Module 2 Flashcards
1
Q
Alopecia
A
baldness, considered autoimmune disease, may be genetic with environment trigger
Can occur anywhere where hair is present
2
Q
alopecia areata
A
hair loss occuring in patches
3
Q
androgenetic alopecia (AGA)
A
or male-pattern baldness
most common cause of permanent hair loss
inherited from both parents
4
Q
four cycles of scalp hair growth
A
anagen- growth phase
latent or involution- catagen
resting- telogen
hair shed- exogen
5
Q
meds that cause hair loss
A
hormones
anticonvulsants
anticoagulants
oral contraceptive
beta blocker
antithyroid
excessive vitamin A
6
Q
trichotillomania
A
hair pulling
more common in teens/kids
usually same side as dominant hand
7
Q
alopecia treatment (greater than 50%)
A
oral corticosteroids, topical immunotherapy and immunomodulators
8
Q
finasteride
A
tx alopecia
approved for men only
use with caution in liver dx
SE: decreased libido, ED
9
Q
minoxidil
A
Topical, available OTC
aka rogaine
Best works for patients with recent onset of alopecia (less than 5 years)
SE: irritation, itching, dryness
10
Q
the larger the melanosome
A
darker the skin color
11
Q
Vitiligo
A
, or the total loss of skin color in patchy areas of the body (rarely over the entire body), is recognized clinically as white macules or patches that are usually located on sun-exposed areas, such as the face, lips, arm, hands, and feet.
most often in mid 20s
thought to be autoimmune
12
Q
tx vitiligo
A
topical corticosteroids, light therapy, psoralen with UVA therapy
13
Q
chloasma
A
“the mask of pregnancy”
caused by increased levels of estrogen, progesterone, melanocyte stimulating hormone
affect face, nipples, genitals, linea nigra
worsened by sunlight
14
Q
tx chloasma
A
retinoic acid, hydroquinone cream, tretinoin, corticosteroid
15
Q
melasma
A
more general term for hyperpigmentation of certain areas of skin regardless of pregnancy status
tx with hydroquinone and sun avoidance
16
Q
Addison’s disease
A
can cause diffuse generalized hyper-pigmentation, especially in skin crease
other symptoms: weakness, fatigue, weight loss, amenorrhea, n/v, diarrhea
17
Q
very dark color on one nail is suscpicious for
A
melanoma
18
Q
pruritus causes
A
insects, contact dermatitis, medications, detergents, alternative meds/ herbs, recreational drugs
19
Q
xerosis
A
dry skin
20
Q
pruritus management
A
eliminate strong soaps, shorter showers, use effective emoillents
use of mild soap- dove, basis, purpose, cetaphil, neutrogena
apply emollient immediately after shower
rx- h1 histamine- hydroxyzine or benadryl (watch for drowsiness)
21
Q
exanthem
A
rash
red/pink colored skin eruption
22
Q
Paget’s disease
A
rash that looks like eczema dermatitis of nipple/areola
onset is gradual
typically on one nipple
23
Q
toxic shock syndrome
A
risk factors- tampon use, greater than 30 hours
may have fever, vomiting, weakness, confusion
also may have bright red, fine maculopapular rash
remove tampon immediately!
24
Q
urticaria
A
hives/wheals
a sudden generalized eruption of pale, evanescent wheals or papules associated with severe itching
25
Cholinergic urticaria
trigger- exercise, anxiety, elevated body temp, hot bath
lesions resolve within 30 mins
hives small, on trunk and arms
26
pruritic urticarial paules and plaques of pregnancy
PUPPP
papules and plaques that start on abdomen and spread to thighs, buttocks
normally during last 2 weeks of pregnancy
resolves after delivery
tx: corticosteroid
27
Scabies
is a highly contagious mite infestation that occurs mainly in children, young adults, health-care workers, and institutionalized persons of all ages. It is characterized by generalized intractable pruritus, often with minimal cutaneous manifestations
28
mode of transmission for scabies
close personal contact
29
crusted scabies
characterized by scaly lesions at the sites of invasion that soon become warty and encrusted, creating a protective barrier for these mites
more common in immune compromised
30
scabies clinical presentation
intense itching, worse at night- does not respond to treatment
changes in feeding pattern with kids
1-2 mm red papules in interdigital web space, wrist, axillary, pelvis, ankles, penis
burrows- white color with black specks
31
scabies diagnosis
burrow ink test
drop mineral oil over burrow, scrape off burrow with scalpel and ID
32
scabies tx
clean environment, close contacts
Kill all live mites- scabicides (permethrin)- first line tx
Some may require corticosteroids if severe
33
scabies follow up
1 week after treatment
34
Pediculosis
Infestation by lice
3 species- crab louse, head louse, body louse
Common in school aged kids
35
Pediculosis clinical presentation
Itching, more severe at night
Feeding pattern change
2-3 mm red erythematous macules or papules, often pruritic
excoriations often present
fresh nits closest to scalp
36
Diagnosis of pediculosis
itching and finding white nits or lice on hair shaft
37
pediculosis tx
Kill/remove lice and their nits- shampoo, cream rinse, lotion
manual delousing
38
pediculosis follow up
if uncomplicated, not needed
if needed, f/u in one week if symptoms persist
39
Candida is part of the normal flora of both the
oropharynx and gastrointestinal (GI) tract
40
two most important factors contributing to candidal infections
Favorable environmental factors and a weakened immune system are the
41
In women with AIDS, one of the earliest and most frequent opportunistic infection is
vaginal candidiasis.
42
thrush clinical presentation
severe sore throat, pain with swallowing
white creamy patches on ant/post pharynx and tongue
43
vaginal candidiasis clinical presentation
burning, itching, irritation of vulva/vagina
white cottage cheese discharge
44
balanitis clinical presentation
red rash and itching on penis
may have female sex partner being tx for yeast infection
45
intertriginous candidiasis
obese patient with red itchy rash, sometimes is weepy and moist
typically occurs where there is skin rubbing against skin
46
candidal paronychia
painful fingertip that is red hot and swollen
frequent water immersion of the hands common
47
subungual candida
no pain or itching
several discolored yellow fingernails for weeks/months
excessive contact from water immersion
48
topical antifungals
nystatin, clotrimazole, miconazole, naftifine, terbinafine, ciclopirox
applied twice daily x2-4 weeks
apply cream sparingly, may cause maceration
49
first line treatment for mild oral candidiasis
clotrimazole troches 10mg five times daily
or nystatin
50
candida infection follow up
2 weeks
51
dermatophytoses
aka tinea
superficial skin infections
52
tinea capitus
ringworm of scalp
53
tinea corporis
ringworm of the body
54
tinea cruris
ringworm of the groin
55
tinea pedis
athlete's foot
56
tinea manuum
tinea of the hands
57
tinea infections more common in
warmer climates
58
most common fungal infection in USA
athelete's foot
59
tinea capitus clinical presentation
typically toddler or school age kid
painless bald spot
may have 3 apprearances- black dot, gray patch, kerion (large bright red boggy bump)
60
tinea corporis clinical presentation
erythematous round and elevated pruritic lesion that grows in size and starts to clear in center
classic shape of ringworm
61
tinea cruris clinical presentation
typically obese man with pruritic rash on groin that spreads to medial upper thigh
"jocks itch"
62
tinea pedis clinical presentation
strong foot odor
macerated soft whitened skin between toes
63
tinea versicolor
hypopigmented spots, mild pruritus
normally on back
64
fungal culture recommended for
onychomycosis and tinea capitis
65
tinea infection treatment (not capitis or onchomycosis)
2-4 week topical treatment with azole class meds
continue at least 1 week after lesion has cleared
66
tinea capitis treatment
oral systemic antifungal along with topical
treatment of choice: griseofulvin po bid for 2-4 months
67
tinea versicolor treatment
topical selenium sulfide lotion applied daily x7 days from neck to waist
repeated once weekly x1 month, then once month for maintenance
hypopigmented spots may take longer to resolve
68
tinea follow up
2 weeks
69
onychomycosis
benign superficial infection of the toenails and fingernails
young/middle aged bothered more by appearance
nail discoloration
first or fifth most likely to be affected
70
onychomycosis treatment
itraconazole
terbinafine
monitor liver function tests
71
onychomycosis follow up
check liver function test q4 weeks, follow up first on fourth week and then q 4-6 weeks
72
impetigo
contagious, superficial vesiculopustular infection of skin commonly seen infants/children
spread through direct contact among people
typically includes staph aureus and strep together
73
impetigo risk factors
insect bite
warm weather
74
impetigo clinical presentation
pruritus from lesions, red crusty rash spreading, normally on face or extremities
75
diagnostic testing for impetigo
bacterial culture and sensitivity
gram positive cocci
76
impetigo management
plain tap water 3-4x/day for 10-20 min to debride lesions
topical and oral abx-mupirocin topical bid x5 days
if fever/toxicity- cephalexin x7 days
77
impetigo follow up
10-14 days after initiation of therapy
78
folliculitis
superficial to deep skin infection of hair follicles
often caused by staphylococcus
most common in middle aged and children
risk factor- immunocompromised
79
folliculitis clinical presentation
"bumpy rash" anywhere on body
typically no itching
small pustules, no involvement of surrounding skin
80
barber's itch
folliculitis of hair follicles on beard area of men
usually upper lip
aggravated by shaving, most common in black men
81
folliculitis diagnostic test
gram stain and culture by rupturing a pustule and taking sample of exudate
positive for gram positive cocci
82
folliculitis management
gentle cleansing by washing twice daily with antibacterial soap
83
furuncle
boil
deep bacterial infection of hair follicle with abscess formation
caused by gram positive s. aureus
most common- scalp, neck, axilla, buttocks, groin, thighs
84
carbuncle
large, multiloculated abscess with multiple furuncles
less common
large, red painful lumps on skin
85
furuncle clinical presentation
hot, tender bright red bump
may develop yellow central plug
86
furuncle diagnosis
gram stain and culture for s. aureus
87
furuncle treatment
must be drained to heal, typically occurs spontaneously within 2 weeks
can use treatment with topical abx like mupirocin twice daily
if on face, refer to physician
88
carbuncle treatment
systemic antibiotics and physician referral
cephalexin, doxycycline
89
furuncle follow up
1 week
90
cellulitis
bacterial infection of skin involving both dermis and subcut tissue
most caused by group a betahemolytic streptococcus or by s. aureus
91
cellulitis clinical presentation
tender warm erythematous area of skin, normally on face, neck, extremities
may have precipitating condition- insect bite, small cute
red borders are flat and diffuse
92
cellulitis treatment
depends on culture and gram stain results
penicillin, dicloxacillin, clindamycin, cephalexin
93
cellulitis follow up
improvement normally within 2-3 days
94
Erysipelas
it can be fatal if it is not treated promptly
only involves superficial level of skin, not subcut
face, lower legs
high fever, chills, malaise
bright red lesion by nares that spread rapidly, becomes enlarging plaque that is warm to touch and has sharp, distinct borders
95
necrotizing fasciitis
rapid progression of tissue destruction
bright red lesion with edema, severe pain at affected site
96
periorbital cellulitis
life-threatening, emergent
pain with certain eye movements, fever, tachycardia, lethargy
97
warts
contagious skin lesions formed by infected keratinocytes, caused by HPV
can be transmitted by touch
risk factor= handle raw meat, bite nails, walk barefoot
98
wart clinical presentation
small bump present for several weeks- months
become dome shaped with black dot on surface
99
wart management
1/2 resolve without treatment within 1 year, 2/3 within 2 years
salicyclic acid plaster
may also treat with cryosurgery/liquid nitrogen
100
HSV infection
2 types- genital and oral.
2 phases- primary and secondary or recurrent infection. symptoms occur 2-21 days after exposure
101
hsv infection clinical presentation
"cold sore"
fever, sore throat- oral
genital- fever, headache, muscle ache, painful urination
102
herpes simplex diagnostic testing
viral culture, dna study- sample must be done in first 72 hours of outbreak
103
herpes simplex management
acetaminophen to control fever and pain
blistex- oral
genital- oral antiviral like valacyclovir and famciclovir
104
atopic dermatitis
eczema
not distinct disease, descriptive term for group of skin disorders characterized by pruritus and inflammation
inherited skin reaction that usually begins in infancy
105
atopic dermatitis clinical presentation
the itch that rashes
cardinal sign-itching
history of episodic exacerbation
infants- lesions affect cheeks, face, upper extremities- excoriated, maculopaular, inflamed
106
RAST test
radioallergosorbent test
identifies antigen specific mast cell activation to quantify levels of allergen specific igE
107
atopic dermatitis management
control signs/symptoms, no cure
eliminate precipating factors, wet lesions should dry, dry lesion should hydrate, inflammation treat with steroids
108
nonpharm atopic dermatitis treatment
mild emollients (cetaphil)
soak baths preferred, followed by moisturizer
no fragrance soap
109
pharmacologic management atopic dermatitis
antihistamines not effective
doxepin
singulair
corticosteroids
110
contact dermatitis
can be either irritant dermatitis or allergic dermatitis
111
allergic contact dermatitis
immunologically mediated
112
irritant contact dermatitis
result of repeated insults to atopic skin from caustic, irritant, detergent substance
113
contact dermatitis clinical presentation
pruritic erythematous rash
weeping lesions with numerous tiny vesicles
rough, reddened patches, but without skin thickening of psoriasis
114
contact dermatitis management
symptom relief while trying to ID underlying precipitant and eliminating it
drying agents (calamine lotion) twice daily
115
seborrheic dermatitis
chronic condition that is characterized by remissions and exacerbations and may be a sign of more serious underlying pathology, such as immune suppression. The rash of seborrheic dermatitis is seen on skin that is rich in sebaceous glands, such as the scalp, forehead, eyebrows, and the area surrounding the nose and ears
116
seborrheic dermatitis clinical presentation
scaly patches that are slightly papular, surrounded by erythema
most frequently on scalp
117
seborrheic dermatitis management
OTC antidandruff shampoo- 5-7 minutes
may require prescription shampoo (2.5% selenium sulfide)
topical steroid
118
psoriasis
chronic relapsing disorder of keratin synthesis that is characterized by well-circumscribed, raised, erythematous papules and plaques, covered with silvery-white scales, usually involving extensor areas in adults such as the elbows and knees, the scalp, and, in some forms, the flexural surfaces of the body. The phrase “heartbreak of psoriasis” was coined because of the physically and emotionally disabling effects of the disease.
strong genetic influence, environmental factors trigger
119
psoriasis clinical presentation
gradual symptoms confined to one area mostly
itchy red inflamed dry scaly plaques
preceding strep throat infection
lesions usually over bony prominences on elbows knees
120
psoriasis management
systemic only for moderate-severe-- methotrexate, otezla, gengraf
topical- emoillient, kertolytic agents twice daily
topical corticosteroids
121
psoriasis follow up
every 2 months by specialist if severe
122
dry eye syndrome
discomfort, visual disturbance, tear film instability- quantity/quality of tears fails to keep surface of eye adequately lubricated
"sand in eye"
123
3 layers to tears
1. outer oily layer- lipids
2. middle aqueous layer- watery portion of eyes, with proteins
3. inner mucin layer- binds water from aqueous layer to ensure that eye remains wet
124
risk factors for dry eye
advanced age, female, computer usage, seasonal allergy, autoimmune disease
meds- antihistamine, decongestants, anti depressants, birth control
125
epiphora
excessive tearing
overflow of tears from one or both eyes
may be from dry eye, exposure to irritant, obstruction of lacrimal duct
126
red eye
nonuniform redness of the conjunctiva
most common cause- pink eye
127
cause of floaters in vision
contraction of vitreous humor
if gradual and become less noticeable, usually benign
if sudden, especially bilateral, may need eval
128
photopsia
flashing lights
should be evaluated immediately for retinal tear or detachment
129
blepharitis
inflammation of eyelids and margins
130
two forms of blepharitis
nonulcerative form- associated with seborrhea of face and greasy scaling at eyelid margin
ulcerative form- may involve eyelash follicles and meibomian glands of eyelid
131
blepharitis clinical presentation
itching, burning, foreign body sensation in eye
sensitivity to bright light
lid margins edematous and erythematous
132
Nonulcerative blepharitis management
Eyelid cleaning with a diluted 1:1 mixture of no-tears shampoo (baby shampoo) and water, using a soft washcloth or cotton balls.
133
Staphylococcal blepharitis/ulcerated lesions management
bacitracin or erythromycin 0.5% ointment can be prescribed and applied on the eyelids one or more times daily or at bedtime after gentle cleansing and using warm compresses
134
blepharitis follow up
2 weeks, then re-eval in 2 months
135
hordeolum
, also known as a stye, is an acute, erythematous, tender lump within the eyelid. This condition is caused by inflammation or infection of the eyelid margin affecting the hair follicles of the eyelashes (external hordeolum) or the Meibomian glands
136
chalazion
is a granulomatous infection of a Meibomian gland that presents as a a painless swelling on the eyelid. Initially, a chalazion may be tender and erythematous before evolving into a nontender lump.
137
hordeolum treatment
warm compress
scrub eyelids with baby shampoo and warm water 2-4x daily
do not squeeze
d/c eye makeup
no contacts
138
otalgia
ear pain
could be pain that originates in ear or outside of ear
139
primary otalgia
cause: external otitis, otitis media, mastoiditis, auricular infection
140
tinnitus
subjective ringing/buzzing
intermittent, continuous, pulsatile
may be unilateral or bilateral
141
sore throat causes
most common- streptococcal or viral infection
142
aging and hearing
degeneration of inner ear structure over time cause hearing loss
men more likely to experience than women
143
risk factors for hearing loss
chronic middle ear infection
ruptured tympanic membrane
acoustic trauma
exposure to loud noises
allergies
144
sensorineural hearing loss
a lesion in the organ of Corti or in the central neural pathways of the ear, including the cranial nerve (CN) VIII and auditory cortex
145
presbycusis
age related hearing loss
form of sensorineural hearing lsos
146
Conductive hearing loss
results when the passage of sound waves through the tympanic membrane and inner ear is impaired.
may occur at any age
often reversible
147
Hearing loss associated with Meniere's disease
fluctuating hearing loss, usually unilateral, associated with tinnitus and vertigo
148
acoustic neuroma hearing loss
rare tumor of CN VIII, causes unilateral constant or progressive hearing loss, possibly associated with headache
149
objective finding with sensorineural hearing loss
Weber- When sensorineural, sound in unaffected ear is louder
Rinne- When sensorineural, ratio remains 2:1
Schwabach- When sensorineural, bone conduction is present for shorter time than examiner’s
150
objective finding with conductive hearing loss
Weber- When conductive, sound in affected ear is louder
Rinne- ratio closer to 1:1
Schwabach- bone conduction present for longer than examiner
151
Cerumen disimpaction-
* place 1:1 mixture of 3% hydrogen peroxide and warm mineral oil in external ear canal and for 1 hour, followed by lavage with warm saline, directed toward canal wall and not toward eardrum
o Debrox (Cerumenolytic) also effective, do not use with perforated tympanic membrane or infection
o If trauma with cerumen disimpaction occurs, use corticosteroid/antibiotic otic solution
152
Sudden sensorineural hearing loss-
referral to otorhinolargyngologist
153
Perforation to tympanic membrane, suspicious for Meniere’s disease
- referral to ENT
154
Acoustic neuroma
* - refer for surgical eval
155
Tinnitus
* Subjective perception of noise when no environmental noise is present
* Can be intermittent, continuous, pulsatile
* Strongly associated with aging
* Risk factors: hearing loss, labyrinthitis, Meniere’s dx, OM or OE, hypo or hypertension, anemia, hypo or hyperthyroidism, allergies
156
tinnitus physical exam
* Orthostatic BP
* Gross hearing tests
* Auscultation of upper part of neck proximate to affected ear
* Neuro exam
157
Meniere’s Disease
* Peripheral sensory disorder of labyrinth and cochlea of inner ear
* Endolymphatic volume and inner ear pressure increased, results in auditory and vestibular dysfunction
* Recurrent attacks of tinnitus, vertigo, progressive hearing loss
* Risk factors: allergies, high salt, caffeine, etoh, hormonal change, change in barometric pressure, exposure to high noise levels
* Patho- possible inflammatory disease?
158
diagnosis of meniere's criteria
* Two distinct episodes of vertigo (lasting 20 mins), along with sensorineural hearing loss, and tinnitus or aural fullness
159
Meniere's treatment
* Rule out all other causes of symptoms
* No proven cure, therapy is mainly palliative
* Tx acute attack- rest with eyes closed, protection from falling
* Dietary modification, vestibular rehab
160
Otitis Externa (Swimmer’s Ear)
* Inflammation of membranous lining of auditory canal
* Invasive OE is life threatening
* 10-20x more likely to occur in warmer summer months than in cooler seasons
* Immune compromised at greater risk for infectious OE
* Likely d/t pseudomonas infection, or staph aureus
* Risk factors: skin maceration, traumatic injury, excessive cleaning, excessive moisture
161
Necrotizing OE
* - most severe, moves from skin of auditory canal into soft tissues, cartilage and bone, may involve multiple cranial nerves
162
objective findings otitis externa
* Tenderness on traction of pina
* Instill several drops of benzocaine/antipyrine otic solutions before exam, but not with ruptured membrane
* Auditory canal- edematous, erythematous
* Fluid- green, yellow, white (fungal)
163
otitis externa treatment
* Comfort is primary focus of care
* Apply heat to outer ear, or ice
* ASA, acetaminophen, ibuprofen prn
* If pain extreme, Tylenol #3 or Vicodin
* Avoid swimming or submersion of ear under water for 4-6 weeks
* If bacterial OE, tx with topical antibiotic
* If ear is edematous, cotton plug soaked in otic prep should be inserted
164
otitis externa follow up
* Normally cured after 7-10 days, follow up in 1 week if uncomplicated
* If ear wick placed, return in 2 days for removal and cleaning
165
otitis media
* Inflammation of structure of middle ear
* Risk control for infants/young kids: stop tobacco exposure, exclusive breastfeeding for first 6 months of life, annual flu vaccine, Prevnar, pneumovax
* Incidence increases in winter months
* Most common in young children
* Risk factors: allergies, sinusitis, rhinitis, pharyngitis, influenza A, RSV, URI, trauma
* Strep pneumoniae is most frequent pathogen, up to ½ from viral infections
166
OME (otitis media with effusion)-
* transudation of plasma fluid from middle ear blood vessels, leads to chronic effusion without signs of acute infections
167
physical exam otitis media
* OME- Mucous membrane infected/edematous, eardrum dull
* Acute OM- tympanic membrane amber or yellow orange, full/bulging
* Discharge may be present
* Chronic OM- perforated, draining tympanic membrane
168
OME treatment
“watchful waiting”, monthly exams, 10 day course ABX if unresponsive
169
AOM treatment
Antibiotics, some watch for 2-3 days before starting therapy and start analgesic only
170
AOM follow up
2-3 days if symptoms don't resolve
171
Rhinitis
(coryza) is an inflammation of the nasal mucosa characterized by nasal congestion, rhinorrhea, sneezing, pruritus, and/or postnasal drainage
172
allergic rhinitis
occurs in all age groups, most commonly in adults between 30-40
173
meds that causes rhinitis
antihypertensive most common
oral contraceptive
174
rhinitis exam
nasal mucosa erythematous, pharyngitis
175
rhinitis treatment
intranasal ipratropium- two sprays in each nostril 2-4x daily to relieve runny nose
176
rhinitis follow up
2-3 weeks
177
rhinosinusitis
inflammation of sinuses
risk factor- smoking, exposure to pollution, sneezing, cold/damp weather, sudden change in temp
178
rhinosinusitis clinical presentation
a gradual onset of symptoms, including recurrent or chronic dull, constant pain over the affected sinuses
179
rhinosinusitis treatment
oral analgesics
expectorants- guaifensin
180
rhinosinusitis follow up
10-14 days from assessment
181
Stomatitis
is a generalized inflammation of the oral mucous membranes characterized by erythema and/or vesicular or ulcerative lesions
182
Glossitis
is an acute or chronic inflammation of the tongue that shares many of the same etiologies as stomatitis
183
types of stomatitis
herpetic
recurrent aphtous stomatitis
vincent's stomatitis (trench mouth)
nicotinic stomatitis
184
stomatitis risk factors
chronic mouth breathing
hot foods
spicy acidic salty foods
infection
long term steroid use
tobacco smoking, chewing
HSV
185
stomatitis clinical presentation
dryness of mouth, halitosis, pain, bleeding, fever, malaise, headache
mouth and tongue bright red and swollen
186
stomatitis management
d/c behavior contributing to cause
baking soda rinse tid
liquid antacid
oral lidocaine 2%
187
epistaxis
is a hemorrhage of the nasal mucosa resulting from the traumatic or spontaneous rupture of superficial veins and/or arteries, located most often on the anterosuperior portion of the nasal septum known as Little’s are
188
epistaxis treatment
continuous pressure 10-15 min
pledget soaked in vasoconstricting agent
cauterization
