Self Care Exam 4

Fat soluble vitamins

A, D, E, K

Lindane 1% (as a lotion, shampoo)

Active ingredien: gamma benzene hexachloride. MOA: CNS stimulant- causes seizures and death of the parasite. Indications (for lice or scabies). WARNING: use with caution in patients who weight <110 pounds (50kg) Use with caution in infants, children and the elderly. Contraindicated in premature neonates and pts with seizure disorders. American Academy of Pediatrics- no longer recommends it as treatment. Efficacy: 45-75% cure rate. Adverse reactions/toxicity: highly lipophilic, neurotoxic, CNS stimulation + seizures. MID 2003 FDA changed prescribing info: very strict guidelines for use: one time applications only Applied to DRY hair- only left on for 4 mins RINSE WELL!!! Do NOT repeat. FDA- a 2nd line treatment only for pts who have failed other therapies.

DEET (N,N- diethykmetatoluamide) (OFF, Skintastic, many others)

Activity: repels a variety of mosquitoes, chiggers, ticks, fleas... Concentrations available= highly variable Adults: 10-50% duration ~2-6 hrs.... 100% lasts up to 10 hrs. The higher the strength= longer duration, NOT increased efficacy. 10-30% appropriate for regular activity. Higher strengths for camping & hiking. Follow the age restrictions- READ the LABELs!. Ex: children >2 months...may use up to 30% once daily.

skin reactions to sunlight

Acute reactions: sunburn, suntan. Pathophysiology of suntan: Melanin: black-brown pigment that gives skin its color, introduced into keratin; incorporated into the stratum corneum. Function= protect the skin from UVR. UVR effects: UVA: increase melanin production by melanocytes in basal layer. UVB: increase in # melanocytes & stimulates their activity, increase epidermal turnover (melanin moves up through skin) Result: increases the tolerance to additional sunlight, reduces the likelihood of subsequent burning. NOTE: Dark skin is NOT immune to sunburn.

Vitamin B12 (cobalamin) Cyanocobalamin (inactive) ---> methylcobalamin (active) vitamin coenzyme involved in red blood cell production, neurological function, and DNA synthesis

Adult RDA= 2.4 mcg/day Sources of B12: animal products only! (dairy, eggs, fish, meat, poultry)- primarily methylcobalamin. Fortified cereals & grains- usually cyanocobalamin. Dietary supplements- usually cycanocobalamin, methylcobalamin may be used. Bioavailability: Animal sources- B12 is bound to protein in food, is seperated from the protein by the activity of gastric acid which activates pepsin. Cobalamin must then bind with the gastric protein intrinsic factor for intestinal absorption. Fortified foods or dietary supplements- B12 is already in the free form, still requires intrinsic factor for intestinal absorption. populations of concern: vegans/ strict vegetarians. Adults >50yo why? atrophic gastritis/aclorhydria- a deficiency of stomach acid secretion. (10-30% of the older population) people who regularly use protein pump inhibitors (PPIs) patients on long term metformin therapy. Recommendation: in populations of concern: eat foods that are forified with and/or take a vitamin B12 supplement.

Water soluble vitamins

C- antioxidant, immune function, blood vessels, collagen/connective tissue B1-12 B1- thiamine B2-riboflavin B3- niacin B5- pantothenic acid B6- pyridoxine B7- biotin B9- folate B12- cobalamin- stored in liver

Vitamin D

D2 (ergocalciferol)- food sources, supplements, and fortified foods D3 (cholecalciferol)- food sources, supplements, and fortified foods; made in the skin

Sunless tanning products do NOT protect against UV radiation

DHA- a topical pigmenting agent; a chemical that darkens the skin MOA: interacts with the keratin in the stratum corneum to produce an artificial suntan. Key points: may stain hair or clothes, may not look natural, must be applied evenly, dry areas of the skin absorb more (knees, elbows) wears off in about 5-7 days.

cryotherapy/freezing: not more effective, works quicker and allows for not everyday treatment, NOT a DRUG

DMEP (dimethyl ether + propane): The product is "activated" at the time of application to creat the COLD. Example products- appropriate for >4yrs. READ directions. AEs/warning: pain, tissue death, nerve damage and scarring may occur if used inappropriately. may only treat one wart on either hand or foot at one time. Expected results: skin may turn white, a blister will form under the wart. After ~10-14 days the wart will fall off, with new skin developing underneath. If it does not fall off: repeat application is allowed after 14 days up to a total of 3 times

comparison: the disruption in the normal turnover & desquamation of cells causes a spectrum of diseases:

Dandruff< seborrhea < psoriasis

Attenuation or Potentization

Decimal scale (1/10) is used to make "X" potency drugs Centismal scale (1/100) is used to make "C" potency drugs

Treatment of corns & calluses

1. try to remove cause of pressure and friction, discussing appropriate shoes 2. non-drug: soak the feet for 5 min in warm water to ease removal of dead tissue. Remove tissue gently- towel, callus file, pumic stone. Cushion the affected area with corn/callus cushions. DISCOURAGE: use of razor blades to remove the corn/callus. Drug therapy: salicylic acid: soft corns are usually treated for 3-6 days. Hard corns and calluses treated for up to 2 weeks. Follow manufacturer directions.

Penlac

Rx only nail lacquer, requires treatment for 1 year. applied to nail and under nail rim daily X6 days, each layer on top of the prior layer. Once a week the lacquer is removed with ISOPROPYL ALCOHOL.

Exclusions to self care fungal infections

any doubt as to what the infection is involvement of the face, scalp, nails, or gential. oozing purulent material (indicated bacterial infection) extensive area, extreme inflammation, debilitating, excessive and continuous weeping. Diabetes, immune deficiency (as evidenced by medical condition or drugs)

calluses

areas of diffuse thickening of skin, often raised, yellowish, skin ridges normal. Typically, they have indefinite borders. May be broad and based and cover a larger surface. May be small with a translucent central core. Usually raised, yellow, has normal pattern of skin ridges. Form on joints or weigh bearing areas (palms, soles or sides of feet)

hyperpigmentation

areas of increased or more intense skin color; cosmetically unacceptable for many patients

Melasma/cholasma- darkened areas that occurs on face/neck

associated with hormone changes such as: occurs often in pregnancy, "the mask of pregnancy"; hormonal contraceptive use.

Terbinafine + Butenafine

athlete's foot between toes >12 yo

Eggs/Nits= oval egg capsules

attached (glued) to the base of hair shaft near the scalp; hatch in ~8-9 days. Unlikely to hatch away from warmth of the scalp.

scabies- clinical presentation... can be difficult to diagnose...why?

burrows may not be visible. If seen, pimple-like rash or burrows (narrow dark bluish lines or raise bumps or blisters). Lesions btw fingers, wrist flexor surface, male genitals, buttocks, breasts, neck, arm pits. A generalized rash may appear on the body of some patients. INTENSE itching; itching may be generalized to non-infected areas. Itching can be especially intense at night. Itching can persist for weeks after being treated.

non-inflammatory lesions

closed comedo= white- microcomedo enlarges; visible as a small nodule just under the skin open comedo= black- material accumulates behind plug, follicle opening dilates; plug protrudes

Signs/symptoms of seborrhea

common occurence in hairy areas ( especially the scalp) beard, moustache, can involve the face, nose, forehead, ears, chest, back. Oily yellow scales that are greasy looking. Red/yellow lesions. Itching and an underlying redness/inflammation of the skin. A wide spectrum of presentation, mild dandruff like to dense scales.

Yohimbe

common use: ED Efficacy: POSSIBLY EFFECTIVE ADRs: dose related, hypotension, hypertension, NE release, dizziness, CNS stimulation

Milk Thistle ** is in Asteraceae FAM

common use: Liver health Efficacy: conflicting

Panax ginseng (asian ginseng)

common use: adaptogen (cure all) efficacy: conflicting evidence ADRs: nervousness (with excessive use) Drug interaction: decreased INR

Kava Kava

common use: anxiety Efficacy: POSSIBLY EFFECTIVE ADRs: with excessive use: yellow dermopathy. Toxicities: hepatotoxicity.

horse chestnut

common use: chronic venous insufficiency (CVI) (varicose veins or hemorrhoids?) efficacy: LIKELY EFFECTIVE!!

flaxseed

common use: constipation ADRs: GI related

Gingko biloba, leaf extract

common use: dementia (does not improve memory) Efficacy: conflicting evidence ADRs: bleeding Toxicities: only seen with seeds (not what we use in this product)

St Johns Wort (hyperforin)

common use: depression Efficacy: LIKELY effective ADRs: photosensitvity (dose related) CYP450 inducer (CYP3A4= major)

cinnamon (cassia)

common use: diabetes, improving glucose control Efficacy: conflicting evidence

Hawthorn

common use: heart failure (NYHA I + II) Efficacy: possibly effective (positive ionotropic effects)

Turmeric (curcumin): extremely low bioavailability- enhanced absorption with black pepper or fatty substance

common use: pain reliever, reducing inflammation Efficacy: POSSIBLY EFFECTIVE ADRs: GI upset

Evening Primrose Oil

common use: skin (atopic dermatitis, psoriasis, dry eyes?) Efficacy: conflicting evidence ADRs: GI related

Saw palmetto

common use: symptoms of BPH (mild-mod) (if men are not already taking a medication. Efficacy: conflicting

topical alternative therapy: tea tree oil (melaleuca alternifloia)

common use: topically used for bacterial and fungal skin infections (acne, ringworm, athlete's foot, nail infections) active ingredient is unknown; contains multiple terpenoid compounds strong antiseptic properties has ability to penetrate pus) used as wound treatment in WWII, abandoned when antibiotics were developed. MOA: possess antibacterial & antifungal properties; disrupts cellular membranes. spares the normal skin flora. Safety: possibly safe when used topically and likely unsafe when used orally. possibly effective for acne

Billberry (Vaccinium myrtillus)

common uses: Retinopathy- POSSIBLY EFFECTIVE for improving retinal lesions: Diabetic, HTN. Night vision- POSSIBLY INEFFECTIVE. ADRs/Drug Interactions/Toxicities- no major concerns

picaridin (cutter advanced)

comparable to DEET in effectiveness, better smelling, more cosmetically appealing, less irritating. Picaridin 7% = ~DEET 10%.

Red Yeast Rice

contains compounds known as monacolins. Monacolin-K... is identical to HMG-coA reductase inhibitor lovastatin (mevacor) cholestin= literally contained lovastatin THEY ARE NOT SUPPOSED TO contain lovastatin but some do. They may contain small amounts of other statin-like compounds or sterols. think of as a statin (do not combine with statin) adverse effects/drug interactions: same as statins likely effective- cholestin

considerations in the treatment of SUNBURN

cool/cold baths and cold compresses may help releive pain. Oral analgesics may be used to relieve pain: NSAIDs are superior in the first 24 hrs, should be taken on a scheduled basis. skin protectant/moisturizers, careful use of local anesthetics- give appropriate counseling.

Duct tape

cut to wart size and applied to wart area and left on for 6 days. Tape removed, wart oaked and debrided (pumice, emery board) tape left off overnight. Reapply tape for 6 days and repeat above. Treatment continued until wart removed or up to a total of 2 months.

cytostatic agents: 1st line for dandruff

decrease the production of corneocytes and subsequent scaling. Ex. pyrithione zinc, selenium sulfide, coal tar.

considerations for superficial partial thickness burns

difficult to use ointment bases on weeping, oozing lesions. Becuase the skin is broken-infection risk is greater: antibiotic ointment/cream is appropriate. topical anesthetics can be absorbed through open skin (lidocaine should not be used on large areas of broken skin). Dressings need to be a type that can handle an oozing burn/ a "non-stick" type.

Method of transmission of lice

direct physical contact with an infected person. Fomites: inanimate objects that transmit disease (hats, combs, towels, pillows). Lice do NOT jump or fly, they come off. Important note: LICE can effect anybody and everybody. Lice don't discriminate! Has nothing to do with cleanliness.

localized tissue destruction

direct- irritation caused by FFA production. indirect- inflammatory response due to neutrophils complement activation.

insulin strength

doses are calculated and administered in "units" of insulin USA standard for most insulin products= U100

arthropod stings- bees, wasps, yellow jackets, some ants

immediate pain- is a normal reaction. Local reaction- redness and swelling, typically disappears in 4-6H. some patients may have edema for up to a week. Some pts may develop papules or vesicles that itch and are painful. Anaphylaxis ~3-4%; usually occurs within 15-60 mins. life threatening. Immediate attention needed.

Infant onset of seborrhea= "cradle cap" - a temporary condition of infancy; usually disappears by age of 6 months; can last 8-12 months.

in terms of self care: scalp hygiene. Frequent shampooing with baby shampoo. Parents may also rub head with baby oil. Parents can also brush the scalp with lil soft brushed

Jock Itch

groin area; inner upper thigh well demarcated lesions fine vesicles may be present; fine scales; significant itching usually spares the penis/scrotum

sleep hygeine

habits around bedtime (stimulus control)

pilosebaceous unit

hair follicle + sebaceous gland

azelaic acid (azelex)

has some antimicrobial activity against C.acnes, less irritating than BPO.

"individualized therapy"

homeopathic remedies are chosen after all the dimensions of the person have been analyzed.

infection process

incubation period; averag 3-4 months (range is 1-9 months) virus assembles in the nuclei of upper layer keratinocytes released into the stratum corneum increased cellular turnover (hyperkerotonic lesions)

Arthropod bites- mosquitoes, fleas

local reaction- redness/swelling, itching. Delayed, more intense itching can occur later.

Melanocytes

located in the basal layer of the epidermis, but their projections go upward into the upper layers. Synthesize melanin; incorporates into cells as they are keratinized & move upwards in the stratum corneum. Melanin: a brown-black pigment that is produced from the oxidation of tyrosine. Function: protect us from UV radiation.

acute ulcerative

macerated, weeping ulcerations on the sole of the foot, odor and white hyperkeratosis often present, often complicated by bacterial infection, often painful; may inhibit the ability of the patient to walk

Nymph

matures into an adut ~9-12 days; females lay eggs ~1.5 days into adulthood. Hatched nymphs require blood meal within hours (of hatching) to survive. Takes about 3-4 days to develop an intact nervous system.

Risk factors of fungal skin infections:

skin trauma occlusions of the skin warm/humid climates or conditions environmental (use of public pools and showers) diabetes mellitus/ immune compromised/ poor circulation

bevel

slanting edge that facilitates injection

vesicular type

small vesicles or vesicopustules, scaly skin, usually involves the instep or mid-anterior plantar surface

solar lentigo/solar lentigines ("age spots", "liver spots")

small, flat, distinct colored areas of skin that appear on exposed surfaces. Is one of the possible consequences of photodamaged skin. Chronic UVB exposure causes melanocyte proliferation (2X normal in affected areas). Persist (they do not come and go)

corns

small, raised, sharply demarcated lesions with a yellow/gray color. Have a central core. Usually become painful.

cleanse

soap&water hydrogen peroxide solution: oxygen reaction is bactericidal, physical action of the reaction helps debride the wound.

Neoplastic disorders/ skin cancer

solar keratosis (aka actinic keratosis) A precancerous condition. If left untreated, usually progress to squamous cell carcinoma. 60% of squamous cell cancer start as solar keratosis, usually a sharply demarcated, roughened or hardened growth. Dry, scaly, pink to red, usually <1cm diameter. Most common non-melanoma skin cancers- if identified early and treated, most are curable, basal cell carcinoma, squamous cell carcinoma. Malignant Melanoma. Risk factors for skin cancer: FH/personal history of skin cancer. Easily sunburned; have dificultly tanning, large number of atypical moles, use of tanning beds, history of excessive sunburn and sun exposure. Photodermatoses: triggered by certain types of radiation. UVB is responsible for most reactions. UVA and visible light may contribute to some of the disorders Examples: polymorphic light eruption (PMLE) Photo aggravated disorders: herpes simplex (cold sores), melasma, chloasma, rosacea, systemic lupus erthmatosis, solar urticaria (hives)

Boils (furuncle)

staph skin infection which involves a hair follicle symptoms: include a tender pea-sized (or larger), red nodule. May ooze, pus, or weep. treatment: warm/hot compresses. Topical antibiotics minimally effective. Draining/oral antibiotic often required physician referral if painful/severe. refer to a physician if boil is very tender and painful, if it has red lines radiating from it or if it is accompanied by fever and chills.

sleep maintenance

staying asleep

Pathophysiology of fungal skin infections

stays in stratus corneum some get an immune reaction spreads outward, not inward

Caffeine (Guarana, kola nut, yerba mate/Mate, Black/Green tea)

studies were of caffeine + ephedra, or caffeine + low fat diet. Rated as possibly effective; conflicting evidence.

Seborrhea

subacute or chronic inflammatory disorder that occurs predominately in the areas where there is sebaceous gland activity (scalp, face, and chest/back).

Tired, aching feet

treatments: padded shoes, better shoes more often, better work surfaces. Insoles- need to be able to fit into the shoe. heel cushion/heel cups

volume

various 3/10cc 1/2cc 1cc 3cc 5cc

length

various 1/2in 1in 1.5in 5/8 in 5/16 in

salicylic acid (0.5-2%)

lipophilic is able to penetrate into the pilosebaceous unit MOA= ketatolytic ADR: drying

Grade IV/severe

severe/persistent pustulocystic acne nodules or cysts lesions >5mm diameter extensive scarring

% Daily Value (DV)

(# nutrient per seving/ RDI) X100

drug treatment fungal infections

Aluminum acetate: are used only IF needed for certain athlete's foot symptoms Not a standard therapy. Appropriate for initial management of inflamed/ weeping wet forms of athlete's foot Goal: convert the inflamed/ wet type into a type that is more dry Soak the feet in or apply by wet dressings 20 minutes 1-3X/day Do not use for more than 7 days. Antifungal agents: adherence is important (therapy is going to take weeks) it is contagious creams/solutions are what you want for treatments (powder/sprays for prevention) Dosage forms: creams & solutions- more effective for treatment b/c they are rubbed into the skin powders and aerosols are OK as adjunct treatment or prevention proper application: affected area should be cleaned and dried well. Massage drug into the skin (if a cream/solution) wash hands well after applying the medication. Most products have BID application. Some improvement should start with 1 week. If no improvement within this time frame, refer to physician. If improvement starts, continue treatment for recommended duration. Once the skin is improved, keep using the drug for 2 more weeks.

age related macular degeneration.

An incurable eye disease. The leading cause of blindness in people >55yo; effects>10 million Americans. Caused by the deterioration of the central portion of the retina (macula). The macula is responsible for focusing central vision in the eye. It controls the ability to read, drive, recognize faces or colors, and see objects in fine detail. Wet (neovascular) Dry( atrophic) AREDS: Vit C 500mg, Vit 400 IU, Copper (as cupric oxide) 2mg, Beta carotene 15mg (equiv- 25,000 IU vitA), Zinc (as zinc oxide) 80mg Changes for AREDS2= Betacarotene--> 10mg lutein 2mg zeaxanthin Zn 80mg--> 25mg "Eye" supplements: optometrists/opthalmologists might recommend for patients with AMD to delay progression of the disease. Lutein is one of many carotenoids located in the retina of the eye.

Exclusions to self care burns

Burns to BSA >2% AND blistering burns involving the eyes, ears, face, hands, feet, genitals chemical burns electrical burns elderly patients patients with diabetes patients with mutiple medical disorders immunocompromised patients burns that have worsened or failed to improve in 7 days.

Calcium

Calcium rich foods: dairy- cheese/yogurt/milk, fortified orange juice/cereal/breads/grains. Dark greens (kale, turnip and collard green) sardines. Who needs supplements?- anyone who is not getting the RDA for calcium from their diet. RDAs for calcim are based on age/sex and menopausal status. >18yo: varies btw 1000-1200mg of elemental calcium. At risk: postmenopausal females, vegetarians, milk allergey/lactose intolerance... UL: Adults: 2500mg, >50yo: 2000mg calcium absorption depends on salt form: calcium carbonate (40% elemental calcium) (caltrate, OsCal, TUMs): an insoluble salt; requires stomach acid for proper absorption. MUST be taken with food. Keep in mind: pts on H2As/PPIs may not be able to absorb calcium from this salt. 10-30% of adults >50yo have decreased secretion of stomach acid calcium citrate (21% elemental caclium) Citracal): A soluble salt; is absorbed equally with or without stomach acid. May be taken with or without food. Efficiency of absorption: maxed out at 500-600/dose. **ASSESS the diet before you make a recommendation.

Head lice (Pediculus humanus capitis) wingless parasites of humans.

Characteristics: Louse (adult) 2-3mm length Injects saliva (anticoagulant/vasodilator) into scalp; feeds on blood every 3 hours Lifespan ~3-4 weeks; lays up to 10eggs/day once matured. If they come off the scalp, they can only live for about 24 hours off the host.

Types of sunscreens:

Chemical sunscreens: MOA: absorb radiation to prevent radiation from penetrating into the skin, different chemicals are able to absorb different wave lengths, most products use a combination of ingredients to cover wave lengths. Ecamsule: broad spectrum 280-400 9covers all of UVB + UVA) Avobenzone: only UVA, PABA- a lot of photosensitivity reactions (lots of products are now PABA free) Physical sunscreens- chemically inert pigments; stay confined to upper epidermis. MOA: reflect light and scatter it. Ingredients: Titanium dioxide, Zinc oxide: BLOCK BOTH UVA and UVB, do NOT cause photo sensitivity.

Scaly dermatoses Background

Desquamation- the process by which the corneocytes of the stratum corneum are shed. The enzymes that break the bonds between the corneocytes of the stratum corneum are shed. The enzyme the break the bonds between corneocytes requires proper skin hydration to function. A balance between formation and shedding exists. Normal turnover rate= 25-30 days. Flaky, scaly skin and plaques can result from the buildup of coneocytes.

Signs/symptoms of dandruff

Diffuse scaling visible on the scalp, especially on the hair shaft. An abundance of dry fine silvery gray scales removed easily by brushing the hair. Itching may be present but often is only a cosmetic problem.

Factors that exacerbate acne

Drugs: phenytoin, isoniazid, Moisturizers, phenobarbital, lithium, ethionamide, steroids environmental- increased hydration of skin (high humditiy, excessive sweating) occupational- ex. vaporized cooking oils, industrial chemicals (petroleum based) increased friction cosmetics/hair products increased androgens stress

Adult onset seborrhea: typically presents after puberty most commonly btw age 30-60.

Etiology- exact cause is unknown. Stress can be an aggregating factor. Men 6X>women. Infectious (fungus pityrosporum ovale 82%; may be a factor in some patients) Seen up to 85% in HIV patients (opportunistic) - this strengthens the likelihood of a fungal cause. Pts with CNS diseases such as Parkinson's or certain paralyses have increased incidence.

Dandruff: a non-inflammatory, hyperproliferative disease of the scalp. A precursor to or a mild form of seborrheic dermatitis.

Etiology: exact cause is unknown, possible correlation with the fungus Pityrosporum ovale. (found in up to 74% of dandruff patients; and only 45% in patients without danduff)

keratolytic agents- encourage the sloughing off of dead corneocytes): 2nd line for dandruff

Ex. salicylic acid, sulfur

Treatment of dandruff

Goals: Decrease cellular turnover, minimize cosmetic embarrassment caused by scaling and itch. Non-medicated shampoo: Wash hair QD or QOD, massage scalp well to break up flakes, brush hair well to remove any flakes. (massage the scalp). Medicated shampoos: contact time with the scalp is v. important. Leave shampoo on scalp for the time recommended by manufacturer (usually 3-5min). Apply/Rinse/Repeat application/rinse well. Medicated shampoos are generally applied only 2-3X per week until condition is controlled... and then once every 1-2 weeks prn to keep it under control.

management of acne

Goals: identify and avoid factors that aggrevate acne (if possible). Prevent new lesions from occuring, prevent scarring. Improve appearance of skin. Self care: non-inflammatory acne: mild-mod, mild papular referral to physician:mod-severe acne/inflammatory lesions (papules, pustules, nodules are more extensive). Lesions present on the back or chest area. Acne associated with a drug. Acne persists beyond mid-20s or starts in mid 20's or later. Time= at least 6 weeks to heal, really deep pustules may need 12 weeks. Prevent new lesions from forming 2-3 months.

Initial treatment of minor burns (superficial and superficial partial thickness)

Goals: relieve the pain, protect the area, minimize infection or scarring. First Aid/initial treatment: immerse the area in cool/cold tap water (NOT ice water for 10-15 minutes)- decrease vasodilation, helps with redness and swelling, helps prevent blistering. Cleanse: with a bland gentle soap, AVOID alcohol and hydrogen peroxide.

Proliferation of curibacterium acnes (c. acnes)

Gram (+) anaerobe, part of the normal flora of the follicle. Sebum is a nutrient medium for C. acnes. Increased sebum= increased quantity of C. acnes. Digestion of sebum by lipase enzymes produces free fatty acids (FFA). C. acnes produces proinflammatory mediators.

Green Tea/EGG

Green tea and green tea extracts contain 2-4% caffeine EGCG (epigallocatechin gallate)- one of the catechin ingredients in green tea INSUFFICIENT evidence to rate its use for obesity

Caffeine dietary supplement sources/OTC

Guarana, Yerba mate, Kola nut OTC drug products; approved for >12 yo NoDoz 200mg caffeine per tablet; Directions:1/2-1 tablet not more often than every 3-4 hours. Vivarian 200mg; Directions: 1 tablet not more often than every 3-4 hours Adverse effects: Excessive caffeine intake: Nervousness, irritability, sleeplessness/insomnia, rapid heart rate. Take without caffeinated liquid. Withdrawal symptoms: throbbing headache, fatigue, anxiety. May start in 12-24 hrs; peak in 24-48 hrs and persist up to 7 days

Lemon Eucalyptus oil

LEO 30%= DEET 10% NOT to be used <3 yrs of age. Recognized by CDC.

Spinosad (Natroba, 0.9% suspension)

MOA- causes neuronal hyperexcitation which causes the paralysis and death of the parasite. Indications: head lice for patients 4 years and older. Advantages: has showen superior efficacy to permethrin, reapplication is NOT required. Adverse effects: is associated with local reactions: erythema, irritation, May cause irritation of the eyes. Application: apply to DRY hair and rub gently into scalp until all hair is saturated starting at the back of the neck and behind the ears. Leave on for 10 mins. Rinse out well with water. Repeat application in 7 days ONLY if live lice are seen.

alpha-hydroxy acids (AHA)

MOA- keratolytic cause detachment of keratinocytes with eventual normalization of keratinization. Penetrates into the stratum cornem; increased water retention in skin (due to pH changes) results: smoother and more elastic skin; reduction of fine lines; normal pigmentation. Ingredients: glycolic acid (sugar cane) lactic acid (milk), other stuff. AHAs are water soluble- they do not penetrate down into the pores. They need to stay on the skin to work; skin washes not likely effective. Adverse effects: IRRITATION: transient stinging, burning, and dryness is common. Redness, itching, pain, and possibly scarring. People with darker colored skin are at increased risk of scarring/pigment changes. Sun sensitivity- increased sunburn risk. People MUST wear sunscreen on their face. FDA guidelines on AHA: must < or = 10%, pH of 3.5 or higher, requires labeling about the need to use sunscreen.

Salicyclic acid

MOA- keratolytic the only GRAS/E drug for OTC treatment of common & plantar warts lower concentrations are appropriate to use on thinner epidermal areas higher concentrations are best used on thicker areas (the soles of the feet) available as: collodion liquids/gels (salicyclic acid 17%) may be applied 1 or 2 times/day. plaser- may be cut to fit the area variable concentrations (salicylic 12%-40$) Examples: Dr. Scholl's, Duofilm, ccurad) variable directions- read the label for application directions Patient education: treatment takes time. Improvement should start in 1-2 weeks. Treatment should be complete in 4-12 weeks. If not completely gone in 12 weeks, refer to physician. pt should find a convenient time to prepare the site and apply the medication. Skin prep/application: OPTIONAL- soak the area for 5 minutes to hydrate the stratum corneum. Wash the wart area, use a rough wash cloth or emery board to gently remove the dead tissue, dry the area, apply according to the directions of whatever dosage form they chose. optional tip: . you can put vaseline around wart area, to help protect.

Benzyl alcohol (ulesfia 5% lotion)

MOA- physical MOA. Causes the lice to become incapable of closing their respiratory spiracles. The vehicle of the product obstructs the respiratory spiracles. Lice die by asphyxiation. DOES NOT kill nits, therefore reapply in 7 days, shouldn't develop resistance. Indication: head lice for patients 6 months and older. Advantages: low toxicity; resistance should not develop to its MOA. Disadvantage: reapplication= required. associated with skin reactions: contact dermatitis, hypoesthesa, itching, irritation, pain. YOU have to use a lot and it's very expensive. Apply to DRY hair and rub gently into scalp until all hai is saturated starting at the back of the neck and behind the ears. Leave on for 10 minutes. Rinse out well. Repeat application in 7 days in REQUIRED.

Benzoyl Peroxide (BPO) (available in 2.5%,5%, 10% formulations)

MOA: Bactericidal against C. acnes. Free oxygen radicals are released, free radicals oxidize cell membrane proteins, a physio-chemical reaction= no resistance. keratolytic: helps break follicular blocking, takes 2 months to see full effect. Appropriate for mild-mod non-inflammatory & inflammatory acne. Clinical response is different with different formulations: gels- more drying, more effective, more irritating creams/lotions (water based)- may counteract the drying and peeling effect. washes and cleansers- have little clinical effect adverse effects:dose related- excessive drying, redness/stinging/burning, flaking/peeling. bleaching, photosensitizing, apply at bedtime

Orlistat (Alli)

MOA: Intestinal lipase inhibitor (enzyme that breaks down dietary fat). Decreased lipase activity, decreased fat absorption= more fat stays in the stool. Fat lost in the stool= calories not absorbed (9cal/gm)= weight loss. What to expect?50% more than diet alone. Required lifestyle modification: must be a low fat diet, <15g of fat per meal. Dosing/adminstration: 1 capsule TID; take during or up to 1 hr after eating a meal. IF a meal is missed or contains no or very little fat- the dose may be skipped. GI side effects: oily spotting, flatulence with discharge, fecal urgency, fecal incontinence. Usually seen in the first 1-2 months; usually mild to moderate. Specific recommendation for nutritional supplementation: multivitamin at bedtime. Drug interactions: cyclosporine- absorption is decreased; do not use warfarin- vitamin K may be affected, consult with medical provider levothyroxine- may affect absroption, consult with medical provider seizure medications; amiodarone (pending)

Ivermectin lotion (skilice 0.5% lotion)

MOA: binds to chloride channels in invertebrate nerve and muscle cells.. resulting in the paralysis and death. Indications: head lice in patients 6 months of age and older. Efficacy: 75% cure rate with a single application. Directions for use. Apply to DRY hair and scalp. Completely cver the scalp and hair starting at the back of the neck and behind the ears. Leave on for 10 mins. Rinse well with water only. Repeat application NOT needed.

Malathion (ovide 0.5% lotion)

MOA: organophosphate; cholinesterase inhibitor, acetylcholine accumulation at receptor sites. rapid death of insect and ova. Bonds to sulfur in hair proteins; provides residual activity. Efficacy: 95% cure rate with a single application. Indications; head lice in patients 6 yo and older. Advantages: high efficacy rate and residual activity; low toxicity. Disadvantages: long application time, unpleasant odor, highly flammable!!!!!!! NO hair dryers. Directions for use: Apply to DRY hair and rub gently into scalp until all hair is moitened starting at the back of the neck and behind the ears. Allow it to dry naturally, NO HEAT!!!! Leave on for 8-12 hours. Wash the hair with non-medicated shampoo. Rinse and comb hair to remove dead lice and eggs. Repeat in 7-9 days ONLY if live lice are detected.

sulfur (3-10%)

MOA= keratolytic ADR: drying, odor, color

Hair Issue: preparation- lice

MOST products are applied to DRY hair. (pyrethrins, malathion, benzyl alcohol, spinosad, ivermectin, (and lindane). The EXCEPTION= permethrin (Nix) is a creme rinse- is applied after washing the hair. A plain shampoo MUST be used to wash the hair. Do NOT use a combination shampoo/conditioner or conditioner before using Nix. The conditioner will leave a film on the hair that interferes with residual effect of the drug. The hair should be towel dried well; the hair should be damp- not wet! If hair is too wet the medication will be diluted.

Non-drug treatment of scabies

clip nails to avoid excoriation of the skin and for application of medicine. Launder clothes and sheets in hot water.

2 major reasons for sunscreen failure:

NOT applying enough NOT reapplying enough How much is needed? an oz. (2 tbsp) for an average adult in a swimsuit to get everywhere. When to apply/reapply: At least 15 mins before sun exposure to allow for penetration and binding. Non-water resistant products should be reapplied every 2 hours. Water resistant products shold be reapplied after 40-80 min of activity ( on the label) THE AAD and the SCF: use at SPF 15 for most individuals starting at 6 months of age. Regular use of SPF 15 through age 18 yo will decrease NON-melanoma cancer by 78%. Infants <6months should be kept out of direct sunlight. HOWEVER: there has been an increase in mealnoma skin cancer with sunscreen use.

Aloe vera gel- an alternative therapy widely used topically for burns/sunburns

Natural product may suppress bradykinin, prostaglandins, may have antibacterial & antifungal properties) Controversy about whether processed products retain any of the properties of the natural product. For sunburn: It is moisturizing, cooling, and soothing. Comes with and without an anesthetic ingredient. Insufficient evidence to know if it is effective for healing burns. Possibly safe, topical aloe is well tolerated.

Garlic (Allium sativum)

POSSIBLY EFFECTIVE for hypercholestrolemia. Likely safe when used appropriately. Adverse effects: Most common- GI upset, bad breath, body odor. Effects on bleeding. Garlic oil, aged garlic, fresh garlic and garlic powder: can inhibit platelet aggregation by interferring with thromboxane synthesis. Raw>cooked. GARLIC=bleeding it's real, adverse effects in humans have been reported. Stop 14 days before surgeries (any herbal products)

Self-care of asthma may be appropriate IF:

Patient has a diagnosis of asthma symptoms are mild, symtpoms of intermittent asthma and last <24 hours. Short-term treatment of mild symptoms (<24 hrs) until patient can be seen by a doctor.

Vitamin E

alpha tocopherol

Scabies- a microscopic parasitic arachnid mite

Process: The mite burrows into the stratum corneum. The mite excretes feces and lays eggs within the burrowed tunnels. larvae hatch in 3-4 days and mature into adults. Sensitization to the mites occurs ~1 month... causing ITCHING. If infestation re-occurs, the itching appears ~3-4 days b/c sensitization has already occurred.

Scabies high risk groups

Prolonged direct skin to skin contact, clothing, sheets. Poor hygiene, crowded conditions... example: nursing homes

Multivitamin use

Purpose: people that don't eat enough variety of foods. Who might benefit? Those who eat poorly due to disease, socioeconomic status, substance/EtOH abuse. Those who eliminate entire food groups from their diet. Those with malabsorption problems.

OTC pediculicides for LICE

Pyrethrins+ piperonyl butoxide ("synergized" pyrethrins) Available as liquid, gel, shampoo, mouse... examples= RID, A-200). Pyrethrins are insecticide oleoresins derived from Chrysanthemum cinerariafolium. Patients allergic should avoid use. MOA- pyrethrins- neurotoxic; blocks neuron repolarization. Acts on nerve cell membranes of the parasites, disrupts nerve impulses that control breathin muscles... causing paralysis and death of the louse. Piperonyl butoxide: a petroleum derivative; enhances effectiveness of pyrethrins by inhibiting ezymatic destruction of pyrethrins by the parasite. Indications: age-2yrs and over for head lice. Has OTC labling for pubic and body lice as well. Efficacy: 75% cure rate (from a sinlge application) ~95% after 2 aplications. A repeat application in 7-10 days is REQUIRED!! Limitation: no residual activity after rinsing it off the hair. Applied to DRY hair from scalp to hair ends until the hair is wet and saturated with product starting at the back of the neck and behind the ears. Leave on for 10mins. Add water, lather, and shampoo with it... then RiNSe well. Comb through hair carefully to remove lice & nits

Folate/ Folic acid (vitamin B9)

RDA: Adult females (and males)= 400mcg. Pregnant females= 600mcg populations of concern: Women of childbearing age, pregnant women, alcoholism/malabsorption disorders The major concern is for any women of childbearing age. Why? Insufficient intake is a leading risk factor for neural tube birth defects (brain/spinal cord). These birth defects happen within the first 28 days of pregnancy. Dietary sources: Folate- naturally occurring in food sources: Green leafy veg, broccoli/brussels/cauliflower, avocado, asparagus, citrus.. beef liver, eggs, meat, fish, poultry, nuts &seeds. folic acid- a synthetic form of folate: OTC dietary supplements/prenatal vitamins. FDA mandated 1998: fortification of flour, cereal, grains. Recommendation: all women who are of childbearing age and have the ability to become pregnant: eat a diet that contains food sources of folate AND take a daily dietary supplement that contains 400mcg folic acid.

Magnesium: an electrolyte cofactor involved in a wide variety of functions/processes in the body.

RDA: Adults: females ~300mg males~400mg UL= 400mg daily dietary sources: green vegetables, nuts/peanuts/legumes, dark chocolate, dairy/meats/fish. Magnesium salts-variable absorption; GI adapts amount absorbed. Common uses: constipation, muscles- leg cramps, muscle spasms ex: soles of feet, calves, "Charly horses", insomnia Who should NOT take Magnesium? dialysis, severe kidney disease

Hair issue: Nit picking

Rationale: reduce diagnostic confusion/no nit policies often in effect at schools. Nit removal may reduce the possibility of unnecessary treatment. Decreases the risk of reinfestation. Specialized comb: metal lice combs are better. Nit remover products= bullpoopy

location on body

Refer to physician: barbae= beard capitis= scalp faciei= face unguium= nail self care is OK: pedis= ATHLETE's FOOT corporis= RINGWORM cruris= JOCK ITCH

OTC insulin

Regular human insulin U100 NPH human insulin U100 NPH insulin + regular insulin mix (Humulin 70/30)

Sunscreen labeling

SPF- sun protection factor: SPF is product specific, SPF number indicated the degree of protection from UVB only. what about UVA? currently there is no standard to indicate a level of UVA protection. New FDA requirement. LOOK for broad spectrum labeling. Substantivity- the sunscreen's ability to fix to the structures in the upper epidermis so its action is longer lasting, is related to its resistance to removal by water or sweating. "water resistant" labeling: must indicate if the SPF is maintained after 40min-80min of water activity/perspiring. NOTHING IS WATER PROOF

Founder of Homeopathy

Samuel Hahnemann (1755-1843) a German physician

OTC 1st gen antihistamines

Selfcare appropriate for: transient (<7days), short term sleep difficulty (<3 weeks). help FALLING ASLEEP the most. options: Diphenhydramine. How to take for insomnia: 25-50mg 30-60mins before bedtime for 2-3 nights. Skip a night to evaluate your own sleep. Repeat for 2-3 nights if needed. Skip a night to evaluate your own sleep... may repeat this process for no more than 14 days. Doxylamine: 25mg tablets. Second line choice; diphenhydramine has more efficacy studies for insomnia. Dose:25mg taken 30mins before going to sleep; similar process as above. Nighttime analgesics (Tylenol-PM) Contain diphenhydramine, are not meant to be used long-term; limit use to <14 days.

Ingrown toenails

Signs/symptoms: Mild (might be able to self-treat)- min to mod pain, minimal redness, no pus/purulent drainage. Moderate-severe (refer to their physician) : severe to disabling pain, extensive swelling, pus/purulent drainage present, ulceration. Goals: relieve pressure on the nail, relieve pain. Treatment: soften the skin: soak foot in warm water about 20 mins/multiple times a day. Place a small piece of cotton under the nail (if possible) . Relieve pain: oral analgesics: NSAIDs or acetaminophen. Sodium sulfide 1% gel MOA- softens the nail. Pads assist in application & also cushion. Apply BID for up to 7 days. Reduce the risk of infection.

homeopathy philosphy

The body has a vital force which is responsible for homeostasis. The body has the power to heal itself. The healing process is variable between individuals (depending on the illness and level of vitality). Homeopathic drugs rebalance the vital force and give the body the capability to heal itself.

"Chiggers" "jiggers" "redbugs"

They are the larvae of harvest mites (egg, larvae,nymph, and adult). They feed off a host only as larvae. Usually found in low grassy areas where are rodents to feed off of. Where do they attach? Typically on thin or wrinkled skin; most commonly areas that are tightly covered by clothes/under elastic bands. Tops of socks and ankles, waistband and leg-band underwear, the bra-line. They cannot be seen with the naked eye. What do they do? Inject saliva with enzymes that dissolve skin cells. They feed off the digested, liquified material. Left undisturbed in ~4 days they are engorged; then they drop off the body. They are not usually left "undisturbed"... scratching usually removes them. Skin response: enzymatic digestion of cells causes inflammation and hardening of the surrounding skin. Reaction occurs ~4-8 hrs after exposure. Skin becomes red and swollen; intense itching may last for several days days. MYTHS: they do NOT suck blood. They are NOT red b/c they are full of blood; they born red in color. They do NOT burrow under the skin. TREATMENT: take a hot bath or shower with soap and water, any external analgesic is cool.

Facotrs that affect UVR exposure:

Time of day and season: UVB- greatest exposure between the peak sun hours 10am and 2pm in mid summer. UVA- fairly continuous throughout the day and season. Altitutde: Sunburn occurs more easily at high altitudes. UVB exposure increases 4% with each 1000ft increase in elevation Latitude- intesity of exposure increases the closer one gets to the equator. Environmental: Clouds: clouds decrease infared radiation (heat), you can sunburnt on a cloudy day!!!! False sense of security. 70-90% of UVR penetrates clouds. Reflection: snow (reflects 85-100%) Sand/white surfaces (reflects 10-15%) Water (reflects ~5%). Water penetration- 95% is transmitted through waters!. Clothes: dry clothes: tightly woven material reflects almost all. If you can see light through the clothes, UVR will penetrate. Wet clothes allow ~50% UVR to pass through

Proliferation of keratinocytes.

an increase in the production of follicular epithelial cells. An altered keratinization process. "retention hyperkeratosis" obstruction of outflow. Creation of microcomedo= the precursor all acne lesions

Athlete's foot: may present from mild, scaly, itching lesions to severe, inflamed, weeping lesions.

Typically take 4 weeks

Dietary supplements/insomnia

Valerian root: POSSIBLY EFFECTIVE for reducing the time to sleep onset and the subjetive quality of sleep. MOA-possibly related to GABA. Adverse effects- sedation/hangover effect is possible. Administration: NOT FOR ACUTE USE!! chronic use= 4 weeks.

policosanol

a CUBAN SUGAR CANE extract of containing 1-octacosanol. MOA: unknown Crazy drop in LDL: 10-40%, increase in HDL 15% but unable to reproduce results thereby tainting its reputation. INSUFFICIENT RELIABLE evidence to rate for effectiveness. Waste of money, don't encourage use.

"Proving"

a clinical trial which observes symptoms when a substance given to a healthy person. Verification trials of clinical efficacy to treat symptoms and recorded in the homeopathic literature. IN the practice of homeopathy: the more dilute, the more potent it becomes.

Sebum

a lipid rich (triglyceride) substance secreted by the sebaceous glands. Purpose is to hold in moisture to help hydrate the skin. Sebaceous glands are found in greater concentrations on the face, chest and back.

Sebum

a lipid substance secreted by the sebaceous glands. It is carried to the skin surface through the follicle. Helps to maintain proper hydration of the skin by holding in moisture.

iron

a mineral required for adequate hemoglobin functioning of red blood cells. It also involved in other processes in the body. FDA approved for prevention and treatment of iron deficiency anemai. Absorption: depends on the dietary source and relative stores of iron in the body (heme iron from meats absorbs well; non-heme iron from grains and vegetables absorbs poorly) Typically ~10-20% is absorbed. Ex. 325mg FeSO4= 65mg Fe, If 20% absorbed= 12mg iron. issues related to absorption/aminsitration/ADRs UL= 45mg, Stomach irritation, nausea, abdominal pain and diarrhea, constipation/dark stools. Site of most absorption- is the duodenum. EC and DR tablets will reduce the incidence of GI side effects BUT will also decrease absorption as it moves away from the duodenum. FOOD- food reduces GI irritation.. BUT also may decrease absorption by ~50%. Taking on empty stomach is preferred... but hard to tolerate. Tannins ( in coffee and tea): decrease absorption. Vitamin C: increases absorption.

"the law of similars"

a symptom is a manifestation of an illness, it is produced b/c or vital force imbalance. A substance that produce a symptom in a healthy person may be used to re-balance the vital force and relieve that symptom in a person with illness.

Permethrin 1% (Nix creme rinse)

a synthetic compound derived from pyrethrin. Chrysanthemum warning is not a concern with this product. MOA- a nerotoxin; blocks neuron repolarization. Acts on the nerve cell membranes of parasites, disrupts nerve impulses that control the breathing muscles... ausing paralysis and death. residual effect that lasts 10 days!!! NO repeat application. advantages: low toxicity, high rate of efficacy with a single application- reapplication is not mandatory. Application directions. WASH the hair with a regular non medicated/non-conditioner shampoo. Do NOT use any other creme rinse or conditioner (to avoid residue) towel dry hair thoroughly so it is DAMP (not wet). Apply to scalp/hair from roots to the tips until well saturated, starting at the back of neck and behind the ears. leave on for 10 mins, rinse out well. Resistance to permethrin has been reported. OFF-label: reapplication in 7 days. application time of the 1% creme rinse increased to 30-60mins, use of 5% permethrin left on overnight under a shower cap.

Aggravation

a worsening of symptoms that occurs after starting the remedy.

garlic

adverse reactions have been reported: burns (chemical), contact dermatitis

Alcohol- inappropriate as a treatment for insomnia

alcohol causes sedation; initially improves insomnia tolerance develops to sedative effects, requiring higher doses of alcohol. Chronic use and higher doses= more frequent awakenings and decrease in total sleep. Addictive adverse effects when combined with sleep medications.

Vitamin D Sources of Vit D: UVB radiation (converst pre-vtiamin D3 to vitamin D3 in the skin). Food sources (Vitamin D2) - oily fish (tuna, salmon, sardines, mackerel) fortified foods- milk, orange juice. Dietary supplements (Vitamin D3/cholecalciferol) (vitmain D2/ergocaliciferol)

calcidiol (25-hydroxyvitamin D) (25-OH Vit D): The inactive form of vitamin D. Serum levels are an indicator of body stores of vitamin D. It is measured to indicate vitamin D insufficency/ deficiency. Calcitriol (1,25-dihydroxyvitamin D): The active form of vitamin D, calcium absorbption from the intestine requires active vitamin D, levels are tightly regulated. Goal= to maintain adequate vitamin D stores; prevent insufficiency/deficiency. Who is at risk/ who should be screened? Dark skinned individuals, adults with a history of falls or bone fractures, CKD/Liver failure, chronic glucocorticoid therapy, anti-seizure drugs. antiretroviral drugs, breast feeding babies, those in cultures who require covering of the skin. Most healthy adults up to 70 yrs: 600 IU/days most healthy adults >70yo: 800 IU/day. UL (adult): 4000 IU per day

Drug induced photosensitivity reactions:

caused by UVA radiation. Photoallergy: drug+ light= antigen- less common not dose related. Requires intial exposure to drug; re-exposure causes the reaction. Cross sensitivity is possible. Rash appears on the light exposed area in ~24-48 hours. Varies from warmth/edema to eczema-like rash with redness, vesicles. presents likes a contact dermatitis. OCCURs most commonly with topical products phototoxicity: more common, may occur with the initial exposure to the drug, dose related. Is a more immediate reaction. May appear as an exaggerated sunburn, may appear as a sunburn that occurs with very little sun exposure. Can occur with plants, cosmetics, and soaps: occurs most commonly with oral medications. EX: sulfa drugs, fluoroquinolones, tetracylcine...

tinea infections

caused by dermatophytes transmission occurs due to contact with infected humans, animals, soil, or fomites. Dermatophytes require keratin for growth- infections occur in the hair, skin and nails. Infections are named based on their location on the body.

corns/callus

caused by friction or pressure in a particular area. causes increased cell division in the basal layer of the epidermis. The extra cells cause a thickened stratum corneum in the area of friction (hyperkeratosis)

blisters

caused by sheer forces that separate the epidermis from the dermis; fluid accumulates. Once the skin appears apply a topical antibiotic is appropriate. Nonadherent dressing (like a bandaid).

Psoriasis characteristics

chronic inflammatory accelerated epidermal proliferation= 10X noraml rate (3 days) epidermal thickness in the affected area forms a plaque nucleated cells capillaries beneath the plaque are larger than normal invasion of dermis and epidermis by inflammatory cells. Various types: plaque, pustular, erthrodermic, and guttate. Only the plaque type is appropriate for self-care.

protecting the eyes

chronic UVR exposure-cataracts, retinal damage, iris/ciliary body melanoma

Seborrhea Characteristics

chronic condition inflammatory (will come and go) increased epidermal cell turnover= 3X normal (8-10 days). Excess sebum causes old cells to attach the skin instead of shedding.

Characteristics of dandruff

chronic condition non-inflammatory Increased epidermal cell turnover= 2X normal (12-15 days) irregular keratin breakup. Incomplete keratinization of cells (some cells have retained their nucleus) Disorganized stratum cornuem- are not tightly packed. Crevices occur in the stratum corneum causing large scales to break off.

non-drug therapy fungal infections

clean the area with soap & water daily and then keep area dry wear less occlusive clothing Athlete's foot: allow shoes to dry, wear sandals to air dry feet if possible. Alternate shoes to let them dry out/use medicated or non-medicated powder. Wear cotton socks, change socks during the day. Wear protective footwear inn family or public showers

Non-drug therapy acne

cleansing the skin : BID (morning and evening) with gentle water and a gentle wash cloth or fingers. Do NOT scrub! Cetaphil!! avoid aggravating factors: avoid drying products, avoid picking and squeezing pimples.

moist wound healing

doubles the speed of epithelialization when compared to dry wounds. Why? living cells stratum corneum- epidermal outer layer; dead cells; prevents the loss of water vapor moisture loss dehydration necrosis: the superficial cells of a wound die due to moisture loss from the underlying layers. This contributes to the formation of a scab. Scab formation: drying blood, drying serous fluid, dehydration necrosis. if you keep the environment of the wound moist, the cells are reponsible for filling in and resurfacing a wound can survive, reproduce and migrate efficiently. Cells cannot migrate across dry, dead tissue. They have to migrate under the scab which takes longer. Infection risk: moisture evaporation from the wound... decreases the temperature of the wound. Hemoglobin hangs onto oxygen to a greater extent in cooler environments which decreases the oxygen available for phagocytes and chemical reactions generated by these cells.

alanine analogs (skin so soft)

effective approximately 20 mins

Types of burns:

electrical: damage at entry/exit points at every point along the way (including bone). always refer for medical evaluation. Chemical: contact of skin with acids/bases (home or workplace exposure). Can cause damage to tissue for hours after exposure if not treated. Immediate first-aid measures should be provided-irrigation, remove source. Always refer for medical evaluation. Thermal: the extent of injury depends on the temperature and duration of exposure. Skin can tolerate up to 104F for long periods without injury. >104F reversible damage occurs; >113F cellular proteins are denatured. Contact of skin with flames, hot liquid, hot objects (oven, pans, curling irons, etc). Inhalation of smoke, steam or hot gases (causes lung tissue damage, edema) Sunburn: acute overexposure to UVB that overcomes the ability of melanin, the skin thickness & hydration, and vascular supply to protect the skin from injury. Pathophysiology: inflammatory mediators (histamine, kinins, prostaglandins) produce vasodilation---> increase permeability, local edema and pain. erythema beings ~4 hrs after exposures, peaks at 12-24 hours, and lasts 24-72 hors

OTC asthma products

epedrine (w/guaifenesin) epinephrine (primatene Mist inhaler)

UVB (290-320nm)

facts: can penetrate into the dermis, is the most erthrogenic UV radiation; causes the sunBurn reaction. UVB does NOT penetrate through glass. cutaneous reactions: Vit D3 synthesis (with 5-20min sun exposure 2-3X weekly), Suntan AND Sunbrun, contributes to photoaging; associated with squamous and basal cell carcinomas.

sleep latency

falling asleep

chronic intertiginous (most common type)

fissures, scales, maceration between the toes (3rd, 4th, 5th toes most commonly), odor, itching, stinging

Plant derived omega-3 ALA= alpha-linolenic acid

flaxseed canola oil soybean oil walnuts

non-drug treatment/ standard counseling- lice

for anything that can be washed- wash all clothing, pillows, bedding in HOT water used by the patient in the few days before treatment and heat dry. Soak combs/brushes in very HOT water for 10 minutes. For stuff you can't wash: put in plastic bags and put away for two weeks. Vacuum like a crazy person, DISCOURAGE use of chemical sprays/cleaners. Environmental house/furniture/carpet chemical sprays and fumigation are NOT needed.

important note for lice products

for most products you don't wash your hair for 1-2 days after use (FDA says 48 hrs)

bunion (hallux valgus)

forms on the inside of the foot; on the side of the great toe. The great toe (hallux) is a dynamic part of the foot. hallux valgus- when the great toe angles toward the other toes. Treatment: remove sources of the pressure on the foot. Surgery. no DRUG treatment.

Exclusions to self-care insomnia

frequent nocturnal awakenings early morning awakenings chronic insomnia (>3 weeks) sleep disturbane secondary to psychiatric or general medical conditions. <12yo >65yo- avoid use of anticholinergic drugs/ beers criteria

Psoriasis etiology

genetics drug induced: beta blockers, lithium environmental stress, smoking, increased alcohol use can aggravate condition. trauma to the skin can be a factor

Notes on dandruff treatment

give 2-4 weeks to judge full effect. May switch to another ingredient if not satisfied. If no effect after ~8 weeks... refer to physician.

Oxytrol (oxybutynin)

indication: overactive bladder in women only >18yo Symptoms: Urinary frequency urinary urgency urge incontinence 2 or more for at least 3 months Key points: Patch is worn for 4 days remove; apply a new patch to a different site. Patch may be applied to abdomen, hips, or buttocks. Wear patch under clothing; do not expose the patch to sunlight ADRs- anticholingers... drowsiness, dry mouth, blurred vision.

common warts

initially small and smooth; skin colored; enlarges over time slightly scaly, rough, papules, or nodules that appear alone or in groups grow to develop a dome-like appearance, have a rough cauliflower like appearance.

skin aging

intrinsic factors- genetic changes, lines from sleep & expression, horomonal changes extrinsic factors- UV radiation, smoking, wind...

ring worm

involves smooth and bare skin demarcated circular lesions with a clear center scaly, and itching possible smaller rings initially, spreads out depending on duration of infection borders may contain vesicles or pustules

basic first aid for minor acute wounds

irrigate with normal saline or bottled water (or) cleanse clean the area around the wound with anteseptic apply topical antibacterial product if necessary (for no more than 5 days) cover the wound with an appropriate dressing/avoid changing the dressing unless dirty observe for signs of infection consult physician if infection is suspected

Bitter orange (Citrus aurantium) aka Seville Orange

is the most common "ephedra-like" substance used supplements. Background: Ephedra (Ma huang)- was found in many weight loss products: 1st dietary supplement removed from the market by FDA. Cotains: synephrine (and octopamine)- sympathomimetic properties similar to ephedrine/pseudoephedrine Safety concerns: CNS stimulation- agitation, insomnia. Cardiovascular effects- hypertension, tachyarrhythmia. Recognized as GRAS used in foods. Possibly unsafe when used for medicinal purposes. INSUFFICIENT EVIDENCE to rate its use for obesity.

thoughts on patient education (acne)

it takes adherence and patience; acne can only be managed, not cured. Drug therapy does NOT get rid of existing lesions. Existing lesions can take up to 6 weeks to heal. The goal is to decrease the number of new lesions. A realistic goal= decrease number & severity of lesions rather than expect no lesions at all. It takes ~2-3 months to evaluate effectiveness (depending on the product) counsel on adverse effects.

Self-care may be appropriate

lacerations (cuts) abrasions (scrapes)

UL-tolerable upper level of intake

largest daily intake unlikely to cause adverse effects Vitamin C= 2000mg (GI upset; an increase risk of kidney stones) Vitamin A= 3000mcg/d (increased risk of birth defects)

Clinical presentation/ diagnosis of lice

lice move quickly; they are difficult to see. Nits usually located within 1 cm of scalp; primarily at the nape of the neck and behind ears. Patients have no symptoms until sensitivity to saliva develops ~4-6 weeks. ITCHING will start. With heavy infestation, tickling might be felt from lice moving around. Diagnosis is made once live lice, nymphs or nits are seen.

prevention of acute reactions

limit exposure to sunlight wear protective clothing, hates, glasses, etc... use an appropriate sunscreen product:must block UVA, can also be exposed through windows

melatonin

melatonin: a hormone produced in the pineal gland melatonin receptors. MT-1 regulates sleepiness MT-2 circadian rhythm, shifts day to night. Dosing considerations. Available in doses ranging from 0.3mg to 10mg. Appropriate dosing is unclear. Drowsiness. Avaible in IR and SR. Safety: likely safe with short term use (up to 9 months) possibly safe with long term use (up to 2 years) LIKELY effective: circadian rhythm sleep disturbance in blind children & adults. Sleep/wake cycle disturbances in autism/mental retardation. Delayed sleep phase syndrome. POSSIBLY effective: primary insomnia, ok for all adult patients. IR for falling asleep. SR for staying asleep. Jet lag for eastward travel across >3-5 time zones. 2-3mg (IR or SR) at local bedtime. Take on the day of arrival and continue for 2-5 days. possibly INEFFECTIVE for shift work disorder: melatonin does not significantly improve sleep latency, efficency or adjustment to rotating shift work. Slight increase in total sleep time/overall sleep quality may occur

chronic papulosquamous

mild inflammation, diffuse dry moccasin-like scaling on soles of the feet, both feet are usually involved

HPV-1

most common on feet

HPV 57

most common on hands

chronic wounds

must be referred to physician pressure sores- good skin care, reposition patients, and inspect skin regularly arterial and venous stasis ulcers (includes diabetic ulcers) any wound that has not started to heal in a week

NO OTC TREATMENT for

nail infections

topical antibiotics

neomycin- aminoglycoside bactericidal against gram - and ome staph species, has the highest risk of hypersensitivity(3.5-19%) bacitracin- polypeptide antibacterial against several gram + bacteria (H:~2%) polymyxin B sulfate- polypeptide, activity against several gram - sensitization= rare in clean uncontaminated wounds the risk of infection is only 5% (minor cuts, scrapes) contaminated wounds carry a 20-30% risk of infection

Seborrhea Management

no cure; only management of the condition. Exacerbation and remission throughout the adult life of the patient. Many of the same ingredients used for dandrugg (EXCEPT sulfu) Many dandruff products also have labeling for seborrheic dermatitis. Occasional use of hydrocortisone 1% when inflammation exists. Best applied after shampooing the hair (hydrates scalp/removes excess sebum) MD should be consulted if condition is severe, worsens or not relieved in 7 days. Minearl oil-optional/prn for thick scales. Apply to areas/left on overnight/hydrates thick scales/easier to remove next day.

Exclusions to self-treatment Asthma

no prior diagnosis of asthma no current asthma care provider patients or symptoms that could be suggestive of another disease (COPD, CHF,...) any patient who has ever required systemic corticosteroids or urgent medical care for asthma. use of Rx medications for long-term control of asthma Rx medications perceived as being ineffective symptoms suggestive of other than mild intermittent asthma. Symptoms that have lasted >24 hrs or are unresponsive to OTC medications.

Grade I/clear-almost clear

noninflammatory comedones only (black or whiteheads) only the face is involved

Recommended Daily Allowance (RDA)

nutrient intake that meets the needs of ~98% of healthy Americans developed by the national academy of sciences in 1968 subdivided by sex and age

hard corns

occur on the surface of the toes, are shiny and polished. Located over nonweight bearing, body promineces or joints (metatarsal heads, bulb of great toe, back of the little toe, or tips of the middle toes)

citronella

offers less than 1 hr protection against mosquitoes

Topical therapy for hyperpigmenatation: hydroquinone

only FDA approved depigmenting agent. 2% OTC, 4% Rx MOA: inhibits the oxidation of tyrosine required to produce melanin. Produces a reversible depigmentation of the skin. slang term= fading cream applied just to dark sports sun exposure reverses the effects. onset of action is gradual; visible change should be seen in ~4 weeks. If no improvement seen in 2 months; discontinue the product. Adverse effects: treatmet inflammation/minor redness... is OK to continue. If itching, excessive inflammation, or vesicles occur... discontinue use. contact dermatitis is possible. proper use: JUST PUT IT ON THE DARK SPOTS, LIMIT APPLICATION TO ISOLATED SPOTS, THEY MUST WEAR SUNSCREEN!!

Psoriasis treatment

only mild cases less than 10% body surface can be self-treated. Non-drug: soaking the plaques in water, bathing; general therapy for dry skin, emollients that contain keratin softening agents. Drug Therapy: Maintenance: Pyrithione zinc, salicylic acid, coal tar. Acute flares: hydrocortisone... short term only for acute flare ups (bright red lesions). Talk to physician for stronger steroid for shorter period of time.

Application issues with insect repellent

only needs to be applied to exposed skin. Do NOT spray on the face... apply to hands first.

gauge

outside diameter of the needle ***INVERSE relationship!! the higher # the gauge, the smaller the diameter of the needle

Grade II/mild

papular acne 10-25 papules on face and/or trunk lesions <5mm diameter mild scarring

inflammatory lesions

papules-redness & inflammation in and round the follicle pustules- redness & inflammation + visible pus in the center of the lesion nodules- follicle wall has been disrupted; contents of follicle are released into the dermis. Larger, painful, solid lesions deeper within the skin. Necrotic purulent lesions penetrate the underlying tissue.

Exclusions to self-care corns/calluses

patients with diabetes or PVD, rheumatoid arthritis, bleeding or signs of infection, extensive and painful/debilitating. Due to anatomical defect; example deviation of the great toe (bunions)

UVA (320-400nm)

penetrates much more deeply into dermis, it can cause serious chronic damage. UVA does penetrate through glass!!! uses: tanning beds (5X more UVA compared to natural sunlight) PUVA therapy (psoralens + UVA) Possible treatment for conditions such as psoriasis and vitilido. Cutaneous reactions to UVA: suntan, contributes to photaging is associated with cutaneous malignant melanoma. UVA is responsible for photosensitivity reactions

warts are defined by their location on the body

periungual and subungual= around and under the nail beds veneral= genital area, anal area juvenile or flat= face, neck, back of hands, knees, wrists common= fingers, hands (and the face) plantar= soles of the feet

chromium: modulates carbohydrate metabolism

picolinate- salt form that is the most bioavailable. Formerly called "glucose intolerance factor"- an insulin cofactor. RDA: = 20-35mcg; it is extremely rare to see deficiency in the US. Doses of 200-400mcg daily are promoted as being useful for weight loss: POSSIBLY INEFFECTIVE

Marine derived (~fatty fish) EPA-elcosapentaenoic acid DHA- docosaheanoic acid

pink salmon tuna (white/albacore/light) herring catfish shrimp/clams

photoaging

prematurely aged skin due to the effects of chronic UVR exposure. Does not appear until decades have passed. symptoms: blotches of hyper-pigmented skin, yellowish discoloration, visible fine capillaries, wrinkled, less elastic coarse, scaling, sagging skin.

consideration for superficial burns

protection: choose a product that will prevent dryness and provide lubrication. Decreases pain- protect burn from friction and rubbing. Prevents drying of the stratum corneum- helps with healing. FDA approved ingredients for protection of minor burns and sunburns: Cocoa butter, petrolatum apply a dressing the to burn IF appropriate: helps reduce friction Reduce pain with oral analgesics if desired- APAP, NSAIDs other ingredients to think about: Topical anesthetics (benzocaine, lidocaine, dibucaine, pramoxine...): relief only lasts about 15-40mins, apply only 3-4 times/day, higher concentration OK for intact skin. lower conc. should be used when blistering exists & only over small area. Benzocaine- causes hypersensitivity in 1% of patients, has no systemic toxicity lidocaine- less hypersensitivity than benzocaine. IS it practical to use one?OK but briefly, NOT necessary TOPICAL antimicrobial: NOT much value

Wart exclusion to self care

pts with DM or PVD or neuropathy, should never self-treat feet! immunosuppressed (HIV, chronic steroid use, on immunosuppressant drugs etc.), around or under fingernails or toenails, warts involving the genital/anal area, wart involving the face, flat warts (brown looking), extensive warts atone site, plantar warts that are PAINFUL

Acute wounds not appropriate for self-care

punctures- deep punctures require medical referral bites- animal and human- require medical referral

grade III/moderate

pustular acne >25 pustules on face and/or trunk lesions <5mm diameter moderate scarring

Pinworm infection: enterobius vermicularis (pinworm) - the most common worm infestation in the USA

pyrantel pamoate (Pin-X, Reese's Pinworm)- the only OTC treatment approved by the FDA. Schmude said something about spreading the but cheeks and putting a piece of tape to check infection.

signs/symptoms of psoriasis

red, inflamed, thick silvery scales, or plaques, sharply demarcated, itching, small bleeding points are seen when the scales are removed. Lesions common on sites of trauma (elbows, knees) and scalp.

Vitamin A

retinol; biologically active (animal sources) (fortified foods & supplements) UL: 3000mcg/day beta carotene; a pro-vitamin (plant sources; fortified foods & supplements) ~30% converted to retinol. UL: 12mcg/day

omega-3 for cardiovascular protection

secondary prevention for ONLY the following: patients with recent CHD event (MI) or heart failure without preserved LV function. ~1gm/day EPA/DHA. available products: Rx only- several types of omega-3 products available. OTC fish oil capsules. GI side effects- are dose related take with food. 1 gm daily is well tolerated; few side effects; 7%vs 4% Indigestion, belching, fishy after taste primary prevention:no recommendation

Why the interest in omega-3 fatty acids?

seem to have less cardiovascular disease. proposed MOA for cardiovascular benefit at lower doses: stabilize the endocardium... which reduces susceptibility to arrhythmias. Promote endothelial relaxation.

viral transmission

self inoculation fomites person to person

classification of burns

superficial: usually from brief exposure to low heat, sunburn is most often of this type superficial- partial thickness: involve higher levels of heat or longer exposures, splash or spill of a hot liquid, brief contact with hot object, more severe sunburn deep partial thickness: more extensive heat exposure, scalding liquid, hot objects, chemicals, flame, up to 6 weeks to heal. Full thickness burns: involves more intense heat, causes death of the full thickness of the involved skin, immersion in scalding liquid, flame, chemical, electric.

risk factors for warts

suppressed immune system meat handling occupation (butcher's warts) (~25% of those who handle meat, poultry, fish) fingernail biting going barefoot public showers/swimming pools personal history of warts

Vitamin K

synthesized by intestinal bacteria; available in a variety of foods

Ephelides AKA freckles- spots of uneven pigmentation

tan to brown macules (flat) typically on the face or forearms. They darken or fade in response to the presence or absence of UVR

Thermogenesis

the production of heat, increase in metabolic rate, increase in energy expenditure. Caffeine, Green Tea (EGCG), Bitter Orange

RDI

the reference daily intake

topical antiseptics

these are meant to be applied to intact skin around the wound to reduce the bacterial load. Most are very cytotoxic and therefore should not be applied to open wounds. Applying only to the surrounding area eliminated the pain & damage associated with them. isopropyl alcohol iodine/iodine tincture povidone- iodine phenol-must be applied to DRY SKIN ONLY (if not extremely caustic to the skin) NEVER use with bandages!!!

plantar warts

they can grow anywhere on the sole of the foot, sometimes hard to distinguish from callus. if surface is exposed, reveals tiny black dots that are thrombosed capillaries. Mosaic warts= several warts grouped together that appear to be 1 wart

factors that affect wound healing

tissue perfusion/oxygenation/moisture nutritional status- Vit C, Vit A, Zn, Fe, protein intake increased age weight diabetes- reduced collagen synthesis, reduced cellular response, delayed epidermal migration, imparied wound contraction. Medications: steroids- reduce motility of phagocytes, reduce collagen synthesis radiation/ chemotherapy- reduce cellular mitosis for new cell formation immunosuppressant drugs & anticoagulants- interfere with the inflammatory phase

treatment goals of warts

to remove the wart; leave no scars prevent self-inoculation or transmission to other people

Antifungal agents: 2nd line for dandruff

topical ketoconazole

adapalene 0.1% (differin)

topical retinoid MOA: reverses follicular keratinization; decreased development of follicular plugging. Slows desquamation and decreases adherence of cells. The most effective topical treatment for inhibiting formation of the microcomedo. Can take 3 months to see full effect. >12yo: mild-mod non-inflammatory + inflammatory acne. Application: applied once a day (usually bedtime) apply a very thin layer over the entire face; a pea-size amount should be enough for the entire face. Avoid the lips, mouth and eyes. Adverse effects: can cause dryness of the skin, can worsen acne (1st month), sensitivity to the sun: makes the skin more likely to burn: NOT photosensitivity. no-go in pregnancy

General treatment insect stings and bites

treat pain (IF needed), cold therapy is an option. Treat the symptoms depending on the reaction/bite etc. External analgesic products: local anesthetics= numb the pain, counterirritants= camphor, menthol. Calamine lotion: can use it in kiddos and can use long term! yay! Hydrocortisone 1% cream: more red and itchy.

Succussion

vigorously shaking in between dilutions, this gives the solution energy

prevention of spreading

warts are contagious! wash hands before and after treatment or after touching the wart. use a specific towel/equipment for preparing the wart, do not probe, poke, or pick at the wart. Do not walk in bare feet if there are warts on soles/ wear foot gear in public areas.

protect them lips

wear lip balm with SPF

AI- adequate intake

wen insufficient evidence exists to set an RDA

Caffeine

what is it? FOOD- recognized as GRAS Dietary supplement- by DSHEA; a component of many herbals Rx drug- in Fiorcet OTC drug MOA- a CNS stimulant. The only approved stimulant in the OTC drug monograph. FDA approved "mental alerness" or "wakefullness" when experiencing fatigue or drowsiness. Dietary sources: Fresh brewed coffee 130-240mg/16oz cup. Fresh brewed tea 20-110mg. Caffeinated soft drinks 30-80mg/12oz. Moderate intake is defined as less than 300mg/day

soft corns

whitish thickenings of skin most often located between the 4th and 5th (little toe) are soft due to excess perspiration that macerates the epidermis

Drug treatment of lice

who needs to be treated? Anybody with a confirmed infestation (you've seen lice or nits) The family members do NOT need to be treated prophylacticly. ONLY treat when needed. Conservatively- people that share a bed might be treated.

Drug treatment for scabies:

who needs to be treated?- Treat all close contacts!!! Treat the entire family usually. OTC treatment= NONE! Rx only scabicides: Permethrin 5% (Elimite) cream, massage cream into the skin from the neck down to the soles of the feet. Leave on 8-14 hours (typically left on overnight). Remove cream by showering/bathing thoroughly. Adjunct treatment for "the itch" from scabies: calamine lotion, sarna lotion (without pramoxine).

Exclusions to self-care acute wounds

wound that still contains foreign matter after irrigation chronic wound deep acute wound wound from a human or animal bite involvement of the genitals, face, or mucous membranes signs of infection present

hering's direction of cure

you heal from inside out, and/or top-bottom. little rash= part of curing process.