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The Treatment of Acute Attacks

Prednisone, and others continue to be commonly used to shorten the attack. These potent anti-inflammatory drugs diminish the swelling within the brain and spinal cord that is seen as cells of the immune system invade and attack the nervous system. They do not appear to alter the long term course of the disease. They are clearly associated with osteoporosis, cataracts, psychological changes, skin acne, weight gain, and salt and water imbalance. Thus their effect on acute attacks must be weighed against potential problems from the treatment.

Avoid Disturbed Patients

The patient perceived her lips as too small and requested a touch up. Please note the small excoriations on the patient's cheek, which are consistent with the features of acne excori e, a neurotic skin disease Fig. 3.2 Dysmorphic patient. The patient perceived her lips as too small and requested a touch up. Please note the small excoriations on the patient's cheek, which are consistent with the features of acne excori e, a neurotic skin disease

Adverse Effects of Steroids

Three broad groups can be identified, although 50 of patients report no adverse event. Early effects are mainly due to high doses and include cosmetic effects (acne, moon face, oedema), sleep and mood disturbance, dyspepsia, or glucose intolerance. Effects associated with prolonged use (usually 12 weeks) include posterior subcapsular cataracts, osteoporosis, osteonecrosis of the femoral head, myopathy, and susceptibility to infections. Effects during withdrawal include acute adrenal insufficiency (from sudden cessation), a syndrome of myalgia, malaise, and arthralgia (similar to recrudescence of UC), or raised intracranial pressure. Complete steroid withdrawal is facilitated by early introduction of azathioprine, adjuvant nutritional therapy, or timely surgery.

Androgen Replacement Therapy

Testosterone therapy is safely and easily accomplished either by periodic intramuscular injection of testosterone esters or with newer (and more expensive) transdermal patches and gels described in detail elsewhere in this volume (see Chapter 18). Replacement doses for the intramuscular esters of testosterone are 100-200 mg intramuscularly every other week in adults, whereas adolescents are started at lower doses (e.g., 50-100 mg every 2-4 wk) and are gradually increased to adult doses over 2-3 mo (13). Testosterone therapy side effects include weight gain, mostly owing to increases in lean body mass, and acne. In older men, erythrocytosis is seen with some frequency. Induction or a worsening of sleep apnea has also been reported (52). In general, testosterone therapy is both beneficial and well-tolerated by individuals with KS, most of whom continue therapy long-term (54). Twenty-year follow-ups of cohorts of men with KS treated with testosterone have demonstrated marked improvements...

Postoperative Care and Complications

Complications of ablative resurfacing can include prolonged erythema, contact dermatitis, acne, infection, pigmentary changes, and scarring (Lewis and Alster 1996 Nanni and Alster 1998 Sriprachya-Anunt 1997). Postoperative erythema typically improves with time it is most pronounced during the first week and steadily subsides over the next few weeks. Prolonged erythema and or pruritus result from contact dermatitis, infection, or thermal damage. Allergic and irritant contact dermatitis occurs more commonly in newly resurfaced skin and likely relates to the increased density of Langerhans cells, which is noted in areas of perturbed epidermis. Thus, anything that comes into contact with the skin can trigger a reaction as the disrupted epidermis more readily attracts the dendritic cells to potential sites of antigen invasion. The most likely contactants are sources of perfumes or dyes such as those found in fabric softener dryer sheets or detergents. Patients should be forewarned to elimi...

Sources for Further Study

Walter, Lynne Paige, and Ellen Hodgson Brown. Nature's Pharmacy Break the Drug Cycle with Safe, Natural Treatments for Two Hundred Everyday Ailments. Upper Saddle River, N.J. Prentice Hall, 1999. Typical of a wave of similar publications that began to appear after the 1996 law that removed food supplements from FDAregulatory responsibility, this 400-plus-page reference catalogs common ailments, from acne to whooping cough, offering signs, symptoms, and suggestions for alternative treatments in addition to traditional Western medicine.

Medical Terminology Case Studies - Skin


K.B., a 32-year-old fitness instructor, had noticed a tiny hard lump at the base of her left nostril while cleansing her face. The lesion had been present for about 2 months when she consulted a dermatologist. She had recently moved north from Florida, where she had worked as a lifeguard. She thought the lump might have been triggered by the regular tanning salon sessions she had used to retain her tan because it did not resemble the acne pustules, blackheads, or resulting scars of her adolescent years. Although dermabrasion had removed the obvious acne scars and left several areas of dense skin, this lump was brown-pigmented and different. K.B. was afraid it might be a malignant melanoma. On examination, the dermatologist noted a small pearly-white nodule at the lower portion of the left ala (outer flared portion of the nostril). There were no other lesions on her face or neck. _____ 2. The characteristic pimples of adolescent acne are whiteheads and blackheads. The medical

Environmental Factors

Fetal Alcohol Syndrome Vulva

Isotretinoin (13-cts-retinoic acid), an analogue of vitamin A, has been shown to cause a characteristic pattern of malformations known as the isotretinoin embryopathy or vitamin A embryopathy. The drug is prescribed for the treatment of cystic acne and other chronic dermatoses, but it is highly teratogenic and can produce virtually any type of malformation. Even topical

Management Of Delayed Puberty

For boys who are hypogonadal, testosterone substitution therapy should be initiated at a low dose, because too large a dose may advance skeletal maturation disproportionately and, thus, compromise final adult height. Furthermore, large doses may cause acne, gynecomastia, or too-rapid change in libido. Doses are adjusted according to the clinical response (Tanner stage and bone age). Most commonly, long-acting testosterone preparations, which are administered intramuscularly, are used for this purpose. Esterification of testosterone with either propionic or enanthic acid at position 17 prolongs the metabolite's activity (69). Testosterone propionate is not a suitable testosterone preparation for substitution therapy, because plasma concentration show wide fluctuations, and the maximal between-injection interval is only 3 d with a 50 mg dose (70). Testosterone enanthate at a dose of 250 mg intramuscularly has a half-life of 4.5 d. Based on multiple-dose pharmacokinetics, an injection...

Consent For Levulan Photodynamic Treatment

Levulan (Aminolevulinic acid 20 ) is a naturally occurring photosensitizing compound which has been approved by the FDA and Health and Welfare Canada to treat pre-cancerous skin lesions called actinic keratosis. Levulan is applied to the skin and subsequently activated by specific wavelengths of light. This process of activating Levulan with light is termed Photodynamic Therapy. The purpose of activating the Levulan is to improve the appearance and reduce acne rosacea, acne vulgaris, sebaceous hyperplasia, decrease oiliness of the skin, and improve texture and smoothness by minimizing pore size. Any precancerous lesions are also simultaneously treated. The improvement of these skin conditions (other than actinic keratosis) is considered an off-label use of Levulan.

Androgens Are Responsible for Secondary Sex Characteristics and the Masculine Phenotype

The growth and secretory activity of the sebaceous glands on the face, upper back, and chest are stimulated by androgens, primarily DHT, and inhibited by estrogens. Increased sensitivity of target cells to androgenic action, especially during puberty, is the cause of acne vulgaris in both males and females. Skin derived from the urogenital ridge (e.g., the prepuce, scrotum, clitoris, and labia majora) remains sensitive to androgens throughout life and contains an active 5a-reductase. Growth of the larynx and thickening of the vocal cords are also androgen-dependent. Eunuchs maintain the high-pitched voice typical of prepuber-tal boys because they were castrated prior to puberty.

Macrolide Antibiotics

Hemiketal Macrolide

Erythromycin is a mixture containing principally erythromycin A, plus small amounts of erythromycins B and C (Figure 3.65). Erythromycin activity is predominantly against Grampositive bacteria, and the antibiotic is prescribed for penicillin-allergic patients. It is also used against penicillin-resistant Staphylococcus strains, in the treatment of respiratory tract infections, and systemically for skin conditions such as acne. It is the antibiotic of choice for infections of Legionella pneumophila, the cause of legionnaire's disease. Erythromycin exerts its antibacterial action by inhibiting protein biosynthesis in sensitive organisms. It binds reversibly to the larger 50S subunit of bacterial ribosomes and blocks the translocation step in which the growing peptidyl-tRNA moves from the aminoacyl acceptor site to the peptidyl donor site on the ribosome (see page 408). The antibiotic is a relatively safe drug with few serious side-effects. Nausea and vomiting may occur, and if high...

Photodynamic Therapy Other Indications

Hidradeniti Suppurativa Acne Treatment

The use of ALA-PDT is not limited to the treatment of AKs, BCCs, and SCCs. PDT therapy has long been recognized as an important treatment in acne vulgaris and other disorders of the pilosebaceous glands. Recent advances have made the use of a variety of lasers and light sources combined with ALA practical for those suffering from acne vulgaris and other pilose-baceous entities. Acne Vulgaris Acne vulgaris accounts for over 30 of all dermatology visits. It has been estimated that between 70 and 96 of all individuals will suffer from acne vulgaris at some point in their lifetime. Recent evidence suggests that over 40 million American adolescents and 25 million American adults are affected by acne vulgaris. In its simplest form, acne vulgaris is a disorder of the sebaceous glands. Obstruction of the sebaceous glands leads to the production and proliferation of bacterial growth within the sebaceous glands. The bacteria most commonly associated with the formation of acne vulgaris is...


S. aureus cause most cases of folliculitis. Micrococcus, Pityrosporum, and Demodex organisms are organisms that normally colonize skin but may become pathogens in the immunocompromised patient (26). Gram-negative folliculitis is caused by Klebsiella, Enterobacter, and Proteus species and may occur as a superinfection in acne vulgaris patients treated with long-term antibiotic therapy (27). As previously noted, hot-tub folliculitis is a special form of folliculitis caused by Pseudomonas aeruginosa.

Personal Laser Technique

Erbium Laser Day After

The first CO2 ablative laser pass is performed mainly to remove the epidermis and feather peripherally to minimize any demarcation with surrounding nontreated skin. The second laser pass, and, if used, a third pass is for heat deposition to promote tightening. Finally, the erbium laser (in the ablation mode) can be used to remove superficial thermal necrosis for further sculpting of deeper rhytides and or acne scars. The second CO2 laser pass is performed at a density of 4-5 depending on the tightening needed and the risk for the area. The upper eyelids and the central face are typically treated at densities of 5, whereas mid cheeks and some lower eyelids may be treated with densities of 4. Delivered energies are also decreased towards the periphery. A second pass is rarely done on the lateral cheeks unless acne scarring is present. A third pass may be done on acne scars and in perioral and glabellar regions to deliver additional heat to enhance tightening. When using the EMLA topical...

Androgen And Prostate Growth


Neither male-pattern baldness nor acne. More importantly, it was observed that their prostate glands, which were poorly developed at birth, grew minimally after puberty despite other masculinizing changes. It was this observation, which is directly tied to the deficiency in 5 a-reductase activity, that led researchers to consider the possibility of therapeutic inhibition of 5 a-reductase enzymes in the treatment of symptomatic BPH.

Clinical Presentation

One of the earliest signs in most all patients with CS (including CD) is obesity in growing children this is combined with growth deceleration or arrest (9-12). The accumulation of visceral fat in patients with CS, a result of excess cortisol and insulin secretion, is associated with the full expression of the metabolic syndrome X (hypertension, hyperlipidemia, hypercoagulation, insulin resistance) and its long-term (cardiovascular) sequelae. Typical signs of glucocorticoid excess are fat accumulation in the face (especially temple area and cheeks), neck (buffalo hump, supraclavicular fossae), trunk, abdomen, and epidural fat, with sparing of the limbs (8,13,14). Connective tissue atrophy leads to thin fragile skin, violaceous striae, and easy bruising. Hirsutism and a variable degree of acne (depending on the individual sensitivity to glucocortioids and androgens) can also be seen. Although mild to moderate hypertension often are present in patients with CD, hypokalemia and...

Other Possible Adverse Effects

Increased oiliness of skin and acne are common complaints after testosterone treatment, especially if high doses of testosterone are used. These conditions can be treated by topical measures, the testosterone dose can be reduced, or the testosterone preparation can be changed. Because testosterone esters and native testosterone are aromatized to estrogens, changes in the androgen to estrogen balance may occur after testosterone replacement, which may cause gynecomastia. Testosterone replacement also causes fluid retention during the early weeks of treatment and should be used with caution in older patients with congestive heart failure or poor myocardial function.

Fluoroquinolones Active Against Gram Negative bacteria

And the availability of effective alternative antimicrobial agents have limited their clinical usefulness. Several different types of tetracycline resistance have been described in Gram-negative bacteria including reduced uptake, energy-dependent efflux mechanisms, and ribosomal modification leading to decreased binding of the antibiotic. Some derivatives of tetracycline such as doxycycline and minocycline have been used for the treatment of serious cases of acne and even as secondary agents for community-acquired pneumonia because of their effectiveness against atypical bacteria.

Gerontologic Alert

With long-term administration, the female patient may experience mild to moderate masculine changes (virilization), namely facial hair, a deepening of the voice, and enlargement of the clitoris. Male pattern baldness, patchy hair loss, skin pigmentation, and acne may also be seen. Although these adverse effects are not life threatening, they often are distressing and only add to the patient's discomfort and anxiety. These problems may be easy to identify, but they are not always easy to solve. If hair loss occurs, the nurse can suggest the wearing of a wig. The nurse advises the patient that mild skin pigmentation may be covered with makeup, but severe and widespread pigmented areas and acne are often difficult to conceal. Each patient is different, and the emotional responses to these outward changes may range from severe depression to a positive attitude and acceptance. The nurse works with the patient as an individual, first identifying the problems, and then helping the patient,...

Clinical Correlates

It is important for physicians prescribing drugs to women of childbearing age to consider the possibility of pregnancy and the potential teratogenicity of the compounds. Recently hundreds of children have been born with severe craniofacial, cardiac, and neural tube defects produced by retinoids (vitamin A embryopathy). These compounds are used for the treatment of cystic acne (isotretinoin, 13-cis-retinoic acid) but are also effective topically (Retin-A) for common acne and reducing wrinkles. Oral preparations are highly terato-genic, and recent evidence suggests that topical applications may also cause abnormalities. Since patients with acne are usually young and may be sexually active, these agents must be used cautiously.


Although the tetracycline antibiotics have a broad spectrum of activity spanning Gramnegative and Gram-positive bacteria, their value has decreased as bacterial resistance has developed in pathogens such as Pneumococcus, Staphylococcus, Streptococcus, and E. coli. These organisms appear to have evolved mechanisms of resistance involving decreased cell permeability a membrane-embedded transport protein exports the tetracycline out of the cell before it can exert its effect. Nevertheless, tetracyclines are the antibiotics of choice for infections caused by Chlamydia, Mycoplasma, Brucella, and Rickettsia, and are valuable in chronic bronchitis due to activity against Haemophilus influenzae. They are also used systemically to treat severe cases of acne, helping to reduce the frequency of lesions by their effect on skin flora. There is little significant difference in the antimicrobial properties of the various agents, except for minocycline, which has a broader spectrum of activity, and...


Ablative resurfacing was first introduced in the mid 1990s. Technological advancements with carbon dioxide (CO2) lasers had emerged to minimize their thermal impact on tissue and, subsequently, possible clinical uses were explored. Two types of CO2 lasers were developed. The first utilized ultrashort pulse durations to minimize heat deposition in the tissue. The other utilized the laser beam in a continuous wave (CW) mode, in conjunction with a scanning device, to shorten the laser dwell time and, thereby, minimize thermal damage (Lask et al. 1995). These lasers were first used for the treatment of rhytides and acne scars however, investigators soon discovered that superficial sun damage changes, including lentigines, as well as actinic keratoses, fine lines, and other superficial imperfections also improved. Additionally, the deposition of heat was noted to cause a tissue-tightening effect, which softened deeper wrinkles (Fitzpatrick et al. 2000). The CO2 laser proved to be very...


The disadvantage of ablative resurfacing is the significant downtime required during the recovery period. During the first week, erythema and edema are significant, wound care is necessary, and social activities come to a halt. Postoperative edema decreases after the first 3-4 days, whereas the erythema is prominent for the first week until re-epithelialization occurs and slowly diminishes over the next few weeks. The risk of infection, pigmentary changes and scarring is higher in the immediate postoperative period, as it is in any procedure where de-epithelialization occurs. Makeup is necessary for several weeks to months until any residual erythema and postinflamma-tory hyperpigmentation diminishes. Contact dermatitis may be more easily triggered in the postlaser disrupted epidermis, leading to pruri-tis and erythema. Acne, activated by the occlusive effect of the petrolatum or other dressings, is more common in the treated area and may take several weeks to clear. Relative...

Vitamin A

The synthetic retinoic acids tretinoin (retinoic acid) and isotretinoin (13-cis-retinoic acid) (Figure 5.72) are retinoids that are used as topical or oral treatments for acne vulgaris, reducing levels of dehydroretinol and modifying skin keratinization. Dehydroretinol levels in the skin become markedly elevated in conditions such as eczema and psoriasis. Acitretin (Figure 5.72) is an aromatic analogue which can give relief in severe cases of psoriasis. All these materials can produce toxic side-effects.

Biological Implants

The injection of the dermal filler substance has been given correctly if the aesthetically disturbing area is overcorrected and the skin becomes white (blanching effect). This technique can be used to treat all wrinkles in the facial area (glabella, eyes, nasolabial folds, lips), acne and accident scars, and also to augment cheeks and lips. If collagen is to be used, a test must be performed with 0.2 ml of collagen on the inside of the forearm 4 weeks prior to treatment to rule out allergies.

The Future

A variety of medical concerns are now being treated with lasers and light sources. The advent of ALA-PDT has heralded a potentially new era for dermatologists and laser surgeons far beyond the treatment of AKs, BCCs, and SCCs. Now photodynamic photorejuvenation is a common term and photorejuvenation treatments are being enhanced with the use of ALA-PDT. Other entities, including acne vulgaris, hidradenitis suppurativa, and sebaceous gland hyperplasia are being treated with lasers, light sources, and ALA-PDT. Lasers and light sources are also being used to treat psoriasis vulgaris, vitiligo, and other hypopigmented disorders, including hypopigmented stretch marks. Lasers and light sources can now be used to treat both medical and cosmetic dermatologic conditions.

Ampullary Receptors

Skate Ampulla

The ampullae of Lorenzini (AoL) found in sharks, skates, and rays were rst discovered by Marcello Malpighi in 1663 they were described in detail by Stephano Lorenzini in 1678, and bear his name. Anatomically the AoL are relatively simple structures. A jelly- lled canal projects through a pore in the skin. The surface pores of the AoL on the face of a shark give it the appearance of having acne. The canal jelly has a high conductivity due to its high content of Cl- and K+ ions it is probably secreted by the cells that line the pore canal and that surround the sensory cells. The length of the canal is species dependent, but is on the order of 1 to 2 mm. Its diameter

Fat Soluble Vitamins

From dietary P-carotene, present in such foods as carrots, leafy vegetables, and egg yolk. The P-carotene is converted by an enzyme in the intestine into two molecules of retinal. Most of the retinal is reduced to retinol, while some is oxidized to retinoic acid. It is the retinoic acid that binds to nuclear receptor proteins (chapter 11 see fig. 11.7) and directly produces the effects of vitamin A. Retinoic acid is involved, for example, in regulating embryonic development vitamin A deficiency interferes with embryonic development, while excessive vitamin A during pregnancy can cause birth defects. Retinoic acid is also needed for the maintenance of epithelial membrane structure and function. Indeed, retinoids are now widely used to treat acne and other skin conditions.


Testosterone Cypionate Levels

Testosterone enanthate (TE) and cypionate are testosterone esters administered by biweekly or triweekly deep im injection. The usual recommended dose for hypogo-nadal men is 200 mg in 1 mL oil administered every 2 wk. The pharmacokinetics (PK) of injectable testosterone preparations have been carefully studied (73,74), and the PK of TE is shown in Fig. 2. Serum testosterone levels peak within 1 to 3 d after administration, and gradually decline to a trough after 2 to 3 wk. In many subjects, the peak level of serum testosterone achieved in the first few days after an injection may reach a concentration that is higher than the normal adult male reference range. In some patients, the high peaks and low troughs of serum testosterone levels may result in mood swings and acne. In such patients, the dose may be decreased and frequency of the injections increased, for example, testosterone enanthate may be administered at a dose of 100 mg every 7 to 10 d. Most patients can be taught to...

Alapdt Technique

The technique which we use varies depending upon the condition which is being treated. The two most common uses of ALA-PDT in our office setting are (1) for photodynamic pho-torejuvenation, and (2) for the treatment of moderated to severe acne vulgaris. Both techniques are described below. For the treatment of moderate to severe acne vulgaris, the procedures previously outlined are once again utilized. For our acne patients, we typically treat patients every other week for up to four visits, all dependent on the patient's response to the therapy.

Neurologic disease

Physical appearance is altered by weight gain that produces truncal fat deposition (moon facies, buffalo hump), hirsutism, acne, easy bruising, and purple striae. Although individual patients differ in their susceptibility to these changes, reduction of the steroid dosage will eventually reduce the severity of these manifestations.

The Onset of Puberty

Physiology Puberty

Menarche (first menstrual flow) Axillary (underarm) hair Eccrine sweat glands and sebaceous glands acne (from blocked sebaceous glands) Growth of testes Pubic hair Body growth Growth of penis Growth of larynx (voice lowers) Facial and axillary (underarm) hair Eccrine sweat glands and sebaceous glands acne (from blocked sebaceous glands)

Anabolic Steroids

Virilization in the woman is the most common reaction associated with anabolic steroids, especially when higher doses are used. Acne occurs frequently in all age groups and both sexes. Nausea, vomiting, diarrhea, fluid and electrolyte imbalances (the same as for the androgens, discussed previously), testicular atrophy,


Cutaneous side effects include acne, hirsutism, striae, purpura, and impaired wound healing. Osteoporosis, myopathy, and aseptic necrosis of bone may occur. Gastrointestinal side effects include peptic ulceration with bleeding or perforation and pancreatitis. Hypertension and edema secondary to fluid retention occur. Steroid psychosis and benign intracranial hypertension are the central nervous system adverse reactions. Ocular effects include cataracts and glaucoma. Patients may suffer growth arrest, secondary amenorrhea, impotence, and suppression of the hypothalamic-pituitary-adrenal axis. Glucose intolerance, hyperosmolar nonketotic coma, and centripetal obesity occur. The risk for infection is increased. Intraarticular corticosteroids may cause a crystal-induced transient synovitis. Immobilization and ice compress will facilitate resolution persistence of the synovitis beyond 24 hours raises the possibility of an arthrocentesis-related infectious arthritis. Topical steroids,...


Administration of the progestins by any route may result in many adverse reactions, although the incidence and intensity of these reactions varies. Progestin administration may result in breakthrough bleeding, spotting, change in the menstrual flow, amenorrhea, breast tenderness, edema, weight increase or decrease, acne, chloasma or melasma, and mental depression. In addition to the adverse reactions seen with progestins, the use of a levonorgestrel implant system may result in bruising after insertion, scar tissue formation at the site of insertion, and hyperpigmentation at the implant site. The use of medroxyprogesterone acetate contraceptive injection may result in the same adverse reactions as those associated with administration of any progestin.

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