Test 2 Flashcards
basal cell carcinoma pop
- men
- Caucasian
- closer to the equator
- Tucson
- Finland
- Australia
- 55-75
basal cell carcinoma pathophysiology
sun exposure low vegetable and fruit intake
Basal Cell Carcinoma RF
- history of BCC
- Caucasians
- Chronic UV radiation
- childhood sun exposure
- number of past sunburns
- SAD diet
- arsenic exposure
- smoking
- immunosuppressive drugs or organ transplant
- tanning beds
- farmers, outdoor jobs
- psoralen plus ultraviolet A light (PUVA)
- Broad band and narrow band ultraviolet (UVB) phototherapy
- ionizing radiation therapy
Basal cell carcinoma location
- ears
- face
- neck
what is the most common BCC?
nodular
round shinny, pearly, flesh-colored papule, telangiectasia, translucent when stretched, can have center ulcerates/bleeding, accumulates crusts/scales and will heal then grow again
nodular BCC
brown, black, or blue; elevated, pearly white, translucent border; papule
pigmented BCC
appear yellow-white when stretched, firm to touch, seemingly well-defined border, doesn’t ulcerate
micronodular BCC
white or yellow, waxy sclerotic plaque, rarely ulcerate, flat or slightly depressed, fibrotic, and firm, borders are indistinct
morpheaform BCC
upper trunk or shoulders, extremities, face; red, round-to-oval, well-circumscribed patch or scaling plaque, whitish scale; thin, raised, pearly white; least aggressive
superficial BBC
BCC complication
- death
- hemorrhage of eroded large vessels
- meningitis
TX nodular BCC
Electrodesiccation and curettage or by simple excision
Mohs surgery
solasodine Rhamnosyl glycosides (SRG’s) (Zycure, Curaderm-nightshade extract) and black salve
Radiation therapy
Anti-inflammatory diet
superficial BCC tx
topical tazarotene
photodynamic therapy
topical 5-Fluorouracil and imiquimod
Tx Morpheaform BCC
wide excision
Mohs micrographic surgery
Curaderm
black salves
Squamous Cell Carcinoma pop
older, white
SCC RF
- Chronic sun exposure
- Fair complexion
- Chronic skin ulcers or sinus tracts
- Long term-exposure to hydrocarbons, arsenic, burns, radiation
- Immunosuppression
- Other radiation exposures
- Chronic inflammation
- Genetics or inherited disorders
- Smoking
- Inflammatory diet
- HPV infection
- Xeroderma pigmentosum
SSC sx
- Hyperpigmented nodular mass which commonly ulcerates
- Papules, plaques, nodules that can be smooth, hyperkeratotic, or ulcerative
- Head and neck (55 %)
- Dorsum of hands/forearms (18 %)
- Legs (13 %)
- Arms (3 %)
- Shoulder or back (4 %)
- Chest or abdomen (4 %)
- Other sites (3 %)
- areas of chronic inflammation
- areas of chronic scarring
Bowen’s disease SCC
- Patch or plaque
- Erythematous
- Slow growing
- Asymptomatic
- lower legs, neck and head.
Erythroplasia of Queyrat
- Well-defined, velvety, red plaque
- Pain
- Bleeding
- Pruritus
- penis
- Asymptomatic
- Painful or pruritic
Invasive SCC
- indurated or firm, hyperkeratotic papules, plaques, or nodules
- 0.5-1.5 cm
- ulceration
Well differentiated SSC
- fleshy, soft, granulomatous papules or nodule
- ulceration
- hemorrhage
- areas of necrosis
Poorly differentiated SCC
Tx Localized SCC
- Cryotherapy
- Electrosurgery (e.g. ED & C)
- Topical (5-fluorouracil, imiquimod)
- Radiation therapy
- Surgical excision
- Mohs surgery
Prevention SCC
- anti-inflammatory diet
- sunscreen
- oral and topical green tea
- grape seed extract
SCC
BCC
Keratoacanthoma pop
50-69, men, with Fitzpatrick I-III classification
Keratoacanthoma Pathophysiology
ultraviolet (UV) radiation, exposure to chemical carcinogens, viral exposure including human papillomavirus (HPV)
Keratoacanthoma sx
- Rapidly growing, dome-shaped nodules with a central keratin-filled crater
- cheeks, nose, ears, hands (post), but can be any location
Keratoacanthoma tx
surgicalexcision
Keratoacanthoma
Melanoma pop
- men
- whites
Melanoma cause
increased UVA exposure and decreased cutaneous Vitamin D3 levels
Melanoma RF
- sun exposure and sunburns
- inflammatory diet
- family history of atypical nevi or melanoma
- light colored skin and red hair
- immunosuppression
- previous history of melanoma
- airline pilots
Melanoma growth pattern
- growth phase
- horizontal phase
- spread out horizontally and can be confined to the epidermis
- vertical
- infiltrate deep into the dermis quickly
- horizontal phase
- from atypical nevi 30-50%
- most common
- 30-50 yo
- grows slowly (5-10 y) and horizontal then will grow vertical
- lower extremities (F), trunk (M), upper back (both)
- brown to black macule, color variation, irregular, notched borders
- less than 1 mm in thickness
superficial spreading melanoma
superficial spreading melanoma
- aggressive, highest risk of spreading, difficult to diagnose
- greater than 2 mm in thickness at diagnosis
- pedunculated or polypoid black nodules
- blue, gray, white, brown, tan, red, or skin tone
- trunk, legs, arms, scalp (M)
- elderly
nodular melanoma
nodular melanoma
Lentigo maligna melanoma
Acral lentiginous melanoma
- aggressive
- most common among Asian and African-American
- on palmar, plantar, subungual surface, between the toes
- lesion raised, develops ulceration, >5 mm in diameter need to look at lymph nodes
- dark brown to black, irregularly pigmented macules to patches
acral lentiginous melanoma
- most common in geriatric pop
- remain close to skin surface for years to decades
- elderly, chronically sun-exposure, damaged skin
- on the face, ears, arms, upper trunks,
- flat or mildly elevated mottled tan, brown, or dark brown
- nodule or papule indicate invasion
- asymmetric foci, color variegation
- most common melanoma in Hawaii
- slow growing and grows outward
- multiple colors
lentigo maligna melanoma
hutchinson’s sign
acral lentiginous
melanoma dx
- Excisional Biopsy- 1-3 mm margins of normal skin and a layer of subcutaneous fat
- Punch biopsy
- DON’T DO Shave
- scoop shave biopsy- scoop out the lesion with 1-3 mm margins
melanoma complication
- death
- metastasis
melanoma tx
- wide local excision, surgical removal
- Mohs micrographic surgery
- interferon
- cytotoxic chemotherapy
- radiation therapies
- Vit C, A and E, carotenoids, dietary antioxidants, fruits, vegetables, Med diet
- curcumin, green tea,
- pre-surgery: modified citrus pectin and bioflavonoid
- Silymarin, curcumin, polysaccharide krestin, Vit E, melatonin
- quercetin, betulinic acid, ginseng, licorice, cordyceps, viscum
- vit D, azelaic acid, genistein, astragalus
- black salves
- fasting before chemo: low protein,
Most SSCs that occur in sun-exposed areas of the skin have a very _____ rate of metastasis.
low
In dark-skinned people, SCCs tends to arise on non sun-exposed areas (e.g. the legs and anus) and are frequently associated with chronic inflammation, chronic wounds, or scarring.
T or F
T
Cumulative UVB sun exposure in the past ________ years of a person’s life increases the likelihood of SCC in the presence of other risk factors.
5-10
A lesion on the vermillion border is ___ until prove
SCC
which is more likely to metastasize?
SCC or BCC
SCC
Why do basal cell carcinomas have a limited capacity to metastasize?
absence of necessary growth factors derived from the stroma of the original tumor site.
Persons aged 55-75 have a ______ -fold higher incidence of BCCs than those younger than 20.
100
About ____ % of patients who have had one BCC will develop another lesion within five years.
40
What is the most important environmental risk factor for developing BCCs?
sun
intermittent, intense sun exposure decrease BCC
T or F
F
rodent ulcer
BCC Center ulcerates/bleeds, accumulates crust/scale then heal with scarring
morpheaform BCC have borders that are easily localized
T or F
F
BCCs must be treated early on to avoid the locally invasive, aggressive, and destructive effects on skin and surrounding tissues
t or f
t
ED&C are the most effective treatment of BCC
t or f
f
Why would one chose radiation therapy to treat a BCC?
not candidates for surgery
List three features of BCCs that account for a high likelihood for recurrence after initial treatment.
size, depth, and irregular border
Although there is no uniform agreed upon screening protocol for malignant melanomas in the US a skin survey to identify suspicious lesions is considered the best option!
T or F
T
Individuals with atypical nevi have a _________ fold elevated risk of developing malignant melanoma.
6
There is a strong association between high nevus counts (more than ____) and malignant melanoma.
> 50
Case studies found the strongest association for malignant melanoma for ____________ sun exposure and ___________ in adolescence or childhood.
intermittent exposure sunburn
During the ___________ growth phase a malignant melanoma is almost always curable by surgical excision alone.
horizontal phase
Nodular melanomas have no identifiable __________ growth phase and enter the _____________ growth phase almost from their inception.
horizontal; vertical
Over 60% of superficial spreading malignant melanomas are diagnosed as thin, highly curable tumors of less than _ mm thickness.
1
Nodular malignant melanomas are the most difficult to diagnose at an early stage – at least half are greater than ____ mm in thickness when diagnosed!
2
The great majority of lentigo maligna melanomas are diagnosed at less than ___ mm of thickness!
1
The most common type of malignant melanoma among Asians and in African-Americans is the ______________ _____________ ____________ which arise most commonly on palmar, plantar, and subungual surfaces.
acral lentiginous Melanoma
______________ _______________ is the single most important determinant of prognosis for a malignant melanoma.
sun exposure
Stage T1: ≤1 mm malignant melanomas have a ten year survival of ____ percent.
92%
The definitive “initial” surgical treatment for primary cutaneous melanoma is a ________ ________ __________ down to the deep fascia.
excision
Because of the potential of metastasis and possible death, any biopsy that comes back positive for malignant melanoma needs to be referred for additional surgery via ______________ procedure.
mohs
SCC TX
oral vitamin A
oral SCC
Present as an ulcer, nodule, or indurated plaque involving the oral cavity
Floor of the mouth and lateral or ventral tongue most common sites.
Lesions arise in sites of:
erythroplakia (premalignant persistent red patches)
leukoplakia (persistent white plaques
Verrucous carcinoma SCC
exophytic, cauliflower-like growths that resemble large warts.
Lesions are sub classified according to site:
Oral – florid mucosal verrucous papillomatosis
Anogenital – giant condyloma acuminatum or verrucous carcinoma involving the penis, scrotum, or perianal region
Epithelioma cuniculatum – verrucous carcinoma on the plantar foot surface
SCC on lip
Primarily occurs on the lower lip
Lesions may present as nodules, ulcers, or indurated white plaques
ELECTRODESICCATION & CURETTAGE advantage
Cost effective
Relatively quick, single visit
Relatively easy wound care
Well suited for multiple lesions
Usually good to excellent cosmetic results
No sedation or general anesthesia required
Disadvantages of ED & C
Not margin-controlled
Recurrence rate unacceptably high with larger (>5 mm) lesions located in high risk sites!
Need special equipment and user experience to get higher cure rates
Poor choice in most BCCs of the head
Must be cautious in patients with pacemakers
surgical excision advantages
Margin-controlled
Resultant scar is optimized both cosmetically and functionally.
Disadvantages of Surgical Excision
Invasive
have to use general anesthesia
not as good results as Mohs micrographic surgery
Advantages of Mohs
Cost effective
No sedation or general anesthesia required.
high cure rates
great cosmetic outcome
Allows for histological evaluation of 100% of the peripheral margin
Disadvantages of Mohs
expensive
long time to get done
Requires special training in the technique.
Advantages of Cryotherapy
Cost effective
Relatively quick – no sedation or general anesthesia required
Relatively easy wound care
Well suited for multiple lesions
Usually affords good to excellent cosmetic results
Low recurrence rates in small primary BCCs that lack “high risk” features
Disadvantages of Cryotherapy
Not margin-controlled.
May require multiple visits
Requires considerable clinical judgment/experience
Potential hyper- and hypo-pigmentation
Possible permanent damage to underlying nerves, vessels, etc.
TOPICAL 5-FLUOROURACIL AND IMIQUIMOD advantages
Noninvasive; avoids operative risks.
Rarely causes scarring.
Good for patients who are otherwise not candidates for surgery.
TOPICAL 5-FLUOROURACIL AND IMIQUIMOD disadvantages
Limited to treating only superficial BCCs located in low-risk areas.
Brisk inflammatory reaction - poorly tolerated in some individuals.
Requires prolonged application (weeks to months!)
radiation therapy advantages
Noninvasive – relative sparing of critical structures
Relatively painless
Good for patients who are not otherwise candidates for surgery
High cure rate for selected lesions
digit block or nerve block
- Cleanse the toe/finger and paint the area with povidone-iodine (Betadine®) solution.
- Using a 27 gauge needle, slowly inject 1% lidocaine (or lidocaine 1%:Marcaine 0.25% 1:1 mix) midway between the dorsal and palmar surfaces of the finger at the midpoint of the middle phalanx.
- Advance the needle and inject lidocaine in the vicinity of the neurovascular bundle.
- Then pull back without removing the needle and fan the needle toward the dorsal surface – repeat injection
alteratives
Nourishing, restorative tonics with effects focused on digestion, absorption, and elimination
Alterative, Nutritive,high in phytoestrogens, lymphagogue, Antitussive, Antispasmodic, Vulnerary
Trifolium pratense actions
menopausal climacteric symptoms, vaginal dryness, chronic skin conditions, Breast cancer estrogen positive
Lots of heat
Cancer, gout, arthritis, acne, spasmodic cough, cachexia, burns with poor healing, ulcers of the skin or mucous membranes, TB or inflammation of the lungs
Trifolium pratense indications
better subjective improvement of scalp hair and skin status, libido, mood, sleep, and tiredness
inhibition of 5-α-reductase activity, reduction of inflammatory reactions, and stimulation of ECM protein synthesis in the vicinity of the hair follicle
Trifolium pratense MOA
Root: alterative, mild digestive bitter, antitumor, antimutagenic, nutritive, antirheumatic, phytoestrogenic, liver tonic
Leaves: used topically as a antimicrobial, anti-inflammatory poultice
Seeds: alterative, diuretic, urinary tonic, vulnerary
Cholagogue
Rumex spp actions
ALBE inhibits the expression of IL-4 and IL-5 by downregulating MAPKs and NF-κB activation in ConA-treated splenocytes
Rumex spp MOA
Root: dry and scaly skin conditions – psoriasis, eczema, dandruff, rheumatic/arthritic conditions, anorexia nervosa, cystitis, wounds and ulcers (poultice).
Leaves: mastitis, joint sprains (poultice), alleviate nettle stings
Seeds: cystitis, skin conditions including exanthems
Rumex spp indications
Oxalate kidney stones, kidney disease, iron overload, pregnancy
Don’t eat the leaves - very high in oxalic acid and can cause poisoning – oxalic acid chelates calcium in the blood.
Rumex spp CI
Alterative, digestive bitter, anticatarrhal, antimicrobial, cholagogue, mild laxative.
Mahonia spp actions
lipoxygenase inhibition and lipid antioxidant properties
Mahonia spp moa
Skin conditions:
Psoriasis, eczema, herpes, pityriasis, acne, syphilis.
Poor gallbladder function: Nausea, fat malabsorption, digestive upset
Infections:
Skin, eye, and intestinal tract (bacterial, fungal and protozoal)
Mahonia spp indication
Mahonia spp CI
pregnancy
Antioxidant, inhibit tumor cell proliferation and induce apoptosis, pro-oxidant, promotes weight loss, decreases LDL, modulates inflammation, decreases sebum production, antimicrobial
Camelia sinensis action
inhibition of MAP kinase signaling, inhibition of growth factor signaling, inhibition of matrix metalloproteinases, inhibit angiogenesis, decrease invasiveness of cancer cells, augments hormonal therapies, decreases free testosterone, increases SHBG, decreases insulin resistance and improves other glucose-related markers
Camelia sinensis moa
Cancer, PCOS, androgenic alopecia, anti-aging, acne, wound and scar healing, sun protection
Camelia sinensis indication
Camelia sinensis CI
Take away from iron supplementation
Berries – antioxidant, modulates inflammation.
Rhizome and root – also modulate inflammation, effects glucose metabolism, antimicrobial
Berberis vulgaris action
Berries – effective in the treatment of acne as well as other inflammatory conditions.
Rhizome and root – source of berberine and uses relate to that constituent.
Berberis vulgaris indication
hepatoprotective, hepatotonic, antihepatotoxic (particularly against aminita phalloides), nephroprotective, bitter, galactagogue, antifibrotic effect,
Increase glutathione
Silybum marianum action
increased GSH levels, decreased MDA and IL-8
Silybum marianum MOA
Liver diseases , jaundice, hepatitis, cirrhosis, alcoholism, fatty liver degeneration, hepatitis, cirrhosis, alcoholism with fatty liver, diabetic nephropathy
Acne
Silybum marianum indication
Silybum marianum CI
Speculative - asteraceae family allergy
Warm, stimulating or calm depending on physiologic state, dispels wind dampness
Eleutherococcus senticosis Energetics
Adaptogen, immunomodulating, mild CNS stimulant
Nonspecific ant stress effects
Ergogenic
Anabolic/anticatabolic
Antitoxic
Radioprotective
Chemoprotective
Immunoprotected
Immunoregulatory
Antiviral
Gonadotrophic
Insulin-trophic/antidiabetic
Neuroprotective
Eleutherococcus senticosis action
reduced frequency of HSV,
Eleutherococcus senticosis moa
Build vitality, increase resistance to infection, stress, and toxicity, improve physical performance, and improve mood
Eleutherococcus senticosis indication
Adulteration is common in the marketplace. Monitor blood glucose in diabetics and hypoglycemics when introducing this herb.
Eleutherococcus senticosis CI
Anti-allergic action of triterpenes, anti-hypertensive, oleic acid inhibits histamine release, hypotensive, decreases platelet aggregation/LDL/arrhythmia/insomnia/angina, protects against ionizing radiation
Ganoderma lucidum action
Used in cancer treatment to increase immune function and help treat fatigue, hypertension, immune deficiency, insomnia, hepatitis
Ganoderma lucidum indication
Potential allergy to spores
Ganoderma lucidum ci
Seborrheic keratosis
Seborrheic keratosis
Seborrheic keratosis
milia
Localized atypia of the epidermis – a precursor to SCC in situ
Gross morphology:
Tan-brown, red or skin-colored
Rough like sandpaper
On face, arms, dorsal hands, lips
Hyperkeratosis
What is this?
Actinic keratosis
Meibomian cyst/Chalazion
Digital mucous cyst
Painful lesions
Early
Central crust
Apex -mc
Long standing
Dense rolled edge
Chrondrodermatitis nodularis helicis
Painful lesions
Early
Central crust
Apex -mc
Long standing
Dense rolled edge
Chrondrodermatitis nodularis helicis
Painful lesions
Early
Central crust
Apex -mc
Long standing
Dense rolled edge
Chrondrodermatitis nodularis helicis
Most common tumor of the intraepidermal eccrine sweat glands
Women>Men
Autosomal dominant
Usually symmetrical distribution
Syringoma
Very common, button-like dermal nodule
pink, brown, tan, darker at center
leg>arms>trunk
few mm to 1 cm
‘dimple sign’ with lateral compression
Tx-leave alone, excision, cryotherapy
Dermatofibroma
Seborrheic keratosis
Ganglion cyst
Lipoma
Basal cell carcinoma
Seborrheic keratosis
Sebaceous hyperplasia
actinic keratosis
Actinic keratosis
Chrondrodermatitis nodularis helicis
Basal cell carcinoma
Dermatosis Papulosa Nigra
Skin tag acrochordon
Skin tag acrochordon
Skin tag acrochordon
Epidermal inclusion cyst
Epidermal inclusion cyst
Present in 5-20% of white population
skin surface of whites-can occur anywhere
acral and mucosal surface of other races
potential precursors to Superficial Spreading melanoma (SSM),
increase risk for developing primary melanoma
Atypical or dysplastic nevi
Present in 5-20% of white population
skin surface of whites-can occur anywhere
acral and mucosal surface of other races
potential precursors to Superficial Spreading melanoma (SSM),
increase risk for developing primary melanoma
Atypical or dysplastic nevi
Dermatofibroma
Dermatofibroma
Junctional nevi
Solitary lesions are:
infrequent
inconsequential
represent spontaneous mutations
These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.
Neurofibroma type 1
Solitary lesions are:
infrequent
inconsequential
represent spontaneous mutations
These lesions characteristically, on compression, invaginate into a slit-like defect in the skin = “buttonhole” sign.
Neurofibroma type 1
BCC
BCC
BCC
Dermal nevi
Dermal nevi
Ganglion cyst
Usually deeper than an epidermal inclusion cyst
May feel rubbery but is usually not malleable.
If uncertain diagnosis, particularly if the lesion feels quite firm, a malignant tumor must be considered
Lipoma
Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years
Hypertrophic scar or keloid
Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years
Hypertrophic scar or keloid
Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years
Hypertrophic scar or keloid
Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years
Hypertrophic scar or keloid
Abnormal scarring in susceptible individuals
More common in darker skin types
1%-16% of the population in response to trauma (acne, body piercing, tattoos, insect bites, vaccinations, surgery)
Age 10-30 years
Hypertrophic scar or keloid
Skin tag
Digital mucous cyst
Alopecia areata cause
autoimmune disease
hashimoto’s thyroiditis
vitiligo
myasthenia gravis
Alopecia areata sx
loss of hair that is asymptomatic
exclamation point hairs
Alopecia areata TX
stress reduction
topical onion juice x2
topical steroids
injection of steroids
topical minoxidil
wig
topical immunotherapy
Acquired loss of pigmentation
Pathogenesis is not known
Theories: autoimmune, neurogenic, self-destruct, genetic background (30%)
Age of onset: any, 10-30yrs (50%)
Incidence: common up to 1%
All races, equal in both sexes
Skin lesions: white macules, sharply marginated, 5mm-5cm
Can affect any area; most common on face and extremities. Accentuated with sun exposure.
Vitiligo
Acquired loss of pigmentation
Pathogenesis is not known
Theories: autoimmune, neurogenic, self-destruct, genetic background (30%)
Age of onset: any, 10-30yrs (50%)
Incidence: common up to 1%
All races, equal in both sexes
Skin lesions: white macules, sharply marginated, 5mm-5cm
Can affect any area; most common on face and extremities. Accentuated with sun exposure.
Vitiligo
Sun exposed areas of skin
male> females
pre-malignant
1 out of 1000 lesions develop into SCC annually
5-10% over a lifetime
actinic keratosis
Acquired light or dark-brown hyperpigmentation
Age of onset: young adults
Female>male(10%)
Race: brown or black skin type
Incidence/etiology: hyperinsulinemia, pregnancy (mask of pregnancy), combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti seizure medication
melasma
Acquired light or dark-brown hyperpigmentation
Age of onset: young adults
Female>male(10%)
Race: brown or black skin type
Incidence/etiology: hyperinsulinemia, pregnancy (mask of pregnancy), combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti seizure medication
melasma
Nodular mass of dilated vessels
80-90% resolves spontaneously within 5-8 years
hemangiomas
Nodular mass of dilated vessels
80-90% resolves spontaneously within 5-8 years
hemangiomas
Nodular mass of dilated vessels
80-90% resolves spontaneously within 5-8 years
hemangiomas
Fair-skinned individuals with excessive sun exposure in childhood at highest risk
Exposure to chemical carcinogens (pitch, tar, crude paraffin oil, fuel oil, creosote, lubricating oil)
arsenic (Flower’s soln. for psoriasis)
other etiologies (HPV, immunosuppression)
SCC
Fair-skinned individuals with excessive sun exposure in childhood at highest risk
Exposure to chemical carcinogens (pitch, tar, crude paraffin oil, fuel oil, creosote, lubricating oil)
arsenic (Flower’s soln. for psoriasis)
other etiologies (HPV, immunosuppression)
SCC
nodular melanoma
Single or scattered discrete lesions
Adherent hyperkeratotic scales – “rough texture”
actinic keratosis
punch biopsy was malignant 20 years history
grows nodule after several years means its spread
lentigo maligna
melanoma
Hutchinson’s sign
Periungual spread from nail
acral lentiginous melanomas
Scaling to ulcer
elevated nodule to tumor
Indurated, eroded nodule that ulcerates and bleeds easily
Common on lower lip, top of ears, tongue, head, neck, back of hands
SSC
Scaling to ulcer
elevated nodule to tumor
Indurated, eroded nodule that ulcerates and bleeds easily
Common on lower lip, top of ears, tongue, head, neck, back of hands
SSC
Autoimmune disease causing localized hair loss w/o signs of inflammation (asymptomatic)
about 2% of population have at least one episode
Etiology-autoimmune, can be assoc. with Hashimoto’s thyroiditis, vitiligo, myasthenia gravis
alopecia areata
Autoimmune disease causing localized hair loss w/o signs of inflammation (asymptomatic)
about 2% of population have at least one episode
Etiology-autoimmune, can be assoc. with Hashimoto’s thyroiditis, vitiligo, myasthenia gravis
alopecia areata
Exclamation point hairs
Course: remission is common (80%)
Management: stress reduction, topical onion juice, topical, intralesional, or systemic glucocorticoids, can add topical minoxidil, wig in severe cases, or refer for topical immunotherapy
alopecia areata
pre-malignant (1 out of 1000 lesion annually) develop into SCC, 10% over lifetime
actinic keratosis
5-Fluorouracil- applied bid for 2-4 weeks – very irritating
Acetaminophen with codeine often given to control pain
Petrolatum often used between applications to soothe skin
actinic keratosis
management: gluten free diet, dipsone,
Dermatitis herpetiformis
Dermatitis herpetiformis
Storke bite lesion
nodular BCC
Course and Prognosis: May spontaneously disappear after delivery or stopping hormones
Management: can be difficult to treat. Use sun blocks and/or reduce UV exposure, hypopigmenting agents (i.e. hydroquinone 2-4% bid), topical tretinoin, azelaic acid, chemical peels (glycolic acid, salicylic acid and TCA), laser cryotherapy, dermabrasion
Melasma
Course and Prognosis: May spontaneously disappear after delivery or stopping hormones
Management: can be difficult to treat. Use sun blocks and/or reduce UV exposure, hypopigmenting agents (i.e. hydroquinone 2-4% bid), topical tretinoin, azelaic acid, chemical peels (glycolic acid, salicylic acid and TCA), laser cryotherapy, dermabrasion
Melasma
most common in 6th decade of life
no radial growth, so early metastasis
nodular melanoma
most common in 6th decade of life
no radial growth, so early metastasis
nodular melanoma
photodynamic therapy
actinic keratosis
rapid growth within few weeks- can self-resolve within a month-year
Keratoacanthoma
Treated 5-FU or Curaderm identify
superficial BCC
Dilated vessels deep in dermis and subcutaneous tissue
Spontaneous resolution, surgery, interferon, propranolol, intralesional and topical corticosteroids, vincristine and cyclophosphamide
hemangioma deep cavernous
Dilated vessels deep in dermis and subcutaneous tissue
Spontaneous resolution, surgery, interferon, propranolol, intralesional and topical corticosteroids, vincristine and cyclophosphamide
hemangioma deep cavernous
Vascular malformation/port wine stain
Vascular malformation/port wine stain
Vascular malformation/port wine stain
asymptomatic, soft benign papule, from dilated venule
venous lake
Develops after a minor trauma
Bleeds easily
<30 years old
pyogenic granuloma
Develops after a minor trauma
Bleeds easily
<30 years old
pyogenic granuloma
spider angioma
spider angioma
25% remit with decrease sun exposure
Antioxidants, fruit, vegetables, green tea, etc
5-Fluorouracil
Black salve (iris, red clover, sanguinaria)
Vitamin A
Curaderm
Cryotherapy (3-10 seconds max/3) w/ 5FU
Sunscreen Type I & II skin
excision for large lesions
actinic keratosis
25% remit with decrease sun exposure
Antioxidants, fruit, vegetables, green tea, etc
5-Fluorouracil
Black salve (iris, red clover, sanguinaria)
Vitamin A
Curaderm
Cryotherapy (3-10 seconds max/3) w/ 5FU
Sunscreen Type I & II skin
excision for large lesions
actinic keratosis
most common skin disorder in adolescents
Typical age range:12-25 years
79% to 95% of adolescents aged 16-18 years-reference
acne
most common skin disorder in adolescents
Typical age range:12-25 years
79% to 95% of adolescents aged 16-18 years-reference
acne
A reactive hypermelanosis of the skin that occurs as a sequela of cutaneous inflammation
EPIDEMIOLOGY
A common disorder that can occur at any age and has an equivalent incidence in males and females.
may occur regardless of skin color, but is clinically more significant with darker skin pigmentation.
hyperpigmentation syndrome
Wheals –transient edematous papules and plaques
Usually pruritic
15-25% of pop will have at least one episode at during their lifetime
Duration: hours-months
Histamine is the most important mediator
urticaria
Wheals –transient edematous papules and plaques
Usually pruritic
15-25% of pop will have at least one episode at during their lifetime
Duration: hours-months
Histamine is the most important mediator
urticaria
Chronic, recurrent, intensely pruritic vesicles, papules, and urticarial plaques that are arranged in groups
Can resembles herpes; therefore the designation of herpetiformis
Almost universally associated with celiac disease (1% of pop)
Age of onset: 20-60 years
Prevalence in Caucasians, M:F 2:1, 10-39 per 100,000 persons
dermatitis herpetiformis
Thickened, hyperpigmented skin in the axillae and groin
Often associated with obesity and hyperinsulinemia
Can be congenital
Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation
Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)
Acanthosis Nigricans
Thickened, hyperpigmented skin in the axillae and groin
Often associated with obesity and hyperinsulinemia
Can be congenital
Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation
Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)
acanthosis nigricans
Thickened, hyperpigmented skin in the axillae and groin
Often associated with obesity and hyperinsulinemia
Can be congenital
Increased circulating insulin causes dermal fibroblast and keratinocyte proliferation
Associated rarely with internal malignancy (stomach and other gastrointestinal malignancies)
Acanthosis Nigricans
Localized proliferation of melanocytes due to chronic sun exposure (esp. sunburns)
1-3 cm macules
>40 years old esp. Type I to III skin
Roughly 75% of white people over 60 have one or more
solar lentigo
Dermatitis Heprtiformis pathophysiology
celiac disease
Dermatitis Heprtiformis population
20-60 yo
Caucasians
M
Dermatitis Heprtiformis Sx
Chronic, recurrent, intensely pruritic vesicles, papules, and urticarial plaques that are arranged in groups
Dermatitis Heprtiformis TX
gluten free diet
dapsone
sulfapyridine
Acanthosis Nigrican cause
hyperinsulinemia causes melanocytes, dermal fibroblast and keratinocyte to proliferation
diabetes, metabolic syndrome
internal malignancy
Insulin and insulin-like growth factor-1, and their receptors on keratinocytes are obviously involved in the complex regulations leading to the peculiar epidermal hyperplasia
Acanthosis Nigrican sx
symmetric velvety hyperpigmented plaques on intertriginous areas like axilla, neck, inframammary, and groin
associated with skin
Acanthosis Nigrican Tx
berberine, metformin,rosiglitazone
remove meds that cause hyperinsulinemia: glucocorticoids, injected insulin, niacin, oral contraceptives
topical retinoids: keratinolytic effects on the skin
vitamin D analogs: reducing keratinocyte proliferation
keratolytics
topicalurea, salicylic acid, glycolic acid peels, and laser therapy
Melasma pop
young age, female, darker skin types
Melasma cause
oral contraceptive use, pregnancy
hyperinsulinemia, combo hormone replacement, thyroid dysfunction, genetics, UV radiation, cosmetics, and anti-seizure medication
Melasma sx
Irregular blotchy patches of hyperpigmentation on the face
Melasma DX
insulin
glucose
Melasma TX
sunscreen
hydroquinone 2-4% bid
topical tretinoin
azelaic acid
chemical peels (glycolic acid, salicylic acid and TCA)
laser cryotherapy
dermabrasion
Postinflammatory hyperpigmentation cause
reactive hypermelanosis of the skin that occurs as a sequela of cutaneous inflammation
acne vulgaris, atopic dermatitis, irritant contact dermatitis, allergic contact dermatitis, psoriasis, and lichen planus.
Accidental burns, nonionizing radiation therapy, phototoxicity, chemical peels, and laser procedures
when inflammation leads to a disruption of the basal layer of the epidermis, causing the release of melanin into the papillary dermis. Macrophages in the papillary dermis then phagocytize the released melanin.
Postinflammatory hyperpigmentation TX
avoid sun
treat underlying cause
Topical hydroquinone (2-4%): cytotoxic effect
topical retinoids, azeliac acid, and chemical peels (Glycolic acid-Alpha hydroxy acids (AHAs) and salicylic acid-Beta hydroxy acid (BHA
laser
lignin peroxidase
mequinol, niacinamide, ascorbic acid, kojic acid, and licorice
Solar Lenitgo cause
Localized proliferation of melanocytes due to chronic sun exposure
Solar Lenitgo pop
> 40, Type I to III skin
Solar Lenitgo sx
1-3 cm macules, brown
Solar Lenitgo dx
punch biopsy
shave
Solar Lenitgo tx
hydroquinone solution
tretinoin
azeliac acid cream
glycolic acid peels and creams
Light cryotherapy
Vitiligo pop
any race, 10-30
Vitiligo cause
unknown, autoimmune, family history
neurogenic, self-destruct,
associated with thyroid disease (30%), alopecia, Addison’s disease, pernicious anemia, type 1 diabetes, chronic candida, melanoma
Vitiligo sx
Irregular, completely depigmented patches
area devoid of melanocytes
white macules, sharply marginated, 5mm-5cm
face and extremities
accentuated by sun exposure
Vitiligo tx
sunscreen
oral and/or topical psoralens with UVA (6-24 month course), UVB(6-12 months)
oral/topical steroids
tacrolimus
B12 (2,000mcg/day) plus folic acid (10mg/day)
L-Phenylalanine 50mg/kg/day orally and a 10% gel topically, plus 30 min of sun per day
Ginkgo biloba - 40 mg orally 3 times daily
urticaria cause
histamine is the most important mediator
Inhalants: pollens, animal danders, mold spores, feather down, aerosols, smoke, dust and volatile chemicals
Injectants: drugs, diagnostic agents, vaccines, insects stings
Ingestants: drugs, food, food additives (dyes, preservatives, etc.)
Infections: bacterial, fungal, viral, parasitic
Contactants: plants, cosmetics, plastic, chemicals
dermographism
cold solar
exercise-induced
pressure
urticaria sx
wheals
pruritic
hours to months
angioedema of glottis leading to air flow obstruction
urticaria dx
CBC with differential: normal or elevated eosinophil or neutrophil
ESR, CRP: elevated or normal
C4 level: decreased
Chronic utricaria
- TSH, antibodies
- ANA
- skin prick testing
- specific IgE blood test to allergen
- allergen elemination diet
- serum tryptase
- C1 esterase inhibitor
- C1-inhibitor
urticaria tx
antihistamines: benadryl, claritin, zyrtex, hydroxyzine, diphenhydramine, cetirizin, prednisone
epinephrine for severe cases
ID the causse
stop all nonessential drugs/supplement/herbs
elimination diet
low histamine diet
Vit C: 1 g tid, Vit D: 1,000-10,000IU D3-test blood levels
Vitamin B12, 1,000 mcg intramuscularly, once a week for 4 weeks, has been reported to provide relief in >50% (Gaby)
Quercetin: 250 mg 20 minutes before meal
Check and evaluate for HCL deficiency
Eradication of H pylori resulted in clinical improvement in 73% of patients with chronic urticaria (Helicobacter 2001;6(1):60-65
Relaxation, homeopathy, acupuncture
For cholinergic urticaria: hot shower depletes histamine store – 24 hour refractory period
Baking soda, starch or oatmeal bath
Botanicals: comfrey, euphoria, yerba sante, feverfew, ephedra
address histamine detox via diamine oxidase
- Gluten intolerance, leaky gut, SIBO, DAO blocking foods (alcohol, energy drinks, tea), genetic mutations, inflammation from Crohn’s ulcerative colitis, and IBD
- Medications such as: Non-steroidal anti-inflammatory drugs (ibuprofen, aspirin)
- Antidepressants (Cymbalta, Effexor, Prozac, Zoloft)
- Immune modulators (Humira, Enbrel, Plaquenil)
- Antiarrhythmics (propanolol, metaprolol, Cardizem, Norvasc)
- Antihistamines (Allegra, Zyrtec, Benadryl)
- Histamine (H2) blockers (Tagamet, Pepcid, Zantac)
Hemangiomas pop
most common tumor in infancy
Hemangiomas sx
deep and superficial
nodular mass of dilated vessels
Dilated vessels deep in dermis and subcutaneous tissue
Hemangiomas TX
Spontaneous resolution
surgery
interferon
propranolol
intralesional and topical corticosteroids
vincristine
cyclophosphamide
Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus sx
Flat, unilateral patches of irregular reddish-blue color.
Face and neck are most common
Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus dx
10% of face send for MRA to rule out CNS problems
Vascular Malformation/Birthmark/Port-wine stain/Nevus flammeus tx
Refer to dermatologist, an ophthalmologist and a neurologist if large
Pulsed dye laser
Cherry Angioma pop
male and females
begin around 30 years old
Cherry Angioma cause
family history
Cherry Angioma sx
bright red, blue, purple, black dome-shaped to polypoid, firm papule
chest and back
Cherry Angioma tx
radiosurgery
shave excision
laser
electrodesiccation
cryotherapy
no treatment necessary
Spider angioma pop
women
Spider angioma cause
oral contraceptive, pregnancy and liver disease
Spider angioma sx
Central arteriole w/ radiating telangiectasia
face, arms, and upper trunk
abdomen is liver congestion
Spider angioma dx
diascopy
Spider angioma tx
optional
radio/electrosurgery
laser
pulsed dye laser
Venous Lake pop
over 50 yo
Venous Lake sx
Dark blue to violet - dilated venule
face, lips, and ear
2-10mm soft papule that blanches with pressure
Asymptomatic, if unsure, R/O melanoma
Venous Lake dx
put slide and the blood drains out
Venous Lake tx
cosmetic
electrosurgery
laser
excision
Pyogenic Granuloma pop
Pyogenic Granuloma pop
any age
Pyogenic Granuloma cause
site of minor trauma
Pyogenic Granuloma sx
recurrent bleeding
red, dusky red, violaceous, brown/black
head, neck, upper trunk and hands and feet
Pyogenic Granuloma dx
rule out melanoma
excision/biopsy
Pyogenic Granuloma TX
electrodesiccation of base to prevent recurrence
Curettage and Cauterization
surgical Excision
Electrocautery Excision
Cryosurgery sometimes possible
Laser Surgery
Sclerotherapy
Injections of Corticosteroids into the Lesion
Benefits of epinephrine
- decreases bleeding
- prolongs the duration of the anesthesia
- minimize the amount of anesthesia
Issues of epinephrine
- goes through breast milk
- reduce uterine blood flow
- induce premature labor
- can cause gangrene or reduced blood flow
Benefits of Sodium Bicarbonate
- reduction in infiltration
- faster onset of action
Cons of sodium bicarbonate
- chemically unstable
- decrease the overall activity of epinephrine
Drug interactions to epinephrine
- MAO inhibitors: hypertensive crisis
- Carbamazepine and Cyclobenzaprine: potentiate effects
- tricyclics and tetracycline antidepressants: hypertensive crisis and dysrhythmia
- phenothiazines: profound hypotension
allergy to anesthetics cause, sx, management
- uncommon to amide
- allergy to methylparaben preservatives
Sx - delayed appearance of skin rashes
- acute onset of localized or general urticaria
- onset of asthma
Management - maintain airway
- legs up
- administer epinephrine, Benadryl, ER
topical anesthetics use and type
- mucous membranes
- cocaine, tetracaine, lidocaine, phenylephrine +lidocaine or tetracaine
local infiltration steps
- injection of local anesthetic directly into tissue without considering the course of cutaneous nerve
- clean the skin with alcohol or use betadine
- Insert a 25-30 g. needle attached to a syringe into the skin at a 15-20o angle and inject the anesthesia around or within the skin in the area to be removed or treated.
- Pull back or tighten the skin before inserting a 25-30 g needle ¼ inch back from wound edge or lesion
- Push the needle attached to a syringe into the skin at a 15-20 angle
- Advance the needle as far as it will go
- Draw back on the syringe to make sure the needle is not sitting in a vessel
- Slowly inject the anesthetic as you withdraw the needle
- Retain needle and advance to the opposite side of the “V”
- Repeat on other side of lesion
- May need to inject into the Sub-Q tissue and around the base of deep structures, i.e. a cyst, for good effect.
- Another injection can be done over future incision
field block
Injection of a combination of intradermal and subcutaneous local anesthetic solution in an inverted V just proximal to and to each side of the lesion (not into the lesion) with no attempt to locate specific nerves anesthetizing the region distal to the site of injection
field block procedure
- Clean the skin with alcohol.
- Use Betadine if needs to be sterile.
- Pull back or tighten the skin before inserting a 25-30 g needle ¼ inch back from wound edge or lesion
- Push the needle attached to a syringe into the skin at a 15-20 angle
- Advance the needle as far as it will go
- Draw back on the syringe to make sure the needle is not sitting in a vessel
- Slowly inject the anesthetic as you withdraw the needle
- Retain needle and advance to the opposite side of the “V”
- Repeat on other side of lesion
- May need to inject into the Sub-Q tissue and around the base of deep structures, i.e. a cyst, for good effect.
- Another injection can be done over future incision
anesthetics except cocaine are vasodilators
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What is the purpose of adding sodium bicarbonate to local anesthetics?
reduce the burning
Can sodium bicarbonate be safely added to local anesthetic products containing epinephrine? Why/why not? What are the effects?
yes
field block definitions
Injection of a combination of intradermal and subcutaneous local anesthetic solution in an inverted V just proximal to and to each side of the lesion (not into the lesion) with no attempt to locate specific nerves anesthetizing the region distal to the site of injection.
Injection of a combination of intradermal and subcutaneous local anesthetic solution completely around the boundaries of the lesion, with no attempt to locate specific nerves an anesthetized “field” inside of the boundaries of the anesthesia.
What are the 2 advantages of a field block over an infiltration anesthesia?
rapid onset
less drug can be used
What are the considerations when choosing an infiltration anesthetic?
the location
allergy
What are the maximum allowable safe single doses of plain 1 % lidocaine and 0.25 % bupivacaine alone and with epinephrine?
lidocaine: 4.5 mg/kg (30 ml per average adult)
lidocaine w/ epi: 7 mg/kg (50ml per average adult)
bupivacaine: 3 mg/kg 70 ml per average adult
bupivacaine w/ epi: 3.5 mg/kg 90 ml per average adult
What are “two” advantages of using langer’s lines when doing minor surgery?
minimize wound tension
heal faster
produce less scarring than those cut across
Langer’s lines
direction in which the skin of a human cadaver will split when stuck with an ice pick.
Correspond to the natural orientation of collagen fibers in the dermis and parallel to the orientation of the underlying muscle fibers
What are the “problem areas” of the body for increased risk of scarring/keloids?
upper chest and back
shoulders
How do Kraissl’s lines compare to Langer’s Lines?
Langer’s lines were defined in cadavers, Kraissl’s lines were based on observations in living people.
When a wound occurs what, essentially, is the body’s only interest?
survival
What is the average tissue strength of a healing wound when the sutures are removed at 10-14 days?
5-6%
inflammatory phase
constriction of the blood supply
leukocytes break down cellular debris and foreign material
macrophages ingest the remaining debris
platelets start to clot
formation of a scab
opening of the blood supply
cleansing of the wound
proliferative phase
fibroblasts new collagen tissue is laid down
new capillaries fills in defect
wound edges pull together
cells cross over the moist surface
cells travel about 3 cm from point of origin
maturation phase
collagen forms which increases tensile strength to wounds
scar tissue is only 80 precent as strong as original tissue
3 weeks to 2 years
clean wound
free from microorganisms
clean-contaminated wound
non-significant contamination and less than 6h elaspsing until medical care
dirty/contaminated wound
without local infection and more than 6 h elapsing until medical care
infected wounds
intense inflammatory reaction and frank infectious process
Is there a “Golden Period” of time for closing lacerations?
no
What are the four “Goals of Surgery”?
Close the wound efficiently
Have no infection occurring during the healing process.
End up with a small scar that is as inconspicuous as possible
Have no loss of function.
What factors involving the surgeon affect wound repair?
length/direction of the incision/wound
dissection technique
careful tissue handling
removal of necrotic tissue/foreign materials
good hemostasis
choice of closure materials
elimination of dead space in the wound
closing with sufficient and proper tension
anticipation of post-op wound stressors
immobilization of the wound if needed
What factors involving the patient affect wound repair?
patient’s age
patient’s weight
nutritional status
degree of hydration
inadequate blood supply to the wound site (e.g. DM)
patient’s immune response
presence of chronic disease
malignancies
debilitating injuries
localized/systemic infection
patient corticosteroids use
immunosuppressive or antineoplastic drugs
hormone use
prior radiation therapy
Understand the concept of “Healing by First (Primary) Intention”. What are the goals and outcomes of this method?
a clean wound to start
prompt closer
minimal edema
no local infection
no serious discharge
normal healing time
good skin edge approximation and eversion
minimal scar formation
What are advantages and disadvantages of “Healing by Secondary Intention”?
Advantages:
its simplicity
relatively low risk of infection
Disadvantages:
may take forever to heal
tends to cause larger scars
What are the two possibilities that lead to a wound “Healing by Secondary Intention”? Can it be a reasonable choice made by the patient or surgeon?
- Wound is left open on purpose, e.g. a “paper cut”, abrasion, or a draining abscess:
- Wound fails to heal via primary (first) intention due to: excessive tissue trauma and/or loss, imprecise tissue approximation, or wound infection
Describe the steps in “Delayed Primary Closure (DPC)”. When should it be used? What are its advantages?
Steps:
Debride the wound of non-vital tissues
Leave the wound open
Pack the wound with sterile dressing
Cover with supporting bandage
REPEAT PROCESS DAILY.
uses: heavily contaminated wounds (combat wounds/major trauma) where there is extensive tissue loss and high risk of infection even with proper cleansing and primary closure.
Advantages
uncomplicated closure
low risk of infection
a “reasonable” scar
better overall than an infected wound!
Name the several different ways to deal with “bleeders” that may appear in a surgical wound or traumatic laceration.
small
-wait for them to stop on their own
-apply pressure with a sterile gauze
clamp with hemostat; then twist around several times
-cauterize with a battery powered high temp cautery pen (“hot wire loop”)
-cauterize with the hyfrecator
-radiosurgery tip directly to the tissue
large bleeding
-clamp with hemostat and tie off with dissolvable suture
-touching the hyfrecator tip to the hemostat
-tie off with a “figure-of-8” suture
What are the other steps in laceration evaluation and treatment?
Assess for wound contamination and tissue damage.
Check flexion/extension of all joints against resistance for underlying nerve and tendon damage – PRIOR TO INJECTING ANESTHESIA.
R/O fractures
In relatively “clean” wounds – first inject anesthesia
In “contaminated” wounds – clean skin first!
Then, if needed, inject anesthesia in a fan-like pattern through the skin surface around the laceration.
REMEMBER – no anesthetics with epinephrine in areas of limited blood supply!
Clean and debride as needed.
Culture if risk of infection – decide about prophylactic antibiotic coverage.
Carefully close wound and bandage appropriately – apply minor surgery tincture, honey, antibiotic, or Vaseline.
Contrast the treatment of an area of skin loss up to 1 cm2 in a fingertip vs. a larger wound or avulsion of the fingertip.
Areas of skin loss up to 1 cm2:
Treat only with dressings changed regularly
Heal with good return of sensation
Skin loss greater than 1 cm2:
Refer for plastic surgical opinion& treatment
May need skin graft &/or re-attachment of severed part!
What are particular concerns about palm wounds?
deep structures could be involved
fracture
tetanus immune globulin administration guidelines
If not certain that the patient has had the last dose of a primary series or a booster within the past 5 years, give tetanus toxoid.
If patient has received fewer than two doses of tetanus toxoid in her/his lifetime and the wound is heavily contaminated, give both tetanus toxoid and tetanus immune globulin (derived from vaccinated patients and confers immediate passive immunity!)
When a wound has a Foreign bodies?
need to look for them but can be hard to identify because of wound type, location, timing, and mechanism of injury
need x-ray
What are the controllable and the uncontrollable issues that affect wound healing?
Uncontrollable factors :
Mechanism of injury
Location of the wound
Age and race of the patient
Patient’s inherent ability to heal
Patient’s tendency toward abnormal scar formation
Patient’s nutritional status
Controllable factors:
Tissue handling – use gentle, meticulous tissue handling, especially on the face.
Do careful, thorough cleaning of the injured tissue.
Splint/cast wounds located near joints to help prevent dehiscence & less scarring
BEFORE APPLYING ANESTHESIA assess the wound site for tissue damage, contamination and possible underlying nerve, tendon, muscle and boney damage.
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Cleaning wound steps
- assessing function, inject anesthesia
- Remove embedded materials with a forceps or hypodermic needle to prevent skin “tattooing”.
- Wear face shield, gloves, and impermeable gown to prevent contamination of the physician and others nearby.
- Minimize operator and room contamination – use splash guard with a 30- or 60-ml syringe and sterile normal saline.
- Use an 18-gauge needle or angiocatheter attached to a syringe to increase irrigation pressure.
- For better disinfection add diluted Betadine or HIBICLENS (chlorhexidine gluconate) to the saline irrigating solution.
- Irrigate until clean with a minimum of 500 ml of solution
- If needed scrub out the wound with a gauze, cloth, or scrub brush.
- Warn the patient about pain in case you may not have obtained good anesthesia.
- Clean thoroughly but try to accomplish the task as quickly as possible.
- Scrubbing/irrigation will often cause a wound to begin bleeding again as blood clots are dislodged.
- Stop this bleeding by one or more of the methods described earlier –the goal is to avoid hematoma formation!
- Remember to rinse the wound thoroughly with sterile saline when finished
Anesthetic usually should be administered by injecting from the inside or center of the laceration out through the side of the wound (unless it is significantly contaminated) into the tissue rather than through the skin surface because it will be less painful.
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All wounds should be considered contaminated, especially human bite wounds, which generally should not be closed, at least not initially.
T or F
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To prevent wound “tattooing,” embedded foreign material must be removed with a forceps and scissors/scalpel or hypodermic needle and the wound copiously irrigated with sterile saline preferably under pressure.
T or F
T
As part of debridement, all debris and devitalized and necrotic tissue should be removed from the wound. However, if there is any question concerning a tissue’s viability, it’s usually best to minimize the debridement at that time and opt for delayed primary closure..
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Wound care steps
- assessing function, inject anesthesia
- Remove embedded materials with a forceps or hypodermic needle to prevent skin “tattooing”.
- Wear face shield, gloves, and impermeable gown to prevent contamination of the physician and others nearby.
- Minimize operator and room contamination – use splash guard with a 30- or 60-ml syringe and sterile normal saline.
- Use an 18-gauge needle or angiocatheter attached to a syringe to increase irrigation pressure.
- For better disinfection add diluted Betadine or HIBICLENS (chlorhexidine gluconate) to the saline irrigating solution.
- Irrigate until clean with a minimum of 500 ml of solution
- If needed scrub out the wound with a gauze, cloth, or scrub brush.
- Warn the patient about pain in case you may not have obtained good anesthesia.
- Clean thoroughly but try to accomplish the task as quickly as possible.
- Scrubbing/irrigation will often cause a wound to begin bleeding again as blood clots are dislodged.
- Stop this bleeding by one or more of the methods described earlier –the goal is to avoid hematoma formation!
- Remember to rinse the wound thoroughly with sterile saline when finished
Skin and hair preparation
avoid shaving
clippers and scissors are okay
When trimming a wound edge the goal is to produce an opening smaller at the base than the surface, which helps produce eversion of the wound edges.
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F
What are the alternatives to consider if a wound can’t be closed by primary intention?
secondary intention or delayed closure
Excessive scar formation can be minimized through gentle handling and careful cleaning of the injured tissue
T or F
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Name the 7 “Wound Closure Technique Basics”.
Handle tissues gently with forceps
Ensure hemostasis
Use as fine a suture as feasible
Enter needle at 90° to the skin surface
Evert the wound edges
Keep the skin edges relaxed but well opposed
Remove sutures as early as reasonably possible to reduce scarring
Excision advantages
- Margin-controlled
- Usually performed under local anesthesia
- Area of tissue removed can be more precisely controlled than with cryosurgery, radiation therapy, or electrosurgery → limiting damage to critical structures
- Resultant scar is optimized both cosmetically and functionally
Excision Disadvantages
- Invasive
- Occasionally needs to be performed under conscious sedation or general anesthesia with their inherent risks.
- Uncertain “clear” margin → a poorer cure rate compared to Mohs micrographic surgery
Lift and Snip procedure
- Apply alcohol to skin
- Clean anesthesia bottle top with alcohol
- Draw up anesthesia with an 18-22 g needle (controversial whether or not to inject air into the bottle!)
- Switch to a ½-1 inch 27-30g needle
- Inject Anesthesia: 0.2-0.4cc 1% lidocaine or 1% lido w/epi to create a cutaneous bleb (or use optional field block)
- Grasp lesion with forceps and elevate a moderate amount
- Snip off lesion with sterile iris scissors
- Apply direct pressure and/or cautery (electro, silver nitrate, styptic) to oozing wound/bleeders
- Dress with minor surgery tincture on Band-Aid
excision types
- Shave, Scoop, Punch Biopsy
- Electrodesiccation (hyfrecation or radiosurgery) & Curettage
- Elliptical (fusiform)Tissue Resection
Lift and Snip
Conditions used for excision
SK
Nevi
Skin tags
Small lesions
Malignancy
Shave biopsy
- Apply alcohol to skin
- Clean anesthesia bottle top with alcohol
- Draw up anesthesia with an 18-22 g needle (controversial whether or not to inject air into the bottle!)
- Switch to a ½-1 inch 27-30g needle
- Inject Anesthesia: 0.2-0.4cc 1% lidocaine or 1% lido w/epi to create a cutaneous bleb (or use optional field block) under the skin lesions at an angle, pull back on syringe then push it in as pull out
- Test it they are numb
- Put on gloves
- 3 iodine swabs from center outward
- Open towel away from you, open up, place on patient and press down
- Dab off iodine
- Open up scalpel and forceps
- If possible, grasp lesion with forceps and elevate
- Shave off lesion with #15 or #10 scalpel or dermablade
- Apply direct pressure and/or cautery (electro, silver nitrate, styptic) to oozing wound/bleeders from the outside to center, put pressure and see if oozes
- Dress with minor surgery tincture and/or Vaseline on Band-Aid
Punch biopsy
- Prep area with alcohol.
- Apply local anesthesia in the skin.
- Prep with Betadine®.
- Stabilize the skin surface with your thumb and index finger.
- Firmly press the punch tip, perpendicular to the skin surface
- Rotate back-and-forth until you feel the punch drop through the skin.
- Grasp specimen with tissue forceps, and snip through the with iris scissors., sub-Q layer
- Deposit in specimen container.
- When doing a 2-3 mm punch, control bleeding with direct pressure and/or cautery or styptic solution, e.g. silver nitrate stick.
- For larger punches close wound with appropriate number of sutures.
- Dress with minor surgery tincture and/or Vaseline on a Band-Aid.
Scoop
- Prep and anesthetize skin
- If possible, grasp lesion with forceps and elevate
- carefully shave it off with a scalpel or Dermablade
- Apply direct pressure and/or electrocautery and/or silver nitrate and/or styptic to control oozing wound or bleeders
- Dress with Vaseline and/or minor surgery tincture on a Band-Aid
- Draw an ellipse around the lesion parallel to skin lines with an indelible marker.
- This orientation reduces wound edge tension and improves the cosmetic effect.
- Ellipses should be 3:1 length to width ratio with 30o angles at the ends.
- Hold the scalpel at a 90 degree angle to the skin to produce perpendicular skin edges to allow for better eversion on closure.
- If sending for biopsy, use atraumatic (no teeth) forceps to avoid tissue damage!
- Undermine as needed and if needed/possible close sub-Q layer with simple stitches
- Appose and align the wound edges using the “Rule of Halves”.
- Carefully suture using a combo of mattress and simple sutures to evert the skin edges and reduce tension
elliptical excision complications
dog ear created
can’t close wound
wound dehiscence
Steri strips benefits
- Rapid, effortless application
- Less pain and anxiety in kids
- Lessscarring and less infection than sutures and staples
- Easy to care for – just keep dry!
- Trim loose ends as needed.
- Leave on until they fall off!
Steri strips
- Thin paper strips with a pressure-sensitive, hypoallergenic adhesive, Reinforced with polyester filaments for added strength
- Apply across a small wound to pull the skin edges together.
- Good for the face, contoured areas, joints, areas of swelling, edema, and hematomas.
- Use to provide wound support after early suture/staple removal.
Surgical glue
Cyanoacetate and formaldehyde combine in a heat vacuum along with a base →liquid monomer.
When this monomer combines with moisture on the skin’s surface, it chemically changes into a polymer that binds to the top epithelial layer.
This polymer → cyanoacrylate bridge that strongly binds the two wound edges together and allows normal healing.
surgical glue use
Best suited for small, superficial lacerations
May be used with confidence on larger wounds AFTER first applying subcutaneous sutures.
low tension
not bleeding
low infection risk
not over a joint
high friction areas
surgical glue advantages
Maximum bonding strength at 2 ½ minutes
Only topical or no anesthetic
Usually need no additional injectable anesthesia no needles!
Faster repair time than sutures
Better patient acceptance
Flexible, water-resistant covering
No sutures to remove – adhesive peels off in five to 10 days.
surgical glue caution
wounds must be dry.
use in wounds that have low risk of infection.
don’t use over joints or high friction areas.
surgical glue results
Long-term cosmetic outcome is comparable to that of traditional repair methods.
when can’t you use steri strips or surgical glue
Lacerations into the deeper dermal layers and Sub-Q
Wounds missing tissue
Wounds with increased wound tension
Eliminate dead space
Reduce the chance of infection and hematoma formation
To reduce the likelihood of dehiscence
Staples advantages
quick placement
fewer infections
lower tissue reaction
staples cons
scarring
Electrosurgery use
to destroy benign and malignant lesions
control bleeding
incise or excise tissue
Superficial lesions – e.g. skin tags
Tiny lesions (may not need anesthesia)
Vascular lesions
Basal cell carcinoma - (only in experienced hands combined with curettage)
Electrodessication
Touching or inserting the active electrode into the skin → tissue destruction
Electrofulgeration
Holding the electrode a short distance from the skin → in “sparking” and a more shallow level of tissue destruction than directly touching the lesion with the tip
Epilation
Inserting a fine-wire electrode into a hair follicle destroys the follicle
Electrocoagulation
Stops bleeding in deep and superficial surgery
Electrosection
The electrode is used to cut tissue
thermal cautery pen
- Disposable – battery powered (1300 and 2200 degree F units)
- Low cost – $15-20
- Individual sterile packaging
- Safe around eyes
- Safe with pacemakers
- Drain subungual hematomas!
- Control bleeding; “cut” off lesions
Hyfrecator unit
- Performs both electrofulguration and electrodessication
- Available accessories:
- blunt/sharp disposable/reusable tips
- epilator needle
Radiosurgery
- Surgitron radio-frequency unit by Ellman
- Available accessories:
- non-disposable and disposable loop & ball electrodes
- epilator needle tip)
Pros of electrosurgery
Simple to master
Rapid technique
Controls bleeding while cutting/destroying tissue
Compact equipment
Affordable – available “used”
Sterile conditions and sutures are not needed.
Infection rarely develops in wounds left open.
cons of electrosurgery
Safety risk (electric shocks, burns, or fires) – e.g. may ignite alcohol on the skin
Risk of hypertrophic scars
Risk of “channeling” of current down vessels and nerves
Risk of smoke plume carrying viruses (e.g. from wart) into respiratory tract.
Delayed hemorrhage while healing
Unsightly wound (initially)
Slow healing vs. scalpel shave excisions = essentially is a “burn”
Biopsies - Hyfrecator (not radiosurgery):
Produces electrosurgical artifact at margins → obliteration of histology
Do shave biopsy first if needed
Cryotherapy over Electrosurgery
Often the treatment of choice for actinic keratosis and simple warts
Faster and easier to perform
Needs no anesthesia
Tends to cause less scarring than electrosurgery
No smoke plume:
- No need for a smoke evacuator
- No risk of developing HPV, HIV or other viral respiratory tract infections
Electrosurgery over Cryotherapy
More likely to cause hypopigmentation due to the cold killing melanocytes – varies with degree of skin pigmentation
Less effective than electrosurgery for large pedunculated lesions, e.g. condylomata.
Final result not immediately visible:
- More guesswork in treating the lesion for the inexperienced physician
- May need to be repeated several times
Causes more postoperative swelling
Does cause transient discomfort
Scalpel over Electrosurgery
Best for shave biopsies and excisions
Inexpensive vs. electrosurgery and radiosurgery devices
Disposable
“Cleaner” edge on the biopsy specimen
No heat-induced tissue damage to obscure borders of the biopsy specimen
Electrosurgery over Scalpel
Does not control bleeding by itself
Small risk of accidentally cutting yourself
Electrosurgery over Lasers
less expensive
easier to use
Laser over Electrosurgery
Very good for treating large hemangiomas
Ideal for treating port-wine stains
Efficiently cut, coagulate and destroy lesions
Good for “resurfacing” (removing wrinkles
Less scarring when treating angiomas and telangiectasias
better cosmetic results
electrosurgery CI
pacemakers
metal plates, pins, or prosthetic joints
suspected melanoma or BCC- need to biopsy
don’t use around nose, eye, body folds
Cautions electrosurgery
alcohol
fire and burns
bowel gas
use three pronged plug
Do not make or break contact with the patient with your free hand while the electrode is activated
no metal
Reduce problems with elctrogsurgery
Always wear gloves.
Use disposable electrodes (OR remove the charred tissue from the electrode after use and sterilize properly).
Use disposable safety needles with Luer Lok syringes.
Use smoke evacuator – hold intake nozzle 2 cm from the operative site
Surgeon and treatment team should wear eye protection (and ideally, surgical masks)
Consider using a different treatment modality – weigh risk vs. benefits
Radiosurgery
Uses a high frequency AM radio spectrum current
Uses an antenna as the “indifferent” electrode applied to the skin on opposite side of the body part
Three to four times the initial cost of the hyfrecator
More efficient cutting than the hyfrecator with less tissue damage (due to less “lateral heat”*).
The unit has 4 different waveforms
- Fully filtered and rectified current - for cutting.
- Fully rectified current - for simultaneous cutting/coagulation.
- Partially rectified current - for coagulation
- Fulgurating current - for destruction of large lesions, similar to the Hyfrecator
Radiosurgery uses
Hemangiomas
Xanthelasma
Spider Veins
Dermatofibromas
Congenital Compound Melanocystic Nevi
Resistant Deep Verruca
Sebaceous Hyperplasia
Thick Seborrheic Keratosis
Porokeratosis
How radiosurgery works?
The intercellular water molecules in the cells are vaporized. The affected cells explode with little or no damage to the adjacent cells, there is only a 10-20 µ of heat spread.
As it cuts, it coagulates saving operation time.
Radiosurgery benefits
hemorrhage Control
reduced post-operative discomfort
minimal scar tissue formation
readability of histological specimen
enhanced healing
good cosmetic results
Medications to stop before surgery
- aspirin
- Alka-Seltzer
- ibuprofen
- clopidogrel
- warfarin
- fish oil
- gingko biloba
- garlic
- ginseng
- ginger
- feverfew
- Vit E
- Saw palmetto
Ecchymoses
blood leaks into the skin and often into the subcutaneous fat
swollen bluish black discoloration of the skin
in and around or dependent to the wound or hematoma
develop during surgery or at the time of trauma or over hours to days later
Ecchymoses treatment/prevention
- Carefully surgery and repair
- Don’t use too much local anesthesia
- Apply proper pressure bandaging f
- ice packs for 2-3 days
- Spontaneously resolve
Hematomas
localized collection of blood outside of the blood vessels, typically in dead space
deep purple, grape jelly-like nodule
hematomas cause
- post-op sustained capillary bed leakage
- or venous/arterial bleeding from the raw surface of a surgical site or within a traumatic lesion
hematomas timing
- develop hours to days after surgery or trauma
- typically resolve naturally in days to weeks
Hematomas prevention
- Assess each patient’s general health status and history of coagulopathies
- Identify any history of significant bleeding during prior low-risk surgical or dental procedures.
- Identify common medical problems that may affect healing – renal dysfunction, hypertension, liver disease, and abnormal coagulation
- Screen for alcohol abuse – impairs coagulation of platelets and decreases vasoconstriction
- Identify all daily and prn medications and the last date taken.
Hematomas management
Intraoperative steps
- use figure-of-8 sutures or suture ligation
- quilting sutures (interrupted deep stitches)
Post-op management
- Pressure bandaging – for 24 hours post-op/repair hold in place 2 twice-folded 4x4s with a pressure bandage of hypo-allergenic paper tape or elastic wrap such as Coban.
- Apply ice packs over the dressing for 20 minutes every hour for six hours
Patient instruction
- Examine wound frequently
- Monitor for a warm, expanding, painful mass:
possible collection of blood and/or tissue fluid
&/or sign of an infection.
- If such a swelling appears apply an ice pack and pressure to the area continuously for 20 minutes.
- Re-examine in 30-60 minutes and re-apply if needed.
- If problem lasts more than 12 hours call or return to clinic – follow up visits are FREE
- The physician will examine the wound site to determine if there is a collection of blood or tissue fluid that needs to be removed/drained.
Hematomas treatment
- Partially or completely re-open the surgical wound
- Identify any oozing vessels
- Stop bleeding by suture ligation or electrosurgery
- Insert a drain/suction if indicated
- Do a full-layer re-closure
- If there is a high risk of more bleeding or the wound is contaminated the best choice may be to let the wound heal by secondary intention!
- Aspirate with sterile procedure – use large needle directly through the wound
- Repeat every 1–2 days until hematoma stops forming
- Continue using pressure bandaging
- Get C & S of aspirate
- Begin empiric antibiotic treatment and adjust based on C & S reports
Seromas
a mass caused by accumulation of serous fluid within tissue or an organ as a complication of surgery or after other traumatic injuries to soft tissues, low infection risk,
Seroma formation
- small blood vessels rupture → blood plasma seeps out
- trauma causes tissue fluid leakage that does not fully subside
- inflammation caused by dying injured cells
- particularly common after major surgeries – breast, abdominal and reconstructive surgeries
Seromas prevention
- Careful tissue handling to reduce trauma
- Thorough wound irrigation and debridement
- Quilting (interrupted deep stitches) in a large wound
to reduce dead space → reduced seroma formation. - Pressure bandaging to reduce fluid collection
Seromas management
- Most resolve spontaneously within days to weeks.
- Avoid blood-thinning analgesics!
- Consider homeopathic Bryonia, Silica and Sepia to reduce pain/itching and speed healing.
- Rest/elevate affected part.
- Intermittent ice packs
- In a few days use alternating hot/cold to help speed resorption.
- If persists consider fine-needle aspiration
Does prophylaxis with antibiotics for routine or elective MS generally lower the risk of infection?
no
Prophylactic antibiotics are indicated in patients with traumatic wounds in what three situations?
- prosthetic cardiac valve
- history of infectious endocardiits
- congenital heart disease
What are the arguments against using antibiotics in traumatic wounds?
- Limited indications for the routine use of antibiotics in lacerations.
- A single reliable study showing an advantage to prophylactic oral penicillin for intraoral wounds.
- Clean, properly debrided early traumatic wounds in patients that are not immune compromised do not require prophylactic antibiotics.
Seroma treatment
fine needle aspiration
-Consider aspiration only for excessive amounts of fluid collection because even an aspiration carried out under aseptic conditions carries a certain risk of infection!
Wound dehiscence cause
- Too much tension on newly sutured tissue – damages the tissue, and interferes with circulation and healing
- Too little tension – wound edges too loosely apposed to allow proper healing
- Inappropriate suture material (wrong size or material) → breakage and/or a tissue reaction.
- Poor tissue quality (poor nutritional status, chronic disease, chemotherapy, etc.) → tissue failure and poor healing.
Wound dehiscence tx
- leave it alone
- re-closure
- retention sutures
Nerve and Vascular Damage prevention
always use a blunt undermining tools
always assess sensation and vascular integrity in traumatic wounds
- two-point discrimination
- capillary refill
tendon and bone damage
test active and passive ROMs
If there is anything more than a simple laceration and if you suspect a lacerated tendon and/or fracture, apply an appropriate splint and immediately refer to a hand specialist or orthopedist!
Hyper/Hypopigmentation
caused by hyfrecation, radiosurgery, lift and snips, shaves, or cryotherapy
1-6 month will be pink then gradually go back to facial color
Treatment: hydroquinone
Hypertrophic scarring
enlargement of the scar within the boundary of the original scar
Keloid scaring
enlargement of the scar beyond the original scar boundary
Hypertrophic and Keloid scarring cause
genetics
body site (esp. upper chest, back, shoulders)
quality of the surgery
skin tension (worse with more tension)
skin types
the patient’s health status at the time
Informed consent implies that the patient completely understands what issues?
make them aware of risks
The nature of the treatment
All material risks for the treatment
The possibility of risk(s)
Alternative treatment(s) available and associated risks of those treatments
Consequences of going untreated
Know the meaning of PARQ and how to use it for “informed consent”.
Procedure
Alternatives
Risks
Questions
Know what/what not to include in the Procedure Note portion of the MS Report.
history
vitals
description of lesion
what procedure
anesthetic used and lot
Describe the skin prep used, record the amounts of anesthesia and bicarbonate mixed & used.
Describe the suture type(s) , size(s), location, and number.
List the duration of the procedure and the amount of blood lost.
Understand the concept of “free margin” on a Pathology report.
means the edges around the biopsied portion are clear of pathology?
Vertical mattress advantages
better than other stitches
helps to close a large area of dead space in a wound
strong stich
use as a stay suture
Horizontal mattress uses
wound under tension
fill up dead space
run and run locking stich
convenient
good approximation of wound edges
good eversion proper tension
faster
valuable on eyelids and neck and other aras where loose skin is found
watertight seal
gathering loose skin
Vertical mattress suture disadvantage
proper placement is time consuming
can cause railroad tracking
acne vulgaris pop
12-25
acne vulgaris pathophysiology
Outlet narrows due to proliferation and accumulation of keratinocytes and skin edema
Sebum (composed of lipids and cell fragments) builds up in blocked follicle
Cutibacterium acnes(formerly Propionibacteriumacnes) lives off sebum and proliferates in comedone
Inflammation of comedone results from leakage of sebum into the dermis and secretion of proinflammatory mediators, chemokines, and degradative enzymes by C. acnes
acne sx
papules or pustules or nodules or cysts red and central core
face, trunk, arms, back, upper chest, shoulders
acne tx standard of car based on severity
acne tx ND
Diet: 100% grass fed pastured or wild meats, fish and eggs, vegetables, fruit, nuts, seeds, and tubers
Eliminate/reduce processed foods, diary, grain fed meat, chocolate, sunflower seeds, salt
Anti-inflammatory/elimination diet
Detox: fasting, sauna, chelation
Botanical (Topicals): azelaic acid, green tea, tea tree oil,
Calendula succus
Botanical (Internal): Berberine (barbarry, coptis, oregon grape, goldenseal), Chasteberry, Indian Gooseberry
Physical medicine: sun (start with 5 minutes a day), hot/cold contrast bath with green tea, calendula
Supplements to consider zinc/copper, chromium, selenium, omega 3 fatty acids, vitamin D
alteratives
An herb that alters the body in a non-specific but broadly beneficial way
Nourishing, restorative tonics with effects focused on digestion, absorption, and elimination
alteratives herbs
arctium lappa
curcma longa
mahonia spp
rumex spp
smilax spp
taraxacum officinale
trifolium pratense
urtica dioica
Mahonia part used
Root bark and stem bark
mahonia action
Alterative, digestive bitter, anticatarrhal, antimicrobial, cholagogue, mild laxative.
mahonia indications
Skin conditions:
Psoriasis, eczema, herpes, pityriasis, acne, syphilis.
Poor gallbladder function: Nausea, fat malabsorption, digestive upset
Infections:
Skin, eye, and intestinal tract (bacterial, fungal and protozoal)
mahonia CI
pregnancy
rumex part used
Root (primarily) also the seed and leaf
rumex actions
Root: alterative, mild digestive bitter, antitumor, antimutagenic, nutritive, antirheumatic, phytoestrogenic, liver tonic
Leaves: used topically as a antimicrobial, anti-inflammatory poultice
Seeds: alterative, diuretic, urinary tonic, vulnerary
Cholagogue
rumex indications
Root: dry and scaly skin conditions – psoriasis, eczema, dandruff, rheumatic/arthritic conditions, anorexia nervosa, cystitis, wounds and ulcers (poultice).
Leaves: mastitis, joint sprains (poultice), alleviate nettle stings
Seeds: cystitis, skin conditions including exanthems
Chronic skin conditions - psoriasis, eczema, acne
Lax bowels, constipation – regulates the GI (Bitter! Enhance digestion, pro motility, tonifying/astringent)
Liver congestion
rumex CI
Oxalate kidney stones, kidney disease, iron overload, pregnancy
trifolum part used
blossom
trifolium actions
Alterative, Nutritive,high in phytoestrogens, lymphagogue, Antitussive, Antispasmodic, Vulnerary
trifolum indications
menopausal climacteric symptoms, vaginal dryness, chronic skin conditions, Breast cancer estrogen positive
Lots of heat
Cancer, gout, arthritis, acne, spasmodic cough, cachexia, burns with poor healing, ulcers of the skin or mucous membranes, TB or inflammation of the lungs
trifolium CI
Caution with blood thinning medications and oral contraceptives
anti-inflammatory/antioxidant herbs
berberis vulgaris
camelia sinensis
silybum marianum
berberis part used
Berries, Rhizome and Root
berberis actions
Berries – antioxidant, modulates inflammation.
Rhizome and root – also modulate inflammation, effects glucose metabolism, antimicrobial
berberis indications
Berries – effective in the treatment of acne as well as other inflammatory conditions.
Rhizome and root – source of berberine and uses relate to that constituent.
camelia part used
leaf
camelia actions
Antioxidant, inhibit tumor cell proliferation and induce apoptosis, pro-oxidant, promotes weight loss, decreases LDL, modulates inflammation, decreases sebum production, antimicrobial resistance
camelia MOA
inhibition of MAP kinase signaling, inhibition of growth factor signaling, inhibition of matrix metalloproteinases, inhibit angiogenesis, decrease invasiveness of cancer cells, augments hormonal therapies, decreases free testosterone, increases SHBG, decreases insulin resistance and improves other glucose-related markers
camelia indications
Cancer, PCOS (particularly in overweight individuals), androgenic alopecia, anti-aging
- Used topically in the treatment of acne vulgaris and rosacea
- UV protection and decreased photocarcinogenesis
- Decrease age-related damage/changes
- Used topically for Condyloma accuminata
- Atopic dermatitis – baths decreased pruritis and area of lesions.
- Decrease hypertrophic scar formation
- vulnerary action in wound healing
- Topical antimicrobial
camelia CI
Take away from iron supplementation green tea block the activity of boronic acid proteasome inhibitors
silybum part
seed
silybum actions
hepatoprotective, hepatotonic, antihepatotoxic (particularly against aminita phalloides), nephroprotective, bitter, galactagogue, antifibrotic effect,
Increase glutathione
silybum indications
Liver diseases, jaundice, hepatitis, cirrhosis, alcoholism, fatty liver degeneration, hepatitis, cirrhosis, alcoholism with fatty liver, diabetic nephropathy
Acne
silybum CI
asteraceae family allergy
astringents herbs
arctostaphylos uva-ursi
black tea
arctostaphylos part
leaves
arctostaphylos actions
Antimicrobial, astringent, tonify
arctostaphylos indications
UTIs
Relaxed urinary tract (tissue laxity), with pain and bloody or mucous secretions; weight and dragging in the loins and perineum not due to prostatic enlargement; chronic irritation of the bladder, with pain, tenesmus, and catarrhal discharge.
Oozing tissues
arctostaphylos CI
Pregnancy
Not recommended for long term use (due to high tannins) anti-nutrient
Toxicity is proportional to the conversion of arbutin to hydroquinone as hydroquinone is potentially toxic and mutagenic
Caution when combining with herbs high in alkaloids as the tannin may precipitate out of solution. The precipitate is active, but it settles to the bottom of the bottle – shake well!
immunostimulants
agents that increase the activity of immune system, used to fortify the body’s response to invasion by a pathogen
MOA: increased phagocytosis, increased production of WBC, and modulation of various cytokines
immunostimulants herbs
allium sativum
baptisia tinctora
echinacea
eupatorium perfoliatum
sambucus nigra
scutellaria bicalensis
spilanthes acmlla
usnea barbata
immunomodulators
agents that have a tonifying effect on immune system
eleuthrococcus part used
Root (most researched), stem bark and leaf
eleuthrococcus actions
Adaptogen, immunomodulating, mild CNS stimulant
Nonspecific ant stress effects
Ergogenic
Anabolic/anticatabolic
Antitoxic
Radioprotective
Chemoprotective
Immunoprotected
Immunoregulatory
Antiviral
Gonadotrophic
Insulin-trophic/antidiabetic
Neuroprotective
eleuthrococcus indications
Build vitality, increase resistance to infection, stress, and toxicity, improve physical performance, and improve mood
eleuthrococcus CI
Adulteration is common in the marketplace. Monitor blood glucose in diabetics and hypoglycemics when introducing this herb.
ganoderma part
fruiting body
ganoderma action
Anti-allergic action of triterpenes, anti-hypertensive, oleic acid inhibits histamine release, hypotensive, decreases platelet aggregation/LDL/arrhythmia/insomnia/angina, protects against ionizing radiation
ganoderma indications
Used in cancer treatment to increase immune function and help treat fatigue, hypertension, immune deficiency, insomnia, hepatitis
ganoderma CI
Potential allergy to spores
