk for nephrotoxicity and bone marrow suppression. It does decrease tacrolimus levels, and cyclosporine increases caspofungin levels. Phenytoin, rifampin, dexamethasone, carbamazepine, and several antiretroviral drugs (efavirenz, nelfinavir, nevirapine) can decrease caspofungin levels. Topical imidazoles, nystatin, ciclopirox olamine, tolnaftate, and undecylenic acid have not been shown to cause adverse fetal effects when used during pregnancy; their pregnancy categories are listed in Table 127. Although a small amount of ciclopirox olamine is absorbed through the skin, animal studies involving mice, rats, rabbits and monkeys showed no harm to the fetus at doses 10 times higher than the topical human dose. In general, topical antifungals are thought to be compatible with breastfeeding11,12. Topical oxiconazole is excreted in breast milk, but it is not known whether other topical imidazoles, nystatin, and ciclopirox olamine pass into breast milk. These drugs should not be used to treat onychomycosis if the patient is pregnant or contemplating pregnancy. During pregnancy, they should be reserved for severe fungal infections and used only if the benefit outweighs the risk. Although animal studies of oral terbinafine have shown no adverse effects during pregnancy, there are no adequate studies in pregnant women. Orally administered Pregnancy and lactation terbinafine is secreted in breast milk and is not recommended for use in nursing mothers. There are no adequate human studies of the effects of azole antifungals during pregnancy or nursing. The risk of fetal abnormalities is increased with exposure to fluconazole, ketoconazole, itraconazole, and voriconazole in the first trimester11; although a single 150 mg dose of fluconazole has not been associated with fetal malformations, recent data suggest that it may increase the risk of miscarriage. Itraconazole is excreted in human milk and should be avoided in lactating patients. Fluconazole is excreted in breast milk, but the level of exposure is substantially lower than doses given safely to neonates11,12. Rare cases of conjoined twins have been reported in women taking griseofulvin in the first trimester of pregnancy. Patients should avoid pregnancy for at least 1 month after discontinuing griseofulvin78. It is almost completely converted to acyclovir by valacyclovir hydrolase while passing through the gastrointestinal tract and liver. Penciclovir is an acyclic guanosine analogue with a mechanism of action similar to acyclovir. It reaches higher intracellular concentrations and has a longer intracellular half-life than acyclovir (2. Like valacyclovir, it is converted to its active form in the gastrointestinal tract and liver80. Topical acyclovir 5% ointment is indicated for the initial episode of genital herpes. In some studies, it has also been shown to be effective in recurrent genital herpes84. Acyclovir 5% cream and an acyclovir 5% plus hydrocortisone 1% combination cream are indicated for recurrent orolabial herpes in immunocompetent individuals ages 12 years and 6 years, respectively; mean healing times are shortened by approximately 0. Although acyclovir ointment is also indicated for limited, non-life-threatening mucocutaneous herpes simplex infections in immunocompromised individuals, these patients often require systemic therapy. Penciclovir, 1% cream is indicated for treatment of recurrent orolabial herpes simplex infections in immunocompetent patients 12 years of age. Oral acyclovir and valacyclovir are indicated for initial and recurrent episodes of genital herpes, herpes simplex suppression, varicella (acyclovir for both children and adults, valacyclovir for children), and herpes zoster; valacyclovir and a single-dose acyclovir mucoadhesive buccal tablet are also indicated for recurrent orolabial herpes. Off-label uses of acyclovir and valacyclovir include prevention of recurrent herpes-associated erythema multiforme and treatment of eczema herpeticum, primary herpes gingivostomatitis, and herpetic whitlow. Acyclovir, valacyclovir, and famciclovir are considered equivalent in safety and efficacy (time to healing, duration of pain, and viral shedding) for initial episodes of genital herpes86. Famciclovir and valacyclovir have the advantage of greater oral bioavailability and more convenient dosing. Valacyclovir is at least as effective as acyclovir in decreasing the duration of pain in herpes zoster87,88. Antiviral therapy (topical or systemic) should be started as soon as possible after the onset of signs and symptoms. A glove or applicator should be used to apply topical antivirals to prevent autoinoculation of the finger. Intravenous, rather than oral, treatment may be required in severely immunosuppressed patients, patients who cannot take medications orally, and those who cannot be relied upon to take the medication correctly89. The physician must decide whether to treat on an episodic basis or in a continuous suppressive fashion. A year-long, double-blind, placebocontrolled study demonstrated that 1 g of valacyclovir taken daily reduced recurrence rates by 78%93. Treatment of varicella in healthy children is controversial, but it does not alter antibody production at 28 days or at 1 year95. Oral therapy is recommended for healthy adolescents and adults as well as children with chronic skin or lung disease or on long-term salicylates; intravenous administration is indicated for immunocompromised individuals, including those receiving chronic systemic corticosteroid therapy96. Cidofovir is an acyclic nucleoside phosphate analogue of deoxycytosine monophosphate that does not require viral thymidine kinase to become activated, but otherwise also has a similar mechanism. As with other medications, antiviral agents are contraindicated in patients with hypersensitivity to the drug or any components of the formulation. Systemic antivirals need to be dose-adjusted for patients with impaired renal function (see Table 80. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome have been reported in immunocompromised patients receiving valacyclovir. Interactions No clinically important drug interactions with topical antivirals have been identified. Pregnancy and lactation 2238 There are no adequate studies of topical antiviral agents in pregnant or lactating women. Small amounts of topical acyclovir are absorbed through the skin and mucous membranes. Topical docosanol has not been shown to cause birth defects or other problems in animal studies using rats or rabbits. Although it is not known if topically applied antivirals pass into breast milk, to date, no problems in nursing infants due to these agents have been reported. However, it has not been shown to be teratogenic in animal studies, and a prospective registry of 756 pregnant patients who took acyclovir showed an incidence of birth defects similar to that in the general population. There is an ongoing registry maintained by the manufacturer to monitor pregnant patients exposed to famciclovir19. Acyclovir is traditionally the drug of choice for primary genital herpes in pregnant women because of its long history of safe use. Recurrent herpes simplex during pregnancy is not usually an indication for acyclovir. Varicella in pregnant women should be treated with acyclovir due to the high risk of maternal mortality from varicella pneumonia as well as fetal death or premature delivery97. It is not known, however, whether acyclovir prevents congenital varicella syndrome. Acyclovir is excreted in breast milk; acyclovir and valacyclovir are considered to be compatible with breastfeeding, and they are preferred over famciclovir during lactation12. Foscarnet and cidofovir are two alternative treatments in this situation (see Table 127. Foscarnet does not require phosphorylation to be activated, and thus it circumvents the commonest mode of viral resistance involving viral thymidine kinase. Side effects of the intravenous form include nephrotoxicity, anemia, erosive penile lesions, thrombophlebitis, seizures, gastrointestinal disturbances, and changes in serum calcium, magnesium and phosphate levels98,99. Cidofovir is an acyclic nucleoside phosphate analogue of deoxycytosine monophosphate. It differs from acyclovir and penciclovir in that it does not require viral thymidine kinase to become activated99. Cidofovir is currently available in intravenous form only, and side effects include nephrotoxicity, iritis, neutropenia, metabolic acidosis, and gastrointestinal disturbances. However, a compounded topical form has been used with some success for herpes simplex resistant to acyclovir, molluscum contagiosum, condyloma acuminata, verruca vulgaris, and viral-associated trichodysplasia spinulosa100,101. In a Japanese study, 7-day courses of amenamevir and valacyclovir had similar efficacy and safety for the treatment of herpes zoster in immunocompetent patients105b. The effects of acne treatment with a combination of benzoyl peroxide and erythromycin on skin carriage of erythromycinresistant propionibacteria. Effects of benzoyl peroxide and erythromycin alone and in combination against antibiotic-sensitive and -resistant skin bacteria from acne patients. Antibiotic resistance patterns in coagulase-negative staphylococci after treatment with topical erythromycin, benzoyl peroxide, and combination therapy. A double-blind study of the effectiveness of a 3% erythromycin and 5% benzoyl peroxide combination in the treatment of acne vulgaris. Treatment of acne with a combination clindamycin/ benzoyl peroxide gel compared with clindamycin gel, benzoyl peroxide gel and vehicle gel: combined results of two double-blind investigations. Nasal carriage of Staphylococcus aureus in patients undergoing Mohs micrographic surgery is an important risk factor for postoperative surgical site infection: a prospective randomised study. Cost-effectiveness of erythromycin versus mupirocin for the treatment of impetigo in children. Topical retapamulin ointment, 1%, versus sodium fusidate ointment, 2%, for impetigo: a randomized, observerblinded, noninferiority study. Efficacy and acceptability of fusidic acid cream and mupirocin ointment in facial impetigo. A comparison of sodium fusidate ointment and mupirocin ointment in superficial skin sepsis. Association or lack of association between tetracycline class antibiotics used for acne vulgaris and lupus erythematosus. Antimicrobial agents implicated in Clostridium difficile toxin-associated diarrhea or colitis.

This nodal group drains the gingival and mucous membranes erectile dysfunction drug overdose buy viagra mastercard, lower eyelids erectile dysfunction statistics buy viagra 100mg mastercard, anterior two-thirds of the tongue xylitol erectile dysfunction buy discount viagra 50 mg, lips erectile dysfunction and diabetes treatment buy cheap viagra 75mg, nose impotence urology order viagra 25 mg, and medial cheeks impotence supplements purchase viagra now. The submental nodes (up to eight) of the neck lie beneath the platysma and drain the anterior third of the tongue and floor of the mouth, in addition to the lower middle lip, chin, and medial lower cheeks. They are best examined by elevating the chin and asking the patient to engage the platysma. Submental nodes frequently drain bilaterally or contralaterally and empty into the submandibular basin or directly into the internal jugular lymphatic chain. Note that up to one-quarter of healthy individuals have small (less than 1 cm), non-fixed, palpable submental nodes4. The superficial lateral cervical nodes are adjacent to the infraauricular parotid nodes and lie near the high external jugular vein. Use the sternocleidomastoid muscle as a landmark to palpate these nodes (up to four) over its cephalad portion. Deeper lateral cervical nodes include the spinal accessory, internal jugular and transverse cervical chains, which form a triangle on the neck. The internal jugular chain is the main lymphatic collection trunk of the head and neck and may contain up to 25 lymph nodes in each patient. The internal jugular chain on the right often drains into the subclavian vein, whereas the left-sided lymphatic chain empties into the thoracic duct. These nodes can be palpated by rolling two fingers over the area of the carotid triangle. Acute or chronic lymphedema may ensue after transection of larger lymphatic channels or nodes, or even after disruption of smaller channels in areas. Adequate drainage can be achieved by orienting flaps in the same direction as lymphatic patterns. The surgeon must be mindful of the variability in drainage patterns and sites and the fact that malignancies do not respect the midline. Since cross-communication between lymphatics may result in contralateral drainage, bilateral examination for lymphadenopathy should be undertaken before a neoplasm is excised. Hruza Local anesthetics are weak organic bases, which, to be water-soluble and injectable, require the addition of a hydrochloride salt. In aqueous solution, the salt equilibrates between the ionized and non-ionized form. The ionized form is water-soluble, allowing injection into and diffusion through tissue. However, it is the non-ionized, lipid-soluble base that can diffuse into the nerve cell membrane. The dissociation constant (pKa) of each anesthetic determines the proportion of the anesthetic base and its cation at a given pH. Alkalinization of the anesthetic solution, as is done with the addition of sodium bicarbonate, will speed its onset of action as more of the anesthetic will be in the non-ionized form. However, if the pH is raised too much, the anesthetic may precipitate out of solution. Anesthetic sensitivity to pH also helps explain why infected tissue is difficult to effectively anesthetize3. The inflammatory response surrounding the infection acidifies the site (reduces the pH), which reduces the proportion of the anesthetic in the non-ionized, lipid-soluble form. Local anesthetics have been in use since the 1880s with the introduction of cocaine hydrochloride, which was extracted from the leaves of the South American bush Erythroxylon coca1. This was followed by procaine in 1904, tetracaine in 1930, and the first amide local anesthetic, lidocaine, was introduced in 19431. The introduction of lidocaine was a major breakthrough because lidocaine is far less likely to cause an allergic reaction than the ester-type anesthetics that preceded it. Local anesthesia has several advantages over general anesthesia, including reduced morbidity (especially in poor-risk patients), reduced cost, reduced procedure time, and faster recovery. The main disadvantages are some limitation on the extent of a procedure and the possibility of greater patient discomfort from the injections. Knowledge of the physiology, dosage, side effects, and proper "painless" local anesthesia technique are essential for performing dermatologic surgery and to keep patients safe and satisfied. Pharmacology Local anesthetics are classified into two groups, depending on the linkage in the intermediate chain (Table 143. Ester anesthetics are hydrolyzed by plasma pseudocholinesterase, and the metabolites are excreted by the kidneys. Patients with a deficiency of functional pseudocholinesterase, who are often diagnosed after prolonged paralysis following administration of standard doses of succinylcholine, are at an increased risk of ester anesthetic toxicity. Amide anesthetics are metabolized by the hepatic microsomal cytochrome P450 enzyme system, and the metabolites are excreted by the kidneys. Patients with severe liver disease may be at increased risk of amide anesthetic toxicity. A low pKa leads to rapid onset of anesthesia, as more of the anesthetic will be in the non-ionized form. Greater lipid solubility is associated with higher anesthetic potency, as the compound penetrates the nerve cell membrane more easily. Duration of action is determined by the strength of anesthetic binding to the sodium channel pore. It is classified as pregnancy category B, which means that, in animal studies, no teratogenic effects have been documented. Studies in pregnant women who received lidocaine during the first trimester of pregnancy have shown no increase in anatomic abnormalities in the newborns. However, it is recommended that lidocaine, as with all other pharmacologic agents, be used cautiously during the first 4 months of pregnancy, when maximum organogenesis takes place. The nerve cell is not depolarized and consequently the action potential is blocked. The cationic form of the anesthetic appears to bind to the inner pore of voltage-gated sodium channels, possibly leading to both narrowing of the pore lumen (steric block) and creation of an electrostatic barrier to permeation2. Smaller unmyelinated C-type nerve fibers that conduct pain sensation are blocked more quickly and easily than intermediate fibers that also carry sensations of heat and cold. The myelinated A-type fibers that carry pressure sensation and motor fibers are blocked last. This is essential to allow the anesthetic to diffuse through nerve cell membranes. In dermatology, lidocaine, an amide, is by far the most commonly employed local anesthetic. Vasovagal reactions are the most common side effect of injections of local anesthesia. Epinephrine is added to the local anesthetic because as a vasoconstrictor, it lengthens the duration of anesthesia and reduces intraoperative bleeding. Nerve blocks are very effective for anesthesia of the central face, digits, and palmoplantar surfaces. Tumescent anesthesia achieves an almost bloodless field and can be used to safely anesthetize large areas, especially for liposuction. For anxious patients or for long procedures, oral anxiolytics and narcotics can improve patient tolerance for the procedure. Additions to Local Anesthetics Epinephrine All local anesthetics, except for cocaine hydrochloride, relax vascular smooth muscle, which results in vasodilation. This causes increased bleeding at the operative site and reduced duration of anesthetic action as the anesthetic is rapidly removed from the surgical site via the dilated blood vessels. The addition of epinephrine (adrenaline) has the beneficial effect of constricting blood vessels, which prolongs the duration of anesthesia 100% to 200% by slowing removal of the anesthetic from the surgical site. The addition of epinephrine provides more effective anesthesia by decreasing the volume of anesthetic needed. The reduced absorption rate decreases anesthetic toxicity and allows larger doses to be used safely. While they usually coincide, blanching does not always denote the anesthetized area. Epinephrine is premixed with local anesthetics at a concentration of 1: 100 000 or 1: 200 000. However, concentrations as low as 1: 1 000 000 achieve effective vasoconstriction, while concentrations >1: 100 000 are associated with a greater risk of side effects. Patients who have relative contraindications to epinephrine should receive lower concentrations, while highly vascular areas such as the scalp should receive higher concentrations. The maximum dosage used at a concentration of 1: 100 000 is determined by the anesthetic with which the epinephrine is premixed (Table 143. Epinephrine is a strong - and -agonist and, as such, it must be used cautiously in patients with altered - and -receptors. Absolute contraindications to the use of epinephrine include hyperthyroidism and pheochromocytoma. Patients taking -blockers, monoamine oxidase inhibitors, tricyclic antidepressants, and phenothiazines are more sensitive to epinephrine. Therefore, epinephrine should be used with caution, with the dose and concentration reduced accordingly. In patients taking -blockers, severe hypertension developing after injection of epinephrine-containing anesthetics has been reported5. This is probably due to unopposed -adrenergic activity with its associated vasoconstriction. Fortunately, this reaction seems to be quite rare6, and mainly occurs when higher doses are used. Patients with severe hypertension or with severe cardiovascular disease (especially coronary artery disease) may have their underlying disease exacerbated if large amounts of epinephrine are administered with the local anesthetic. However, the low doses of epinephrine used in cutaneous surgery can be safely used during pregnancy. Historically, epinephrine was not used on digits for fear of causing vasoconstriction that might result in digital necrosis. More recent studies have not demonstrated any increased risk from epinephrine in digital anesthesia. It appears that most cases of digital necrosis occurred due to vessel compression from too much anesthetic volume being injected (tamponade), constricting circumferential dressings, tourniquets, postoperative hot soaks (possibly due to heat-induced edema), infection, use of vasoconstrictive anesthetics such as cocaine hydrochloride, or non-standard mixing of lidocaine with epinephrine7. There is no evidence of digital necrosis due solely to commercially available lidocaine with epinephrine7. I have found that combining lidocaine with dilute epinephrine (1: 500 000) and small volumes provides safe digital anesthesia. Self-limited systemic side effects of epinephrine include palpitations, anxiety, fear, diaphoresis, headache, tremor, weakness, tachycardia, and elevated blood pressure. These signs and symptoms can be seen on occasion even with normal doses used for skin surgery, but they usually resolve within a few minutes (Table 143. They are more commonly seen when injecting highly vascular areas, especially the face and scalp. Skin necrosis from vasoconstriction is an extremely rare complication of epinephrine injection and would be an issue only in patients with severe vascular compromise at the injection site. However, it is prudent to limit the total dose injected in patients with severe cardiac disease. Therefore, when epinephrine is premixed with local anesthetics, the pH is lowered into the 3. This acidic solution not only is more painful at the time of injection8, but also slows the onset of anesthetic action, as less anesthetic is in the non-ionized form. By preparing the mixture fresh daily and using it by the end of the day, the mixture has a higher pH, which is less painful. Alternatively, the lidocaine with epinephrine can be neutralized with sodium bicarbonate (see below). Hyaluronidase is most useful for periorbital surgery and to increase the rate of successful nerve blocks. In addition, the preparation may contain thimerosal preservative, which can cause contact dermatitis. Anesthetic Mixtures In an attempt to take advantage of different anesthetic properties, some surgeons combine two local anesthetics in one syringe. For example, a combination of lidocaine, for its rapid onset of action, with bupivacaine hydrochloride, for its longer duration of action, is often used. However, a study looking at such combinations has found that these mixtures do not live up to their promise. The mixture seems to take on the properties of one of the components to the exclusion of the other11. Therefore, most surgeons will inject the rapid-onset anesthetic first and the longer-acting anesthetic later, to minimize the pain of injection and maximize the duration of action. Side Effects Vasovagal reactions By far the most common side effect of local anesthetic injection is a vasovagal reaction, in which the vagus nerve discharges due to patient anxiety, resulting in an increase in parasympathetic tone (Table 143. Vasovagal reactions are manifested by dizziness, diaphoresis, syncope, bradycardia, and hypotension. To avoid significant vasovagal reactions, all patients should have local anesthetic infiltrated in the recumbent position. Sodium bicarbonate Injecting the standard mixture of lidocaine with epinephrine at a pH of 3. As the epinephrine activity is lost at a rate of 25% per week in an alkaline or neutral environment, the mixture should be labeled with the date prepared, kept refrigerated, and used within about 1 week. Allergic reactions the most important side effect of local anesthetics is the development of allergic reactions. The allergy is usually a type I IgE-mediated reaction manifested by urticaria, angioedema, bronchospasm, and, on rare occasions, anaphylaxis with associated hypotension and tachycardia (Table 143. Most true local anesthetic allergies have been reported with ester anesthetics; amide anesthetics are implicated only very rarely.

Patients with a prior history of melasma or other pigmentary disorders might be pretreated with topical hydroquinone prior to the procedure81 erectile dysfunction doctors in el paso tx discount viagra online amex. Photorejuvenation by "subsurface remodeling" is designed to induce dermal remodeling and volume restoration via selective dermal injury alone erectile dysfunction studies viagra 75 mg line. Stimulation of wound healing responses offered early evidence to substantiate the use of non-ablative lasers for photorejuvenation and scar amelioration erectile dysfunction due to diabetes icd 9 order viagra once a day. Photorejuvenation of the skin entails improvement of actinic telangiectasias impotence or erectile dysfunction buy viagra 75 mg mastercard, lentigines erectile dysfunction drugs on nhs discount 50 mg viagra otc, solar elastosis erectile dysfunction over 60 purchase viagra 25mg visa, and wrinkling. To a broader extent, it involves enhancing the color, tone, and texture of the skin. Complete photorejuvenation often requires targeting hemoglobin, melanin and water, and no one laser or wavelength meets all of these objectives on its own. Infrared light is absorbed primarily by water and leads to collagen remodeling and an improvement in skin texture and tone. Visible light lasers are effectively used to treat the telangiectasias and dyspigmentation associated with photodamaged skin. While collagen remodeling has been demonstrated histologically, clinical improvement of wrinkles is variable and modest. Its broad range of wavelengths allows the telangiectatic and pigmentary aspects of photoaging to be addressed simultaneously. It has been postulated that the shorter wavelengths are responsible for the improvement in pigmentation and telangiectasias, while the longer wavelengths are responsible for collagen remodeling via thermal effects on tissue water82. This is followed by a thin coat of white petrolatum ointment or generous amounts of a bland moisturizing cream until re-epithelization is completed. Edema and erythema of treated skin is observed following both ablative and non-ablative fractionated therapies, but these side effects are much more pronounced after ablative procedures79. Well-documented side effects of generalized and persistent erythema or delayed hypopigmentation that are seen with traditional resurfacing have been reported only rarely with fractionated lasers. There are some descriptions of angulated erythema and infection related to poor technique leading to bulk heating and slow healing. Additionally, lines of demarcation are easily avoided by feathering the transitional skin between treated and untreated regions with nearminimal fluence and density settings. Because only minute areas of damage are induced and the skin heals rapidly, fractionated ablative systems offer an unparalleled safety margin as compared to traditional ablative lasers. However, infection is still the most significant complication and it can lead to permanent scarring. It is essential that all patients begin oral antiviral therapy from at least the morning of the procedure and early on have frequent postoperative skin evaluations. Use of oral antibiotics and antifungal agents can be decided on a case-by-case basis. Although scarring is an infrequent event, recent case reports have alerted laser surgeons to be cautious in "underprivileged" areas such as the neck and chest80. Because it is an ion, water has a high dipole moment whereas fat has a low dipole moment. As a result, there is less absorption in the subcutaneous layer and selectivity for the dermis. Furthermore, application of concurrent cooling protects the upper dermis and selectively heats the deeper dermis. Dielectric heating by microwaves was found to induce both eccrine and apocrine sweat gland thermolysis with relative selectivity. Studies have shown that 90% of patients had at least a 50% reduction in sweating, and ~80% maintained this reduction at 12 months89. All subjects experienced transient swelling, discomfort, and/or numbness within the treatment area, with a few patients noting longer-lasting side effects including altered sensation in or around the treatment site, papulonodules in the axillae, and hair loss90. Although other early studies reported similar conclusions, results in clinical practice were far more variable and unpredictable, and the treatments were associated with significant patient discomfort85. Aside from transient erythema and edema, irregular depressions ("mattress-top" irregularities) were seen, which were attributed to excessive treatment (outside the recommended parameters) causing localized fat atrophy. New algorithms and devices were developed, which increased both the reproducibility of the results and patient comfort. The latter was designed to reduce discomfort and increase the efficacy of tissue tightening. There are reasons to believe that the bipolar devices are not as efficient as monopolar devices in their ability to tighten tissue. The primary mechanism is the absorption of focused acoustic energy (with millisecond pulse durations) that induces vibrations at the molecular level within tissue, creating coagulative necrosis in targeted zones. These ultrasound waves can cause significant focal damage at nearly any depth within the skin without damaging its surface. While the distribution, density and color of hair is related to gender and genetic background, the acceptability and desirability of hair are often related to societal and cultural norms. Markedly excessive hair can be a marker for an underlying endocrinopathy or a medication side effect, and a possible etiology should be investigated prior to photoepilation (see Ch. While most patients who undergo photoepilation have the cosmetic objective of decreasing unwanted hair, there are several medical applications of laser hair removal, such as treatment of pseudofolliculitis barbae. Realistic expectations are key and the laser surgeon should clearly and specifically communicate these objectives to the patient. For some patients with particularly coarse, dense unwanted hair, a successful outcome might be a transition to finer, lighter hair. Potential side effects should be reviewed, including pigmentary changes (hyper- or hypopigmentation), erythema, edema, discomfort, and very rarely scarring. Photoepilation is based on selectively delivering energy to the hair follicle, specifically to the bulge region where follicle stem cells reside, causing their destruction while minimizing non-selective injury to the surrounding tissues. Additional follicular melanin targets are the hair shaft, the outer root sheath of the infundibulum, and the hair bulb matrix (see Ch. These include: (1) photothermal injury to the follicle via direct heating of the follicle; (2) photomechanical injury by induction of shock waves and violent cavitation; and (3) photochemical injury by production of toxic intermediaries such as singlet oxygen or free radicals93. There can be transient growth arrest via induction of catagen or permanent hair removal via follicular fibrosis. Although the absorption of melanin corresponds to wavelengths from 400 to 1200 nm, the best lasers for photoepilation have wavelengths between 600 and 1100 nm, a range where there is more selective absorption by melanin and the light penetrates relatively deeply into the skin. Given this relatively broad therapeutic spectrum, many laser systems have been utilized, including the ruby (694 nm), alexandrite 2381 Lasers and Other Energy-Based Therapies water, and, consequently, the absorbed energy is scattered throughout the dermis. This characteristic permits penetration to at least 500 microns, and potentially up to 2 mm, into the skin83. The 1320 nm laser has an incorporated cryogen spray (CoolTouch3) which can be set for pre-cooling, mid-pulse cooling, and post-laser pulse cooling. These options, like other cooling strategies with non-ablative lasers, provide epidermal protection and reduce epidermal injury. Furthermore, the 1450 nm laser has been reported to be useful for the treatment of sebaceous hyperplasia. When used for the treatment of wrinkles, the 1450 nm diode laser produced only modest improvement and the improvement was not as clearly appreciated by study patients. Side effects include focal bruising and pain, reported by 25% and 55% of patients, respectively. The optimal wavelength is probably in the ruby laser range (694 nm), but longer pulsing beyond 3 to 4 milliseconds is problematic, which has led to the utilization of alternative wavelengths. From a practical perspective, this entails accurate selection of: the laser system, the optimal pulse duration, and the appropriate fluence to achieve hair removal, while protecting the epidermis and minimizing non-selective dermal heat injury. Selection of the appropriate pulse duration is critical for effective photoepilation. However, extension of the pulse duration beyond the thermal relaxation time of the follicular unit could promote delivery of thermal damage to the surrounding non-pigmented stem cells and might induce more consistent follicular destruction92. In general, the ideal pulse duration would be between the thermal relaxation time of the epidermis (1 ms) and the hair follicle. Coarser, thicker and darker hairs may have relatively longer thermal relaxation times compared to thinner, finer hairs93. However, since overzealous fluence might induce excessive collateral heat, a conservative selection of parameters is recommended. Typical danger zones are the chin and lip (where there is a greater density of hair follicles) as well as pigmented genital or inguinal skin. It is incumbent on the operator to know how to operate each system that he or she employs. Laser hair removal in patients with darker skin can be more problematic as epidermal melanin competes with the follicular target. Cooling can be applied immediately prior to (pre-cooling), during (parallel cooling), or after laser pulsing (post-cooling). Aside from protecting the epidermis from excessive heat, contact cooling handpieces allow compression of the skin and facilitate delivery of more laser energy to the targeted hair follicles. Most studies have shown comparable efficacy rates when sufficient fluence is used and multiple treatments are performed. As stated previously, the "ideal" patient for photoepilation is one who has light skin and dark hair. Long-term efficacy of laser hair removal correlates with higher concentrations of eumelanin95. Recent attempts have been made to treat non-pigmented, gray or white hair, but so far there is little evidence of benefit. Paradoxical hypertrichosis following the use of hair removal devices is a common and well documented side effect of photoepilation. Initial reports suggested that affected patients should be evaluated for hyperandrogenemia96. However, the largest retrospective analysis to date of 750 patients found that the overall incidence of paradoxical hypertrichosis was 4. These authors postulated that the hair induction occurred at the borders of the treated areas, perhaps because of sub-therapeutic fluences during laser therapy and local inflammatory responses following photoepilation97. It has been suggested that application of ice to the perimeter of the treatment area and use of the highest tolerated fluence may prevent this side effect. Proper pre-treatment preparation of the skin prior to photoepilation allows for optimal treatment results. Failure to recognize the need to avoid treating suntanned skin has resulted in numerous burns, scarring, and permanent pigmentary changes. In sunny climates, patients should be advised to apply broad-spectrum sunscreens for weeks prior to laser therapy and to avoid tanning both before and after photoepilation, in order to prevent postinflammatory hyperpigmentation. Secondly, patients should avoid plucking, waxing, threading, and electrolysis prior to laser treatment as these will remove the target chromophore. Shaved hair (or at least hair cut flush with the skin surface) also minimizes inadvertent heat transfer to the epidermis during laser therapy. Finally, given that photoepilation is often associated with some degree of discomfort, topical anesthetics can be applied prior to treatment. While increasing patient comfort during the procedure is an important objective, several deaths have been reported with misuse of strong topical anesthetics applied to large areas in unsupervised situations. In practice, however, there are multiple devices that can efficiently remove hair, reduce the signs of photodamage, induce a degree of skin tightening, and improve acne. That said, there is an even larger number of devices that are totally ineffective. In general, those devices that are effective and designed by highly skilled engineers are rather expensive, while the ineffective devices are relatively cheap and therefore appealing to the consumer. Although little peer-reviewed literature is available, one small officebased study demonstrated that nearly all of the patients were able to correctly administer their own treatments. Additionally, the observed side effects of hyper- and hypopigmentation, crusting, and blistering were transient and had resolved by the conclusion of the study98. Use of these devices on inappropriate skin phototypes and tanned skin is clearly contraindicated. There will be complications, but we should not underestimate the ability of the public to use (or abuse) these devices. Laser engineers are very insightful, and they can provide us with semi-intelligent laser, light, and other energy systems that can more precisely target the correct structures, and induce the correct healing responses. We should celebrate the enormous energy that goes into newer and more sophisticated devices, just as we should criticize and reject devices which underperform and overpromise. Those of us who are involved in new technology development know that, just around the corner, advances are going to bring us smarter, cheaper, more durable, more tunable devices. Our hope is that as this new technology comes online, there will be a continued attempt to answer the ongoing tough questions pertaining to both surgical and medical dermatology.

The dermal infiltrates are also more pronounced erectile dysfunction injection medication purchase viagra on line amex, and they may contain a higher number of atypical cells with cerebriform nuclei and occasional blast cells erectile dysfunction questions safe viagra 50 mg, as well as admixed eosinophils and plasma cells impotence at 46 cheap 25 mg viagra mastercard. These specific diagnoses can generally be excluded by histologic and other standard dermatologic examinations erectile dysfunction genetic buy cheap viagra online. This category may also include patients with large plaque parapsoriasis (parapsoriasis en plaque) who show slightly scaly constipation causes erectile dysfunction buy generic viagra 25mg online, sometimes atrophic erectile dysfunction freedom discount viagra online mastercard, erythematous patches or plaques, which are commonly located on the trunk and buttocks (see Ch. Examples of these are lymphomatoid contact dermatitis, lymphomatoid drug reactions, and actinic reticuloid. Examination of other organs, including the bone marrow, should only be performed if clinically indicated. These skin-directed therapies include topical or intralesional corticosteroids, topical cytotoxic agents. Systemic multi-agent chemotherapy is not useful in these early stages, since it does not improve survival and is associated with considerable morbidity. In general, systemic chemotherapy is only indicated in advanced stages when there is nodal or visceral involvement or in patients with rapidly progressive tumors unresponsive to less aggressive therapies. In patients with limited patch/plaque stage disease (mainly patches), complete remissions in up to 60% of patients have been reported36. Mechlorethamine, either dissolved in water or compounded in an ointment- or gel-based preparation (see Ch. Side effects include skin irritation, allergic contact dermatitis, and an increased risk for the development of skin cancer related to long-term use. However, in most centers, such patients are treated with phototherapy or topical chemotherapy. Side effects are generally mild and include erythema, scaling, and temporary loss of hair, nails and sweat gland function. Local radiotherapy with X-ray or preferably electron beam may be considered for single tumors in patients with plaque stage disease, either in combination with other modalities. Using non-myeloablative reduced-intensity conditioning regimens, durable responses have been reported, but the optimal conditioning regimen and optimal timing for the transplant are still a matter of debate44,45,45a. Side effects are generally mild and reversible, and they include flu-like symptoms, hair loss, nausea, depression, and bone marrow suppression. In many centers, bexarotene has replaced the earlier-generation retinoids, but comparative studies have never been performed. In patients with patches or thin plaques, topical retinoids (bexarotene, tazarotene, alitretinoin) may be considered, but skin irritation is a limiting factor36. Most cases show mucinous degeneration of the hair follicles (follicular mucinosis; Ch. From a biologic point of view, the most relevant feature (irrespective of the presence or absence of follicular mucinosis) is the deep, follicular and perifollicular localization of the neoplastic infiltrates, which makes them less accessible to skin-directed therapies. Denileukin diftitox can have substantial side effects, including capillary leak syndrome, fever, and fluid retention. The most common side effects are fatigue, gastrointestinal symptoms, and reversible thrombocytopenia. It remains to be determined which patients are most likely to benefit from this therapy. Systemic multi-agent chemotherapy should only be used in patients with unequivocal lymph node or visceral involvement, or in patients with progressive skin tumors that have failed to respond to other therapies. The skin lesions are often associated with alopecia, and sometimes with mucinorrhea. Differential diagnosis the distinctive clinical and histologic features should facilitate an early and correct diagnosis. The atypical cells have medium-sized or large, sometimes hyperchromatic and cerebriform nuclei and abundant, vacuolated cytoplasm. The superficial dermis may have an infiltrate of mostly small lymphocytes, but rarely contains neoplastic T cells. Most cases show mucinous degeneration of the follicular epithelium (follicular mucinosis), as assessed with Alcian blue or colloidal iron staining, and some show involvement of the eccrine glands and coils (syringotropism). There is often a considerable admixture with eosinophils and sometimes plasma cells. In the perifollicular infiltrates, the neoplastic T cells may be blast cells rather than cerebriform cells, and therefore may be easily mistaken for histiocytes. Useful criteria for pagetoid reticulosis include the characteristic clinical presentation and the often strictly epidermal localization of the neoplastic T cells. In approximately one-third of the reported patients, an association with Hodgkin lymphoma was observed. Lymphadenopathy, alopecia, onychodystrophy, and palmoplantar hyperkeratosis are common findings. The bone marrow may be involved, but the infiltrates are often sparse and mainly interstitial. The differential diagnosis includes erythroderma secondary to psoriasis, atopic dermatitis or other forms of dermatitis, pityriasis rubra pilaris, and drug reactions as well as 2138 Treatment Being a systemic disease (leukemia) by definition, systemic treatment is required. This great variation in response rates may reflect differences in patient selection and/or concurrent therapies. Thus, histologic criteria alone are often insufficient to distinguish between the two ends of the spectrum. In the end, the clinical appearance and course are used as decisive criteria for the definite diagnosis and choice of treatment. Cases previously designated as regressing atypical histiocytosis, as well as rare cases of primary cutaneous Hodgkin lymphoma with an indolent clinical course, also belong to this spectrum66. However, a slowly progressive form that sometimes has only cutaneous lesions has been described (smoldering variant)63. In addition, a high prevalence is seen in Jewish individuals whose ancestors were from Mashad, Iran. Such cases have a more protracted clinical course, but progression to a high-grade malignant disseminated form of the disease may occur. Extracutaneous dissemination occurs in ~10% of patients, and it mainly involves the regional lymph nodes. The prognosis is usually favorable, with a 10-year diseaserelated survival exceeding 85%66,68. Pathology Skin lesions demonstrate a superficial or more diffuse infiltration of small, medium-sized or large pleomorphic T cells, which often display marked epidermotropism. Skin lesions in the smoldering type may have sparse dermal infiltrates with only slightly atypical cells. In most cases, the tumor cells have the characteristic morphology of anaplastic cells, with round, oval or irregularly shaped nuclei, prominent (eosinophilic) nucleoli, and abundant cytoplasm. Treatment Radiotherapy or surgical excision is an initial treatment in patients presenting with a solitary or a few localized nodules or tumors. However, if a solitary lesion disappears spontaneously, no further therapy is required. Patients presenting with multifocal skin lesions can best be treated with radiotherapy (if there are only a few lesions), lowdose methotrexate, retinoids, or interferon-78. Patients who present with or develop extracutaneous disease or those rare patients with rapidly progressive skin disease should be treated with doxorubicinbased multi-agent chemotherapy. Early aggressive therapy may also be considered in patients presenting with extensive skin lesions on one or both legs, since such patients are at risk for a more aggressive clinical course68,79. The youngest patient reported to date was 8 months old, and the oldest was 84 years of age. The papulonodules may leave transient hypopigmented or hyperpigmented macules and, occasionally, superficial atrophic (varioliform) scars, or they may disappear without ulceration or sequelae. Lesions may be localized, sometimes clustered within rather welldefined areas, or generalized. In a study of 118 patients with LyP only five, patients (4%) developed a systemic lymphoma, and only two patients (2%) died of systemic disease over a median follow-up period of 77 months66. It should be noted that different types of LyP may occur in different but concurrent lesions, and that a single LyP lesion may show histologic features of different subtypes of LyP. Knowledge of the variable histologic presentations of LyP is more important for pathologists than for clinicians as the subtype has no therapeutic or prognostic implications. Since the introduction of the term LyP in 1968 by Macaulay81, there has been continued discussion as to whether LyP is a malignant, premalignant, or benign condition. Obviously, when the clinical features are taken into account, differentiation between LyP and the malignant lymphomas it may resemble histologically is not difficult. Because of the clinical similarities between LyP and pityriasis lichenoides, a relationship between the two conditions was initially suggested. More recently, clonal T-cell populations have been demonstrated in skin biopsies of both conditions. Pityriasis lichenoides occurs more often in younger patients, is often relatively short-lived, does not develop nodular lesions, and rarely, if ever, progresses to a lymphoma. The mechanisms involved in the spontaneous disappearance of skin lesions, or in the tumor progression observed in some patients with LyP have not yet been identified. Since a curative therapy is not available and none of the available treatment modalities affects the natural course of the disease, the short-term benefits of active treatment should be balanced carefully against potential side effects66,78. In patients with relatively few non-scarring lesions, active treatment is not necessary. When larger skin tumors develop in the course of LyP they can be observed for a, period of 4 to 12 weeks for the possibility of spontaneous remission. If spontaneous resolution does not occur, such lesions can be excised or treated with radiotherapy. Because of the potential risk for developing a systemic lymphoma, long-term follow-up is required in all patients with LyP. It may occur in adults as well as in young children, and both sexes are equally affected. Clinical features Patients generally present with a solitary or multiple nodules or deeply seated plaques with a diameter varying from 1 to 20 cm. Systemic symptoms such as fever, fatigue, and weight loss may be present in over half of the patients. Laboratory abnormalities including cytopenias and elevated liver function tests are common, but a frank hemophagocytic syndrome is observed in only ~15% of patients87. Dissemination to extracutaneous sites is rare and while hepatosplenomegaly may be seen, it is generally not due to lymphomatous involvement. Up to 20% of patients have an associated autoimmune disease, most commonly systemic lupus erythematosus. However, the presence of hemophagocytic syndrome is associated with a more unfavorable prognosis. Small, medium-sized, or sometimes large pleomorphic T cells with hyperchromatic nuclei are present and are often admixed with many macrophages. In the early stages, the neoplastic infiltrates may lack significant atypia and a heavy inflammatory infiltrate may predominate. Pathology these lymphomas are characterized by dense infiltrates involving the dermis and often the subcutis. Prominent angiocentricity and angiodestruction are often accompanied by extensive necrosis. In some cases, a heavy inflammatory infiltrate of small lymphocytes, histiocytes, plasma cells, and eosinophils can be seen. The T-cell receptor usually has a germline configuration, but can be clonally rearranged in the rare tumors with a cytotoxic T-cell phenotype. Treatment While doxorubicin-based chemotherapy has traditionally been used, recent studies suggest that more conservative immunosuppressive regimens. In patients presenting with a solitary lesion, local radiotherapy may be effective87. Treatment In patients with localized disease, radiotherapy is the preferred treatment91. When more advanced, these lymphomas have an aggressive clinical behavior and are often resistant to chemotherapy. The skin is the most common site of involvement after the nasal cavity/nasopharynx, and skin involvement may be a primary or secondary manifestation of the disease. They may disseminate to other visceral sites (lung, testis, central nervous system, oral mucosa), but lymph nodes are often spared93. Involvement of mucosal and other extranodal sites is frequently observed, but involvement of lymph nodes, spleen or bone marrow is uncommon. Histologically, three major patterns of involvement can be seen: epidermotropic, dermal, and subcutaneous. Often more than one histologic pattern is present within a single biopsy specimen or in different biopsy specimens from the same patient. The epidermal pattern can vary from mild epidermotropism to a marked pagetoid reticulosis-like infiltrate. Most patients have aggressive, often rapidly fatal disease, which is resistant to multi-agent chemotherapy.

It contains the highest concentration of polyphenol antioxidants of any tea erectile dysfunction virgin cheap generic viagra uk, save perhaps for white tea can you get erectile dysfunction young age order viagra australia, which is the least processed of all teas erectile dysfunction studies purchase viagra 25 mg without prescription. Both topical and oral green tea can protect against inflammation impotence 25 buy viagra 25mg fast delivery, ultraviolet lightinduced photodamage erectile dysfunction in diabetes patients order 25mg viagra with mastercard, chemical carcinogenesis erectile dysfunction in young men buy viagra us, and photocarcinogenesis13. Feverfew Feverfew (Tanacetum parthenium) is a flowering plant from the daisy family. Originally named for its fever-reducing properties, it is also used to treat headaches, arthritis, and digestive disorders. Use of topical feverfew had been limited by the presence of irritating parthenolides in the plant, but an industry-patented process now allows for removal of these irritants12. Feverfew possesses antioxidant and anti-inflammatory properties; it is thought to inhibit proinflammatory mediators released from macrophages and to reduce neutrophil chemotaxis8. Dermatologic Honey Honey is a bee-derived substance composed primarily of fructose and glucose, but also contains numerous proteins, amino acids, vitamins, enzymes, and minerals. Release of enzymes from activated leukocytes is considered one component of the pathophysiology of chronic venous insufficiency. Natural horse chestnut seeds are poisonous and need to be processed to remove esculin, a toxic component. Side effects of esculin include hepatotoxicity, renal toxicity, anaphylaxis, and possible potentiation of anticoagulation. Indigo Naturalis Indigo naturalis is derived from the Strobilanthes formosanus plant and provides a well-known name for a dark blue color. Topical indigo naturalis has been observed to improve plaque psoriasis5 as well as nail psoriasis in children17. The latter may be explained by an inhibition of epidermal keratinocyte proliferation by indirubin, the active component of indigo naturalis. Common complementary and alternative therapies with potential use in dermatologic surgery: risks and benefits. Licorice Root Licorice root (Glycyrrhiza inflata; Glycyrrhiza glabra) has long been considered a natural remedy. Glycyrrhiza glabra contains glabridin and Glycyrrhiza inflata contains licochalcone A, both of which have antiirritant and anti-inflammatory properties8. Licorice extract is produced by first boiling licorice root and then allowing the water to evaporate. It is used both topically and orally for rosacea and dermatitis and is typically found in preparations that target sensitive skin19. Licorice also contains glycyrrhizin, a substance that, if ingested in high doses, can cause hypokalemia, arrhythmias, hypertension, and/or congestive heart failure. Marigold Marigold (Calendula officinalis) is a flower native to northern Mediterranean countries. Topically, marigold is most commonly used to treat dermatitis, but has been employed for wounds, ulcers, thermal burns, and herpes zoster. There is also evidence to support the use of calendula ointment to reduce radiation-induced skin toxicity20. Marigold contains flavonoids, triterpene saponins, and carotenoids which confer antiinflammatory, antimicrobial, and immunomodulating properties. In animal studies, an increase in glycoproteins and collagen was observed in wound sites treated with topical marigold. There are rare reports of allergic contact dermatitis to Calendula, but it is generally well tolerated6. Menthol Menthol is a naturally occurring plant compound that is used in multiple industries and products, including pharmaceuticals, pesticides, and flavoring agents. Topical preparations that contain menthol are used for their antipruritic, analgesic, and cooling properties. In addition to affecting sensory pathways, menthol exhibits antibacterial and antifungal activity21. The latter effect is thought to be due to its antimicrobial properties and the enzymatic release of hydrogen peroxide. Medical-grade honeys are now available by prescription, suggesting that honey may be entering the realm of conventional medicine. Although an allergic contact dermatitis to honey has been observed (probably related to propolis), Prebiotics and Probiotics Prebiotics are non-digestible sugars that encourage the growth of certain desirable types of bacteria within the intestine. Diagnostic evaluation includes parameters such as pulse rate and appearance of the tongue as well as an assessment of tendencies and habits. For example, patients with the Western diagnosis "acne" would not necessarily all be treated in the same manner because their underlying diagnoses could be vastly different, requiring different approaches. For health to occur, balance and harmony must be achieved between two opposing and complementary forces, Yin and Yang. Additionally, normal flow patterns of qi, or lifeforce, is essential for health, and disruptions of flow cause pain and disease. Regulation of flow is the goal of therapy, often via acupuncture, moxibustion, and massage. Tea Tree Oil Tea tree oil is an essential oil from the leaves of the native Australian tree, Melaleuca alternifolia. The indigenous people of Australia use tea tree oil from crushed leaves as a traditional remedy for coughs and colds as well as to treat wounds and skin infections. Tea tree oil is commonly used as a topical antimicrobial agent and has shown efficacy in treating acne and cutaneous fungal and bacterial infections. There are multiple reports of the antiseptic properties of tea tree oil, thought in part to be due to disruption of bacterial membranes23. Tea tree oil can be very irritating and is a cause of allergic contact dermatitis; it may also produce gynecomastia24,25. While a complete discussion is beyond the scope of this chapter, the next sections highlight some of the evidence for its use in atopic dermatitis and psoriasis. Turmeric Turmeric is the ground root of Curcuma longa and its active compound is curcumin. Curcumin is the yellow pigment that gives turmeric, curry and yellow mustard their color, and it has been used for centuries in cooking and cosmetics. Turmeric has antimicrobial, antioxidant, antiinflammatory, and anticancer activities26. It inhibits lipoxygenase and cyclooxygenase, thereby reducing levels of leukotrienes, thromboxanes, and prostaglandins. Topical turmeric has been evaluated for psoriasis and wound healing19, but color and odor limit its use. Atopic dermatitis A Cochrane systematic review analyzed 28 studies of Chinese herbal preparations for atopic dermatitis, both ingested and applied topically. They found that in most of the studies reviewed,Chinese herbal therapy was superior to placebo in terms of reducing eczema severity and decreasing pruritus32. Nonetheless, the authors concluded that there is still insufficient evidence for efficacy as the quality of the studies is low. Herbal preparations are generally considered safe; side effects are rare and usually mild when they do occur. In addition to associated allergic reactions and photosensitivity, herbs may have pharmacologic effects Vitex An extract of vitex dried fruit (Vitex agnus-castus) has been used to treat menstrual cycle disorders. The extract is thought to be helpful in regulating ovulation and in reducing levels of luteinizing hormone, prolactin, fasting insulin and testosterone, thereby improving menstrual cycle-associated acne. Given the hormonal effects of oral vitex, it should not be used by pregnant or nursing women6. Over the past two decades, there has been renewed interest in employing dietary modifications to influence cutaneous diseases, in particular psoriasis, acne, and atopic dermatitis. Obesity is now thought to contribute to a proinflammatory state and there is some evidence that weight loss is beneficial in psoriasis28. Dairy and high-glycemic foods may be contributing factors for acne, and avoiding these Western dietary features appears to significantly reduce acne severity27. There is widespread belief outside the conventional medical community that foods are the "root cause" of atopic dermatitis, and while it is a compelling idea, there is limited evidence to support this theory30. There is some support for avoiding known allergens (specifically eggs)31, especially in infants. However, overall, excluding foods in patients without specific allergies appears to have an insignificant effect22. Probiotics can be ingested in a tablet form or as a component of foodstuffs, especially yogurt, fermented and unfermented milk, miso, tempeh, and soy beverages. The most commonly used probiotics are Lactobacillus, Bifidobacterium, and Saccharomyces boulardii. Probiotics decrease intestinal inflammation and permeability, and potentially may alter antigen presentation in a way that is beneficial to patients with eczema. However, the results of clinical trials have been mixed and outstanding questions remain, including the ideal patient, the type and dosage of the probiotics, and the timing and frequency of administration22. Side effects usually consist of mild gastrointestinal symptoms, but there have been case reports of probiotic sepsis. They may also be adulterated with corticosteroids and contain arsenic or mercury33. Acupuncture has been used anecdotally for a variety of skin conditions, including atopic dermatitis, lichen planus, psoriasis, alopecia areata, verrucae, herpetic infections, postherpetic neuralgia, and urticaria34. More support exists for the use of acupuncture for alleviation of symptoms associated with dermatologic disorders. A pilot study demonstrated decreased pruritus in patients with atopic dermatitis after applying acupressure to a single point on the arm35. Acupuncture and acupressure may work via so-called "gate control" and/or by stimulating release of neuroactive substances including endorphins and enkephalins36. By altering the release of neurotransmitters, acupuncture may exert antiinflammatory and immunomodulatory effects. Acupuncture has also been shown to increase adrenal production of corticosterone and cortisol as well as production of -endorphin and corticotropin by the pituitary. Side effects of acupuncture include pruritus, petechiae, ecchymoses and subcutaneous hematomas, but are fairly rare. Infectious risks are minimized with single-use needles, and the risk of pneumothorax is minimized by using traditional angles of insertion. In a study of 801 psoriatic patients, over half responded to a decoction of five herbs (Rhizoma sparganii, Rhizoma zedoariae, Herba serissae, Boswellia resin, and Commiphora myrrha)37. Acupuncture has not been well studied in psoriasis, but there are several reports of plaques appearing at sites of acupuncture needle insertions due to Koebner phenomenon38. Moxibustion, Cupping and Other Treatment Modalities Moxibustion is the practice of burning dried moxa (Artemisia vulgaris), arranged in small cone-shaped piles, over acupuncture points. Moxibustion may be either direct, in which the moxa-cones are allowed to burn completely down to the skin surface, or indirect, in which the cones are removed prior to the burning fibers touching the skin. It is accomplished by igniting alcohol-soaked cotton, placing the burning cotton in a jar, and placing the jar on the skin. Nowadays, some practitioners use a simpler vacuum device that negates the risk of fire. Skin scraping, also known as coining or spooning, is commonly practiced in Southeast Asia to improve circulation. Any patient with cutaneous lesions in patterns suggestive of external causes should be asked about traditional medicine before accusations of abuse arise. Homeopathic remedies come from substances that are derived from plants, minerals or animals, many of which are considered toxic in their crude form. The latter represents the therapeutic use of aromatic essential oils which can be made from any plant part, including leaves, stems, flowers, fruits or roots. Essential oils are typically obtained via steam distillation or by cold pressing the plant. Those oils used in aromatherapy are derived from a number of plants including chamomile, geranium, lavender, tea tree, lemon, cedarwood, and bergamot42. Essential oils contain a mixture of various organic compounds, in particular alcohols, aldehydes, esters, ketones, terpenes, lactones, aromatic aldehydes, and phenols. Oils high in ketones are used for their wound healing properties, whereas oils high in alcohols are used for their antimicrobial properties. There is evidence that essential oils, when applied topically, can enter the bloodstream43. The most common routes of administration are inhalation and massage, but compresses, creams, gels, sprays, and baths are also employed. Aromatherapy may be used directly to treat dermatologic conditions, or indirectly to treat the anxiety or other psychiatric symptoms associated with cutaneous disorders. Aromatherapy has been used to treat acne, alopecia areata, pruritus, xerosis, psoriasis, contact dermatitis, radiation dermatitis, herpes viral infections, and scarring as well as for analgesia and wound healing. Tea tree oil (Melaleuca alternifolia) is one of the most commonly employed essential oils in aromatherapy of skin conditions. A singleblind trial in acne patients found similar efficacies for tea tree oil 5% gel and benzoyl peroxide 5% lotion; tea tree oil had a slower onset of action but fewer side effects. In a randomized, controlled, doubleblind trial for alopecia areata, an aromatherapy essential oil blend of thyme, rosemary, lavender and cedarwood led to significantly greater improvement than did the placebo (44% vs 15%)45. It is important to note that essential oils have biologically active components and may be toxic. For example, oils with high concentrations of aldehydes and phenols may cause skin irritation.

Purchase viagra uk. Erectile Dysfunction.wmv.