1. Wash feet nightly with soap and warm water.  Be certain to check the water temperature to avoid very hot water; 120 degrees will cause a burn.
2. Dry the feet with a clean, soft towel.  Pay special attention to the areas between the toes.  Do not rub the towel vigorously over the skin or between the toes.
3. Trim toenails straight across.  Do not attempt to round the nail or cut into the flesh.  It is easiest to cut the nails when they are soft after bathing.  If your vision is affected, do not attempt to cut your own toenails.  Trimming nails is easier if you use a heavy toenail clipper.
4. Keep feet soft by rubbing in Vaseline, Lanolin, Keralac, Salac, Eucerin+ cream, Amlactin or Lachydrin Cream.  This can be done after bathing.  Dry skin is more susceptible to cracking and infection.
5. Wear soft, clean socks or stockings.  Be certain that the socks are smooth over the foot to avoid irregularities from seams and creases.
6. Wear shoes of adequate size, especially adequate width.  Injuries and ulcers occur from the friction and pressure of poorly fitted shoes.  Avoid shoes with open toes and open heels.
7. Inspect all shoes for foreign objects such as gravel, nails protruding through the shoes, and torn linings.
8. Avoid walking in bare feet, especially on irregular surfaces and on hot sidewalks or beaches.
9. Walk properly.  Do not walk for long periods of time.  Do not do a lot of running or jumping.  Avoid stepping on hard objects.
10. Inspect the feet for blisters and any “red or irritated areas”.  Inspect feet for cuts, punctures, and ulcerations.  Deep bruises often cannot be seen and a small amount of redness or swelling might be the only sign on the skin.  Feel the feet with the backs of the hands for increased warmth in areas of irritation.
11. Do not cut corns or calluses with knives or razor blades.  If calluses or corns develop, look for pressure sites in shoes.  Roughened surfaces of the calluses can be removed gently with an emery board or pumice stone.
12. If you discover irritation or an ulcer, avoid weight bearing and keep the foot “quiet”.  Consult your physician about all areas of inflammation or persistent irritation.
13. After an ulcer on the foot has healed, avoid friction and shearing forces in these areas.  Healed skin is less resistant than normal skin.
14. Do not apply hot water bottles, electric pads or heating devices to the lower legs or feet.
15. Do not wear tightly fitted garters or stockings.  They restrict circulation.

Dry Skin Requires Regular, Daily Care

 Treatment:

        Bathing:

• A daily 10 minute bath in lukewarm (NOT HOT) water hydrates the skin.
• Use mild unscented soap; suggestions include:  White Unscented Dove, Cetaphil Bar or Cetaphil Liquid Cleanser, Basis, Neutrogena, Oilatum, Camay, Aveeno
• NO SCRUBBING!  Do not use brushes, loofah sponges, or washcloths
• An alternative to short baths or showers may be a 20 minute soak in lukewarm water followed by lubriation.

        Lubricating:

• After bath, pat skin ½ dry with towel.  DO NOT rub hard to dry the skin.
• If applying medication to your skin, apply it first, then apply moisturizer.
• Apply moisturizer to moist skin immediately after bathing.  Suggested moisturizers include:  Cetaphil Cream, Eucerin cream, Vaseline Petroleum Jelly, Aquaphor ointment, Aveeno, Moisturel, Plastibase, Eucerin Plus, Neutrogena.  Rarely, creams may cause stinging due to the preservatives.  If this occurs with your or your child’s skin, use petroleum based products such as Vaseline Petroleum Jelly.
• Use moisturizers at least twice daily, especially during winter.
• In-Between Baths, if skin is very dry, may sprinkle lukewarm tap water onto skin, wait a few minutes, then pat off excess and apply moisturizer as above.  Moisturizer is applied to moist skin in order to seal in water.

      Laundry

• The use of unscented laundry detergents is recommended, e.g. Dreft, Cheer-free, All-free, etc.
• Avoid fabric softeners including dryer sheets.

General Guidelines:

• Avoid rough, irritating and tight clothing.
• Avoid excessive heat and excessive cold.
• A humidifier helps reduce dry air in the home, but must be cleaned regularly.
• Keep fingernails cut short and filed smooth to reduce injury during scratching of dry, itchy skin.

We need to do several things to try to get your eczema better, but it really comes down to two things:

1. Reduce the amount of damaging things your skin is exposed to
2. Make your skin more resistant to things that we can’t eliminate

You should do some or all of  the following, depending on the type of eczema you have: Reduce the amount of damaging things your skin is exposed to: Dust Mites: Get a mattress cover and pillowcase that will protect you from dust mites while you sleep.  They have these at Target.  Once you put them on, you can leave them on for a long time (years).  You put your sheets and pillowcases over them and change them once a week   Vacuum once a week in the bedroom. Allergens in the Air: Get at least two showers a day.  The idea is that as you go through the day, especially when you go outside, allergens accumulate on the skin.  When you get a shower, you rinse these allergens off of the skin.  You only need to use soap (see below) for one of these showers everyday.  You MUST APPLY CERAVE IMMEDIATELY AFTER EVERY SHOWER.  Bacteria That Live on the Skin: Once a week you should fill the bathtub ½ full with water and add ¼ cup of bleach.  This makes swimming pool water – you won’t be able to feel the bleach, but it kills the bacteria on your skin if you stay in for 15 minutes.  After you get out, you need to make sure the towels you use to dry off have been freshly laundered so they don’t have bacteria on them from the last time you dried off.  You should have freshly laundered sheets on the bed so they don’t have bacteria in them from the last time you slept in them.  If you wear pajamas, they should be freshly laundered also so they don’t have bacteria on them from the last time you wore them.  Yeast That Lives on the Skin: You should start washing your face, neck, and entire body with Head and Shoulders 2-in-1 Dry Scalp Care &use it as a bodywash).  It helps to kill yeast that lives on the skin. Make Your Skin More resistant to the things it is exposed to: Make the Barrier Work Better After every shower or bath you must apply CeraVe Cream (found at Walgreens and Rite-Aid in the Olympia Area).  You should turn off the water, reach outside the shower, get your towel and bring it back in, then dry off and apply CeraVe before you open the shower curtain or shower door. You may have two jars of CeraVe – one regular jar and one “medicated” jar.  Make the medicated jar by adding one bottle of clobetasol (0.05% solution, 50cc) to a jar of CeraVe and mixing it up.  You should apply the medicated CeraVe to any areas that are itching or broken out and the regular CeraVe to areas that are doing well. CeraVe works best (BY FAR) when it is applied immediately after bathing (either bath or shower).  This is because, unlike other moisturizers, it must be absorbed into the skin so that it can stimulate the skin to produce more natural moisturizer. Make the Skin More Resistant to Bacteria: Start taking 4000 units of Vitamin D every day.  This dramatically boosts the skin’s natural resistance to bacteria.  It is a much higher amount of Vitamin D than is usually recommended.

Sunlight in the form of ultraviolet A and ultraviolet B light can cause the skin damage leading to wrinkles and cancers.  Studies have shown that much of the harmful side effects of sun light which we are exposed to is additive, and early childhood sun exposure can cause problems, 10, 20, or 30 years later.  Therefore, early sun protection is essential in avoiding problems such as skin cancers in adulthood.

SPF –      Look for an “SPF” or sun protection factor of 15 or higher.  The SPF means the amount of time one can stay in the sun without getting burned.  Water proof and water resistant sunscreens usually stay on for up to one hour in water, but also need to be reapplied frequently.

The following is a list of commonly found sunscreens but may change regularly.  The most important thing to look for is full spectrum coverage that includes UVA as well as UVB coverage.  For the best UVA protection:  Read the labels and look for Zinc Oxide, Titanium Dioxide, Parsol 1789, or Avobenzone.

SUGGESTED SUNSCREENS

• Noncomedogenic, and with Broad-spectrum UVB and UVA Protection:
• Water Babies Spectra 3-SPF 50.
• Coppertone Spectra 3-SPF 50.
• Hawaiian Tropic 45+, 50+
• Coppertone Faces, Oil Free 15, 30, 45
• Shade 45
• Neutrogena Sunblock 45. Sensitive Skin.
• Neutrogena Healthy Defense 30
• Neutrogena Dry Touch 30
• Neutrogena Ultrasoft 30, 45
• Neutrogena Active Breathable 30 and 45
• Neutrogena Oil Free Sunblock Stick
• Ombrelle, 15 or 30

 UVA and UVB Protection:

• Coppertone Sport cream, spray, and gel 30, 48.
• Water Babies stick 30.
• Banana Boat Kids stick 30.
• Banana Boat Aloe Vera 30 lip balm.
• Bullfrog Superblock 40, 45.
• Banana Boat Kids Quick Block 45.
• Banana Boat Sport 30, 45.
• Coppertone Kids 45.
• Hawaiian Tropic 70+.
• Hawaiian Tropic Ozone Sport 60+.
• Baby Faces 60+
• Blistex 30 SPF Lip Balm

Facial Moisturizers, Noncomedogenic, Blocks UVA and UVB broad spectrum:

• Purpose Daily Moisturizer, 15
• Neutrogena Healthy Defense, 30
• Eucerin Daily Facial Lotion, 25
• Cetaphil Daily Facial Moisturizer, 15
• Aveeno Daily Moisturizer, 15
• Oil of Olay Complete, 15

Factors to consider: Do you like how it feels?  Does it need to be waterproof?  Sweat proof?  Rub proof?  Liquids and sprays are good for hairy areas, such as scalp and arms.  Sticks for forehead and eyebrows won’t run into your eyes if you sweat.  Lip cover can be colored lipstick or no-color sunscreen.  Apply often and liberally.

SIMPLE GUIDELINES TO HELP PROTECT YOU FROM THE DAMAGING RAYS OF THE SUN

1. Minimize sun exposure during the hours of 10am and 4 pm when the sun is the strongest (the sun is higher in the sky.)  Try to plan your outdoor activities for the early morning or late afternoon.  If your shadow is shorter than you, you are at greater risk.
2. Wear a hat and UV-coated sunglasses, long-sleeved shirts and long pants when out in the sun.  Choose tightly woven materials for greater protection from the sun’s rays.
3. Apply a sunscreen 30 minutes before every exposure to the sun, and reapply frequently and liberally, at least every two hours, as long as you stay in the sun.  Sunscreen should always be reapplied after swimming or perspiring heavily, since products differ in their degrees of water resistance.  We recommend sunscreens with an SPF (sun protection factor) of 15 or more printed on the label.
4. Use a sunscreen during high altitude activities such as mountain climbing or skiing.  At high altitudes, where there is less atmosphere to absorb the sun’s rays, your risk of burning is greater.  The sun also is stronger near the equator where the sun’s rays strike the earth most directly.
5. Don’t forget to use your sunscreen on overcast days.  The sun’s rays are as damaging to your skin on cloudy, hazy days as they are on sunny days.
6. Individuals at high risk for skin cancer (outdoor workers, fair-skinned individuals, and persons who have already had skin cancer) should apply sunscreens daily.  People with fair skin and eyes who burn easily should be extra careful with sun exposure
7. Photosensitivity – an increased sensitivity to sun exposure – is a possible side effect of certain medications, drugs and cosmetics, and of birth control pills.  Consult your physician or pharmacist before going out in the sun if you’re using any such products.  You may need to take extra precautions.
8. If you develop an allergic reaction to your sunscreen, change sunscreens.  One of the many products on the market today should be right for you.
9. Beware of reflective surfaces!  Sand, snow, concrete and water can reflect more than half the sun’s rays onto your skin.  Sitting in the shade does not guarantee protection from sunburn.
10. Avoid tanning parlors.  The UV light emitted by tanning booths causes sunburn and premature aging, and increases your risk of developing skin cancer.
11. Keep young infants out of the sun.  Begin using sunscreens on children at six months of age, and then allow sun exposure with moderation.
12. Teach children sun protection early.  Sun damage occurs with each unprotected sun exposure and accumulates over the course of a lifetime. Sun protective swimsuits are now available for children.

 SLIP  SLAP  SLOP

 SLIP on a shirt & sunglasses         SLAP on a hat       SLOP on some sunscreen

What are dysplastic nevi?  Typical (or common) nevi, also called moles, are pigmented skin growths, present in 85% of adults, regardless of skin color.  Most typically appear after the first 6 months of life.  Most nevi are harmless.  Typical acquired nevi are raised bumps or flat spots, usually smaller than an uncooked lentil bean (   ).  They have an orderly appearance, with uniform round borders, even and symmetrical brown, tan-pink or flesh coloration, with or without excess hair.  Dysplastic nevi do not conform to the usual appearance of typical nevi.  Dysplastic means “not of the usual mold” and implies a class of nevi that is atypical, intermediate between typical and cancerous.  Dysplastic nevi are usually larger than a lentil bean, unevenly pigmented or very darkly pigmented or “target” in appearance with a dark center and light rim or light center and dark rim, relatively flat throughout or raised centrally with a flat component on the edge, often but not always with fuzzy or irregular margins.  Dysplastic nevi are important to recognize because they are a marker of increased risk for developing melanoma anywhere on the skin, and individual dysplastic nevi are potential precursors of melanoma.  The diagnosis of a dysplastic nevus may be suspected based on its naked eye appearance.  The presence of one or more dysplastic nevi may be suspected in individuals who have prominent nevi.  Dysplastic nevi are extremely rare in non-whites. What is melanoma?  Melanoma of the skin is a potentially deadly tumor that usually arises as a change within a pre-existing nevus, or as a new spot on previously normal skin.  People who have melanoma surgically removed in an early phase of development (when tumors are small and thin) are cured.  When diagnosis is delayed (tumors thick or oozing), cancerous cells of melanoma may spread via blood vessels and lympatics to vital internal organs, resulting in illness and death.  Melanoma is extremely rare before puberty.  More than half of melanomas develop before the fifth decade of life.  Conditions that may warrant an evaluation for melanoma include a new nevus on previously normal skin, a nevus that has changed or is changing, an unusual nevus, presence of prominent nevi, a nevus present at birth, one or more dysplastic nevi, a prior melanoma, and a family history of melanoma.  The risk of melanoma in whites is about 1 in 50 by age 72 years.  Melanoma risk in non-whites is about one-tenth as common as in whites. What causes dysplastic nevi?  Melanoma and dysplastic nevi often occur in families as a genetic trait.  This means that a parent may pass the trait of dysplastic nevi and/or melanoma to children.  Sometimes, the dysplastic nevus trait will skip a generation.  In other words, a parent may carry the gene for dysplastic nevi (and melanoma) but not express the trait, while at the same time, the trait is passed on to one or several children who eventually express the trait.  Blood relatives of people who have dysplastic nevi (or melanoma) have an increased likelihood of having dysplastic nevi and thus and increased melanoma risk. When do dysplastic nevi first develop?  If dysplastic nevi are going to develop, they are usually evident by age 20 years.  Dysplastic nevi are commonly evident before puberty.  Dysplastic nevi usually begin as one or more prominent nevi appearing first in early childhood.  Over time, the prominent nevi become more irregularly pigmented with uneven or fuzzy outlines, or with a “target” pattern and smooth outlines, usually at least as large as this spot (   ).  If someone has a trait of one or more dysplastic nevi, additional dysplastic nevi may continue to appear throughout life.  People who have dysplastic nevi often have a pattern of many nevi and/or relatively large nevi. What is the melanoma risk related to dysplastic nevi?  People who have even one dysplastic nevus have a significantly increased risk of developing melanoma, even in the absence of a personal or family history of melanoma.  When melanoma develops in someone who has one or more dysplastic nevi, the melanoma can develop in a pre-existing dysplastic nevus or as a new spot on previously normal-appearing skin.  The risk of developing melanoma by age 60 years is 50% if someone has dysplastic nevi and comes from a family in which two or more members have had skin melanoma (familial melanoma); the melanoma risk in the familial melanoma setting even applies to children and is markedly higher if a person has already had melanoma.  In general, melanoma risk is rare before puberty if there is no family history or melanoma. What happens to dysplastic nevi in time?  Not all changes in dysplastic nevi are cancerous, and relatively few dysplastic nevi ever become melanoma.  Non-cancerous changes that may occur in any nevus include irritation from trauma, inflammation, and expansion related to overall body growth during childhood and puberty.  Simply being aware of having the dysplastic nevus trait increases self-awareness of suspicious nevus changes and the chance of early melanoma detection in curable state of development.  Surveillance is the key to early melanoma detection in someone at high risk. What is the treatment for dysplastic nevi?  For people who have only one or two dysplastic nevi, surgical excision may be recommended to reduce the frequency of surveillance examinations.  Sometimes, one or two of the most suspicious nevi are removed to establish the diagnosis and eliminate the melanoma risk related to those nevi.  A pathologic diagnosis is not required to recommend surveillance examinations of people who have clinically apparent dysplastic nevi or a prominent nevus pattern.  If dysplastic nevi have been diagnosed, periodic surveillance examinations are recommended at least yearly for life.  Photographs of the total skin surface are often used to establish baseline and aid follow-up for persons who have (or had) dysplastic nevi (or melanoma).  Excision of each and every nevus is not usually recommended for people who have dysplastic nevi or prominent nevi (or melanoma).  New nevi may continue to appear over time, so people who are affected require periodic surveillance examinations, at intervals varying from 3 to 12 months, depending on how rapidly nevi are changing  and whether or not melanoma has occurred in an individual or family member.  While most changes in pre-existing nevi or the appearance of new nevi are not melanoma, suspicious changes require immediate consultations.  Blood relatives of people who have dysplastic nevi or melanoma should be examined for atypical nevi and early melanoma. What changes in dysplastic nevi may indicate melanoma?  The most common early signs in a nevus that could indicate melanoma include darkening (or occasionally lightening), overall enlargement, expansion in an edge, or surface elevation.  While the majority of melanomas are the size of this spot or larger (   ), any nevus that is new or changing warrants evaluation, regardless of size.  Persistent itching, pain, ulceration or oozing in a nevus also may indicate cancerous change. What about sun exposure?  Avoid sun-bathing, becoming red in the sun, and exposure during peak hours of the sun intensity (between 10 AM and 4 PM in most temperature climates) from early spring through late fall.  For unavoidable exposure, tightly woven clothing (and/or sunscreens with a sun-protection factor of 15 or greater for areas that cannot be covered by clothing) should be worn, particularly for people who burn easily and tan poorly.  Sunscreens should not be used to prolong time spent in the sun.  Excessive sun-exposure, particularly during the first 15 years of life, is an important risk factor for developing melanoma, epithelial skin cancer (basal cell cancer and squamous cell cancer), premature skin aging, cataracts, and suppression of the immune system.  Excessive sun exposure and/or sun sensitivity may influence the development of atypical and dysplastic nevi, and may cause dysplastic nevi to devleop melanoma. What kinds of examinations are required?  People who have dysplastic nevi should examine their skin monthly for new nevi and nevi that have changed in color, surface, size, and/or outlines.  Family members and mirrors may be helpful in checking difficult-to-see areas, including the back, buttocks, anus, scalp, and genitalia.  A friend or relative using a blow-dryer on the hairy scalp, or parting hair throughout the scalp after washing may help to detect hidden nevi.  Though your doctor may have examined your scalp, repeat examinations are useful to detect hidden nevi by hair.  Any nevi detected in “hidden” sites, or nevi that concern you for any reason, should be brought to your doctor’s attention.  Encourage first degree blood relatives to be examined for dysplastic nevi and early melanoma when melanoma or dysplastc nevi have been detected in any family member. Can fatal melanoma be prevented?  Periodic surveillance of people at high risk for devleoping melanoma leads to early detection of melanoma in a curable stage of development.  Early recognition of nevi that have recently developed melanoma may be life-saving.   Copyright, Arthur R. Rhodes, 1996

HERPES INFECTION

 CAUSE:  Herpes is caused by a virus which enters the body through broken skin and lives within nerve fibers.  There are generally two types of herpes virus (Type I and Type II) which produce similar disease, usually around the mouth or in the groin.

CLINICAL COURSE:  The initial infection may be silent or present 3 to 20 days after acquiring the virus, as a mild to extensive painful blistering with associated swollen lymph nodes and occasionally with fever, generalized aching and joint discomfort.  This may last 7 to 21 days.

Recurrent disease may be precipitated by any number of events (local trauma, sunshine, illness, stress) anywhere from twice monthly to less than once a year.

TREATMENT:

1. EDUCATION:  Dealing with denial, loneliness, anger, fear, and guilt.
2. PREVENTION: Because of the silent shedding of virus of either sex, current prophylactic recommendations include the following;
   1. Abstinence if active lesions are present.
   2. Females with history of recurrent genital herpes – the use of a spermicidal foam by the female and the concurrent use of a condom by the male, followed by washing of the external genitalia with soap and water after intercourse.
   3. Males with a history of recurrent genital herpes – use of a condom by the male or foam by the female, followed by washing.  Reasons for male and female difference is the stronger evidence of asymptomatic shedding by females.
   4. Avoidance of contact with very young infants or debilitated individuals when active evidence of disease is present.

3. AWARENESS OF KNOWN PRECIPITATING FACTORS, i.e. heavy sun exposure, stressful situations, etc.

4. SYMPTOMATIC RELIEF:  A topical steroid applied 2-4 times daily at the first sign of recurrence.  Moist soaks twice daily with air drying to dry blisters.

5. PRESCRIPTION TREATMENT (Acyclovir, Famcyclovir, or Valcyclovir):  These antiviral agents may be taken in one of three ways:  First, to minimize the extent of disease, those with occasional recurrence may treat daily for 1-3 days beginning with the first sign of recurrence.  This demands medicine be kept on hand.  Alternatively, in those with frequent eruptions, antiviral may be used to suppress recurrence by taking medication daily.  The most frequent adverse reactions to treatment are nausea, diarrhea, and headache but generally it is a very well tolerated medication.  Lastly, for those who know what events precipitate relapses, antivirals can be taken when such events are anticipated (i.e. acute sun exposure, illness, etc.).

CONCERNS:  It is important that your obstetrician or family physician know you have had herpes.  Infections at the time of delivery of a child may necessitate delivery by Cesarean section.

Resources for reliable information include www.aad.org

HOW COMMON IS PSORIASIS?

Psoriasis affects between one and four percent of the population.

 WHAT DOES PSORIASIS LOOK LIKE?

Generally, psoriasis consists of red, scaling patches of skin.

WHAT IS HAPPENING TO MY SKIN?

There are many theories as to why this happens.  No one knows the cause for sure.  Presently we believe an overactive immune system may release very potent immune stimulators followed by a cascade of events which culminate in the overproduction of otherwise normal overlying skin.

 WHERE DO PEOPLE HAVE PSORIASIS?

Although you may have psoriasis anywhere, most individuals have only a few spots at one time.   Many sites commonly involved include the elbows, knees, scalp, belly button, and the lower back.   The nails may also show lifting and pitting.

 HOW LONG WILL I HAVE PSORIASIS?

Most patients have some evidence of disease all the time, but the extent of the disease may vary.

 CAN I GIVE PSORIASIS TO ANYONE?

No.   You are not contagious.   You can touch and be touched without fear.

 WHY DID I GET PSORIASIS?

While no one knows the exact cause of psoriasis, we are aware of many contributing factors.   To some extent, psoriasis is hereditary; one fourth of patients have a family member with the disease.   Triggering factors may include streptococcal infections, injury to skin (Koebner phenomena), low humidity, emotional stress, and some medications (lithium, beta blockers).

 ARE THERE OTHER PROBLEMS ASSOCIATED WITH MY PSORIASIS THAT MAY BE IMPORTANT?

Generally the answer to this question is No.  But patients with significant widespread psoriasis, associated arthritis, obesity, hyperlipidemia and hypertension warrant special more aggressive attention to address these problems and more specifically there general health.

 HOW DO YOU TREAT PSORIASIS?

While psoriasis cannot be “cured” with present technology, it can usually be controlled with careful medical supervision and some modifications in lifestyle.

1.  MOISTURIZERS – Mainly soften dry, scaling skin and help with itching: ex. Cetaphil, Cerave, Eucerin cream.
2. KERATOLYTICS – Help soften and dislodge scales: ex. Salicylic acid (T/Sal and Salex Creme), alpha hydroxy acids (LacHydrin and AmLactin), or urea-containing preparations (Eucerin plus cream, Keralac, Carmol).
3. TARS – Help with itching and slow cell turnover: ex. T/Gel, MG 217, T/Derm, LCD.
4. TAZAROTENE (Tazorac) – Topical vitamin A acid.   Promotes normal maturation of skin and decreases inflammation.   May initially cause more irritation of surrounding “normal skin”.   Often more effective when used in combination with other treatments (Taclonex).
5. CALCIPOTRIENE (Dovonex) ACTIVATED VITAMIN D ­­– (Dovonex ointment, cream, and lotion) – fewer side effects.   May sting or burn initially.   Often more effective when used in combination with cortisones (Taclonex).
6. CORTICOSTEROIDS – Lotions, gels, foams and sprays are used in the scalp while creams and ointments are used elsewhere.   Do not use strong cortisones on the face, ears, or groin.
7. NONSTEROIDAL IMMUNOSUPPRESSANTS– (Protopic and Elidel).  Best used in groin and on the face.
8. ANTHRALIN – Best used in selective areas as it stains skin and clothing and may be irritating.
9. ULTRAVIOLET B light and sunlight – One of the best ways to treat more generalized disease.   This may be done at home or the doctor’s office and may even work better when combined with tar, anthralin, Tazorac, or Dovonex.   Guard against sunburn!
10. ANTIFUNGALS – Psoriasis in the scalp and groin may be a result of irritation cused by yeast in hair follicles.
11.  ANTIBIOTICS – Psoriasis is sometimes triggered or aggravated by bacterial infections.

RESERVED FOR MORE SEVERE DISEASE

12. PUVA – (Psoralen and Ultra Violet light in the A range) – Psoralen markedly augments the effects of UVA light, suppressing cell turnover.   Psoralen may be used locally for hands and feet or orally to treat entire body.
13. METHOTREXATE – Low dose chemotherapy.
14. RETINOIDS – Oral vitamin A acid derivative (not plain vitamin A) used either by itself or in combination with other modalities.
15. CYCLOSPORIN – used in organ transplant patients.   Suppresses immune response.   Also works in psoriasis,
16. BIOLOGICS – Enbrel, Humira, Amevive , Remicade, Golimumab, and Raptiva.  Agents which directly inhibit the immune response felt to trigger psoriasis.
17. READ about new immune, gene and combination therapy in the National Psoriasis Foundation Bulletin.

Psoriasis is a chronic skin condition that affects 1% to 2% of the people in the United States.  Approximately 50% of people with psoriasis have involvement of the scalp, ranging from areas of mild scaling to thick crusted plaques over the entire scalp.

Scalp psoriasis is like psoriasis elsewhere on the body.  Skin cells are reproduced to quickly, and are shed conspicuously from the surface.  The scales accumulate and form silvery patches on the skin.  In scalp psoriasis, both scale removal and treatment are complicated by the presence of hair.

Scalp psoriasis is occasionally accompanied by alopecia (hair loss).  Also, it is often misdiagnosed as chronic seborrheic dermatitis.

Most over the counter treatments for scalp psoriasis center on the use of coal tar.  Coal tar is commonly used in concentrations between 1% and 5%, although higher concentrations are sometimes used.  Refined coal tars, such as T/gel, Ionil T +, and Van Seb T have less odor and may cause less staining.  Unfortunately, the refined tars are less potent.

The use of keratolytics, such as salicylic acid, may improve the coal tar treatment by removing thick scales of the psoriatic lesions before the coal tar is applied.  Removal of scale is commonly achieved through a gentle regimen of mineral oil or other lotion, foam, cream, or ointment applied to a damp scalp and combed through with a round-toothed comb.  It is important to apply lubrication to a damp scalp.  After the lubrication is applied, it should be allowed to set.  Lubricating agents and keratolytic agents work better if a hat, cap, or hot towel is placed on the head over them.

Keratolytic agents are used if it is necessary to break up a tough layer of scale buildup.  Salicylic acid is the most commonly used keratolytic agent in the treatment of scalp psoriasis.  It is generally applied as a 2% to 10% preparation.  Patients receiving tratment with the higher concentrations should be cautioned to expect some irritation.  It is important to watch for signs of salicylate toxicity, especially in children.  Examples of over-the-counter keratolytics include Baker’s P&S Liquid, T/Sal, and Salac 6%.  Some prescription compounds contain citric acid, lactic acid, and urea in a cream base.

The scalp is treated with a preparation by parting the hair and holding it in place while dribbling the preparation on the scalp, or if it is a foam or cream, rubbing it in.  The preparations should be used sparingly and thoroughly massaged into the scalp.  All affected areas, including around the ears and hairline, should be treated.

The amount of time that the preparation should remain on the scalp will vary from product to product.  After a suitable amount of time, scales can be removed by coming gently with a round-toothed comb.

Too vigorous scale removal can lead to infection, and can break the hair off at the scalp.  New psoriasis can form at the site of scratching or scraping injury (Koebner phenomenon).  For these reasons, gentle scale removal is essential.

After treatment with the lubricating and the coal tar preparation, shampooing with a cleansing shampoo is recommended.  A coal tar shampoo can also be used.  The coal tar shampoo should be left on the scalp for the time indicated by the directions.  Thorough rinsing is important.

These treatments can cause drying of the hair and scalp.  Moisturizing lotions or conditioners may be helpful.

There are many other prescription options available for treatment of scalp psoriasis.  They include special topical vitamin A and vitamin D preparations, various cortisones, antifungals, and antibiotics.

If you are not satisfied with the results of your efforts, let us know.  We will investigate other options.

“Scalp Psoriasis”, PHARMACY NEWS, Vol. 5, Issue 1, pp. 1-2, NATIONAL PSORIASIS FOUNDATION, March 1998, Portland, Oregon.

What is melanoma?  Melanoma of the skin is a potentially deadly cancer that develops as an unusual or “ugly” mole, a new mole, or a mole that changes.  Melanoma is curable if detected and surgically removed in an early stage of development, before cancer cells have had a chance to spread to vital internal organs via lymphatic and blood vessels in the skin.  Melanoma can occur anywhere on the skin or mucous membranes, in any racial group, and at any age, but it occurs most commonly on the skin of white adults.  Melanoma is extremely rare before age 12 years.  The life-time risk of developing melanoma is about 1-2% for whites.  (Melanoma is one-tenth as common in non-whites.)  When melanoma occurs in non-whites, about half the time it appears as a black spot (or occasionally a pink or red growth) on palms, soles, nail beds, or mucous membranes.

 What are the most important risk factors for developing melanoma?  The following melanoma risk factors are listed in decreasing order of importance:

1.  A new mole, or a mole that has changed or is changing.  People who have a new mole or a mole that has changed or is changing have a melanoma risk that is increased 20-fold to 100-fold.  A new mole on previously normal skin, or a pre-existing mole that has changed in some way (color, borders, or surface), should be checked immediately.  Such a mole may be melanoma or on its way to becoming melanoma.  A change in a pre-existing mole could also represent infection, irritation, or some other type of lesion.  Infection or irritation in a mole will usually resolve within 7 to 10 days.
2. Prominent moles.  Melanoma risk can be assessed by measuring and counting moles.  People who have at least 12 moles this size or larger (   ) have a 41-fold increased melanoma risk.  The presence of at least 5 moles this size or larger (   ) indicates a 7 to 10-fold increased melanoma risk.  Prominent numbers of smaller moles also may indicate risk.  The presence of at least 20 moles this size or larger () is associated with a 7 to 14-fold increased melanoma risk, and at least 50 moles this size or larger () a 54-fold increased risk.  Prominent moles often indicate the dysplastic mole trait (see below).  Among people who have an elevated melanoma risk because of prominent moles, melanoma usually develops in a pre-existing mole but also can develop on previously normal skin.  Prominent moles tend to occur in families as a genetic trait.  People who are affected with prominent moles require periodic surveillance to detect the earliest signs that might indicate melanoma.  Common benign growths that have no cancer risk and may be mistaken for moles include seborrheic keratoses (brown or tan, dull, scaling patches comprised of epidermal overgrowth), cherry angiomas (small red bumps comprised of blood vessel overgrowth), warts, and skin tags.
3. Dysplastic moles.  A dysplastic mole is striking for relatively large size (   ), haphazard coloration or “fried egg” pattern, and often uneven or fuzzy borders.  Abnormalities in dysplastic moles fall midway between typical moles and melanoma.  Dysplastic moles tend to occur in families as a genetic trait, with a 50% chance of passing the trait to offspring.  New dysplastic moles tend to appear throughout life.  Dysplastic moles usually occur by age 20 years among people destined to have them.  The presence of one or more dysplastic moles marks an individual as having a 7 to 27-fold increased melanoma risk.  This risk is higher if there are many dysplastic moles and/or a personal or family history of melanoma.  A dysplastic mole may itself develop melanoma or indicate a markedly increased risk at some other skin site.  Only one dysplastic mole is needed to develop melanoma.  People who have any dysplastic moles have an estimated 5 to 10% life-time risk of developing melanoma if none of the moles is removed, and a lesser risk if high risk moles are removed.  Approximately 40% of melanomas develop in a dysplastic mole.  Indications that melanoma may be developing in a dysplastic mole include an abnormal change in color (usually a darkening, occasionally a lightening), elevation of surface, or spreading of borders.
4. Congenital moles.  A congenital mole is a mole that is present at birth.  (Most acquired moles develop after the first 6 months of life.)  Only 1% of newborns have a congenital mole, and just one in 95% of cases.  Most congenital moles are medium or light brown in color and at least slightly elevated above the skin surface.  People who have a congenital mole have an estimated 5% risk of developing melanoma by age 60 years.  Approximately 3% to 15% of melanomas develop in a congenital mole.  Indications that melanoma may be developing in a congenital mole include an abnormal change in color, surface, or borders.  In infants and children, congenital moles usually expand in proportion to growth of the body part in which it is located.  After body growth ceases, expansion of the mole should cease.
5. Lentigo maligna.  Lentigo maligna usually appears as a light brown “varnish stain” at least this size or larger (   ) on sun-damaged skin, usually after age 35 years.  People who have lentigo maligna have a 10-fold increased melanoma risk, and an estimated 5% life-time risk of developing melanoma in the spot.  Lentigo maligna accounts for 5% of melanomas.  Indications that melanoma may be developing in lentigo maligna include a darkening of color, elevation of surface and/or spreading of borders.
6. Prior melanoma.  People who have had one skin melanoma have a 9-fold increased risk of developing another melanoma, compared to people who have never had melanoma.  The increased melanoma risk is related to the presence elsewhere of high-risk moles, including dysplastic and congenital moles.  People who have had melanoma require periodic surveillance for new or changing moles.
7. Melanoma in parents, siblings, or children.  People who have an immediate blood relative with skin melanoma have an 8-fold increased melanoma risk and ought to be examined at least once for early melanoma, high-risk moles, or prominent moles.  The increased melanoma risk is believed to be related to the family trait of one or more high-risk moles (including dysplastic moles and congenital moles) and/or prominent moles.  Those affected with high-risk moles and prominent moles require periodic surveillance to detect the earliest signs that might indicate melanoma.
8. Immune system suppression.  Suppression of the immune system, which may occur when medication is taken for an organ transplant or treatment for lymphoma or other cancer, increases melanoma risk by 4-fold.  People most at risk in this category include those who have prominent moles and/or high-risk moles, including dysplastic and congenital moles.
9. Sun-induced freckles, sun sensitivity, relative inability to tan, excessive sun exposure.  Sun-induced freckles increase melanoma risk by 4-fold and epithelial skin cancer (basal cell cancer and squamous cell cancer) by 6-fold.  A rare sun-induced freckle may become larger and darker and pre-cancerous.  People who are sun sensitive (tendency to sunburn and relative inability to tan) or who have had excessive sun exposure have a 2 to 3-fold increased melanoma risk.  The exact relation of sun sensitivity and excessive exposure to the development of melanoma is not as clear as that for epithelial skin cancer (basal cell and squamous cell cancer).  It is possible that excessive sun exposure or sun sensitivity brings out the tendency for moles.  Excessive sun exposure may induce high-risk moles to develop melanoma.  Epithelial skin cancer usually appears as an enlarging pink or warty bump or a non-healing sore and is most often related to excessive sun exposure and/or sun sensitivity and a family or personal history of epithelial skin cancer.  Epithelial skin cancer is usually completely curable if recognized and treated in an early stage of development.  Everyone should practice sensible sun exposure habits to reduce premature skin aging and epithelial skin cancer, as well as melanoma.  Sensible sun exposure means avoiding getting red in the sun, avoiding sun exposure during peak intensity (between 10 am and 4 pm in most temperate climates from early spring to late fall), covering up with clothing if sun exposure is unavoidable, and using sunscreens to protect skin not easily covered by clothing.  Sunscreens should not be used to prolong time spent in the sun.  Sun protection during the first 15 years of life has been estimated to reduce the risk of epithelial skin cancer by 80%.

Melanoma of the skin is curable if detected and surgically removed in an early phase of development.  Do not ignore the warning signs of melanoma or high-risk traits.

Copyright, Arthur R. Rhodes, 1996

What is Skin Cancer?

Skin cancer is not one disease.  The most common type of skin cancer is epithelial skin cancer, which includes basal cell cancer and squamous cell cancer.  Epithelial skin cancer is rarely deadly and usually appears as a persistent pink bump, a sore that does not heal, a scaling red patch, or a warty growth.  The less common but more serious form of skin cancer is melanoma.  Melanoma is a potentially deadly cancer that develops as an unusual mole, a new mole, or a mole that changes. Melanoma and epithelial skin cancers are curable if removed at an early stage of development.  More than half of all melanomas are discovered by patients. You can help in early detection.  The following information will help you take personal responsibility for early detection of melanoma and epithelial skin cancer.

 Who has the greatest risk for developing skin cancer?

Epithelial skin cancer

Epithelial skin cancer (basal cell carcinoma and squamous cell carcinoma) is mostly caused by excessive exposure to sun or artificial sources of ultraviolet radiation, mostly in white adults.

Epithelial skin cancer risk is increased several-fold if you have one or more of the following:

• Personal history of epithelial skin cancer.
• Family history of epithelial skin cancer in a parent, sibling, or child.
• Actinic keratoses: red, rough, scaling patches on sun-exposed skin.
• Tendency to freckle following sun exposure.
• Excessive exposure to sun or sun lamps.
• Tendency to burn and relative inability to tan in the sun.
• Red or blond hair, and blue or green eyes.

Not all epithelial skin cancers are caused by excessive sun exposure.  Other predisposing factors for developing epithelial skin cancer include the following:

• X-ray (radiation) therapy to skin or internal organs, usually for treatment of disease.
• Scar related to heat burn, chemical burn, and scarring skin diseases.
• Chronic ulcer or chronic draining sinus.
• Immune suppression from disease or medication, such as organ transplant.

Melanoma

Melanoma occurs mostly in white adults.  However, anyone can develop melanoma, regardless of gender, race, or age.  Melanoma is extremely rare before puberty and tends to increase with age.

Your melanoma risk is markedly increased if you have one or more of the following:

• Prominent moles:  5 moles at least as large as this spot (   ) (7 to 10-fold risk), 12 moles at least as large as this spot (   ) (54-fold risk), or 20 moles at least as large as this spot (  ) (7 to 14-fold risk).
• Dysplastic moles (atypical moles): moles this size (   ) or larger that have uneven or dark coloration or fried egg appearance, and often uneven or fuzzy boarders ( 7 to 27-fold risk).
• A congenital mole: a mole that your parents told you was present at birth (2 to 21-fold risk).
• Lentigo maligna: single, irregular, large “varnish stain” spot on sun-damaged skin (10-fold risk).
• Personal history of melanoma (9-fold risk).
• Family history of melanoma in a parent, sibling, or child (8-fold risk).

The above traits do not guarantee that you will develop melanoma but justify your seeking medical advice.

Your melanoma risk is slightly to moderately increased if you have one or more of the following:

• Suppression of the immune system, due to disease or medication (4-fold risk).
• Tendency to freckle following sun exposure (2 to 4-fold risk).
• Tendency to burn and relative inability to tan in the sun (2 to 3-fold risk).
• Red or blond hair, and blue or green eyes (2-fold risk).
• Excessive sun exposure (2-fold risk).

 Signs and symptoms of a developing skin cancer

The following signs and symptoms may indicate a developing skin cancer:

• Mole or freckle that has changed or is changing in some way for more than 2 weeks, for example, becoming darker or lighter, larger, more raised, or changing shape or outline.
• New mole or freckle that you are sure wasn’t there before.
• Mole or freckle that is continually tender, itching, or scaling for no apparent reason.
• Unexplained sore that oozes, bleeds, scabs, and has not healed after 4 weeks.
• Persistent pink or red bump, lump, or warty growth.
• Mole or freckle that is prominent or unusual in some way.
• Single scaling pink or red patch that has not responded to treatment with ointments or salves.

These signs and symptoms do not guarantee that you have a skin cancer, but justify your seeking medical advice.

 COMMON MISCONCEPTIONS

Some people avoid or delay seeking medical advice because their information is misleading or false.  The following are some of the more common misconceptions about skin cancer:

Melanoma is always deadly.  Some people believe that melanoma is not treatable.  Not true!  Melanoma is curable if detected and treated in an early stage of development.  Currently, 94% of people whose melanoma shows no sign of spread at the time of diagnosis are without signs of cancer 5 years later.  Timely detection and surgical excision of melanoma usually result in cure.

Don’t touch a mole that is changing because you will cause cancer to spread.  This myth started 50 years ago when patients delayed seeking medical advice until melanomas were large, oozing, and painful.  Neglected tumors have a greater chance of spreading to vital internal organs.  Once the cancer cells of melanoma are removed, these cells can no longer do harm.  If cancer cells of melanoma have not spread elsewhere before surgical removal, the cure is guaranteed.

All skin cancers are the same.  Melanoma is the least common but potentially most deadly of the main types of skin cancer.  The more common epithelial skin cancers, basal cell cancer and squamous cell cancer, are curable at least 98% of the time.  Epithelial skin cancers cause local destruction of tissue but rarely spread to vital internal organs.  Some squamous cell cancers can spread to lymph nodes and vital internal organs, particularly when developing in scarring skin disease and skin sites exposed to x-ray (radiation) therapy and in patients whose immune system is suppressed by medication or disease.  When diagnosed early, epithelial skin cancer is usually able to be treated with less complicated therapy and with a minimum of destruction of involved tissues.

Only whites develop melanoma and epithelial skin cancer.  While non-whites rarely develop melanoma and epithelial skin cancer, the same warnings signs and symptoms apply.  Melanoma can appear anywhere on the skin of non-whites, but in about half the cases, melanoma appears on the palms of the hands, soles of the feet, nail beds, or mucous membranes (inner eyelids, nose, mouth, anus, and genitalia), usually as a new or changing black spot and sometimes a pink or red patch.  Epithelial skin cancer rarely occurs in non-whites unless there has been exposure to x-ray (radiation) therapy that has been used to treat disease; a chronic ulcer related to burn or scarring skin disease; a chronic draining sinus; excessive exposure to natural sunlight or artificial sources of ultraviolet radiation; or within areas of pigment loss.

 What can you expect during an examination for skin cancer?

A physician will usually offer to examine your entire skin surface.  In addition to areas exposed to the sun, melanoma and epithelial skin cancer can occur on skin sites not commonly exposed to the sun, such as palms, soles, hairy scalp, genitalia, anal area, between toes and fingers, and nail beds.

What can you do to help prevent death from skin cancer?

Delay in seeking help is responsible for the majority of skin cancer deaths.  Denial of a problem is your greatest enemy, second only to ignorance of the meaning of the usual signs and symptoms that could indicate a developing cancer.  If you have questions about skin cancer and its warning signs, or if you have any of the signs or symptoms or risk factors listed above, take action by consulting your dermatologist or general physician.

Copyright, Arthur R. Rhodes, 1996

DEFINITION

Warts are a very common skin condition, with the following characteristics:

• Caused by the human papilloma virus (HPV)
• Virus infects the top layer of skin (the epidermis) and produces warts
• Can occur anywhere on the human body
• Most commonly found on hands and feet
• Spread by direct contact with affected persons
• Frequenly will resolve on their own (30% per year), though it may take 2-3 years or longer
• Some people are more susceptible to the HPV virus than others

 TYPES

Common and Plantar Warts

TREATMENT

Treatment is indicated to prevent spread, to reduce cosmetic disfiguring, and for painful foot warts.  Three methods are available:

 Salicylic Acid Preparations:

1. These are over-the-counter treatments available in liquid or plaster bases.  Liquid (Occlusal HP) is applied with an applicator to the wart, let dry for 15 minutes and cover with adhesive tape for 12 to 24 hours.  Then, remove tape and soak wart (or bathe for 10 minutes).  Remove white, dead, top skin with a piece of rough pumice stone, piece stone, piece of emery board or sand paper.  Throw away the piece after it is used.  Be sure not to get any of the acid near the eyes.  May take 2 months, 40% successful.
2. For feet and knees:  Duofilm Patch System or Mediplast – are sticky medicated patches which are precut or cut to the size of the wart and taped, and dead skin debrided after 24 hours, as above.  This process is repeated daily for 2 to 4 weeks until wart is gone.  Be sure not to apply patch to surrounding normal skin to prevent irritation.  This treatment is best for warts on very thick skin, such as feet and knees.  Sometimes a prescription paint called FluoroSal can be added to this regimen.

 Liquid Nitrogen Treatment:

Liquid nitrogen is a very cold (-196ºC) liquid applied by Q-tip or sprayed from a thermos directly onto the warts for 10 to 30 seconds, then after a thawing period, re-frozen again.  Temporary discomfort for 5 to 30 minutes after freezing is expected and can be treated with Tylenol.  A blister is expected to form within several hours to days.  If needed, puncture the blister with a sterile (flamed) needle to express the fluid and promote healing.  The blister may contain some blood, this is perfectly normal.  This procedure may leave a scar behind.  Several treatments are needed, average is 4-5 freezes 2-3 weeks apart.  50-60% successful

After a blister is punctured, apply antibiotic ointment (Bacitracin, Polysporin, Neosporin, etc) at least once daily and cover with a bandaid during the day.  After a scab forms, the wart should completely fall off with the scab.  Frequently, re-freezing is necessary to completely clear warts, especially when they are located on the feet or around fingernails.  An average of 5 to 6 freezes is often necessary for thicker warts.

 Cantharone:

Blistering agent.  40 % successful.

Curettage destruction (surgical removal).

Perhaps 60-80%successful for a few warts. When there are numerous or very large warts present, cure rate decreases.

 Bleomycin:

Chemotherapy. Injected into warts about every 3 weeks with an anticipated 80% cure after 3 injections 3 weeks apart.

 Dinitrochlorobenzene (DNCB):

Patient is made allergic to DNCB, and then DNCB is applied to warts with an 80% cure rate. Used for the patient with numerous or very large warts which may have failed other therapy.

High dose for 2 months is very effective for children with lots of warts.

1. Poke small hole in the Aldara packet with a pin.
2. Squeeze small amount out and rub on the affected area. Fold the packet over and put remainder of packet in a ziplock bag and seal.  The Aldara loses potency if left out in the air after being opened.
3. Use this once on Monday and Thursday the first week, use once on Monday, Wednesday, Friday the second week, then use daily Monday through Friday the third week if only minimal redness is developing.  May stay at 2 or 3 times a week if response is vigorous.
4. A little redness will likely develop which shows the product is working.  This may be larger than the spot you are treating.  If so, this usually indicates the medication is picking up and destroying other abnormal spots it contacts, not just what we can see with the naked eye.  IF THE REDNESS BEGINS TO BECOME MORE PROMINENT OR SORES START TO DEVELOP, YOU MAY STOP THE MEDICATION for awhile.  Stop it for 3-7 days and use 1% hydrocortisone ointment or polysporin over the counter or plain Vaseline petroleum jelly until the redness improves and sores heal.
5. After stopping the Aldara for a few days, the area should start to look better.  Then you may restart it at 2 or 3 times a week.  If nothing happens after a few applications, you may increase it to daily again, but STOP AGAIN IF THE IRRITATION BEGINS TO DEVELOP, following the same healing procedure as above.
6. It normally takes from 6-16 weeks to clear an area with the Aldara.  We usually like to check the area after you start to see how it is coming along.

PLEASE CALL IF YOU HAVE QUESTIONS or are not sure it looks the way it should and we will schedule a time to check it sooner if necessary.

PATIENT INFORMATION REGARDING ELIDEL (pimecrolimus) CREAM and PROTOPIC (tacrolimus) OINTMENT On 3/10/05 the FDA issued a Public Health Advisory informing the public about potential safety concerns associated with the use of two eczema drugs, Elidel and Protopic.  As a result, you may have some questions about these medications.  In addition to having a conversation with your doctor, here is some additional information about this issue.  If you have questions, please speak with your doctor. Elidel Cream and Protopic Ointment have ben shown in human clinical trials to be safe and effective treatment options for patients 2 years and above with mild to moderate atopic dermatitis (eczema). You can use Elidel or Protopic for short or intermittent long periods of treatment.  Intermittent means starting and stopping repeatedly, as directed by your doctor.  You can use it on all affected areas of your skin, including your face and neck.  Elidel is an important treatment option for patients who have had an inadequate response to other therapies or in cases where other therapies are deemed inappropriate. Novartis and Fujusawa have conducted extensive human clinical studies with Elidel Cream and Protopic Ointment. In clinical studies started over 8 years ago and involving more than 19,000 patients worldwide, including more than 9,000 children, these medicines were found to be effective with a favorable safety profile.  Long-term trials are underway with a pediatric registry that will track the long-term safety of the use of these medicines in children ages 2 to 17 years. The current Elidel Cream and Protopic Ointment product labels were the result of extensive clinical trials and discussions with the FDA and work continues with the FDA to ensure that physicians and patients have the information they need to effectively treat eczema. We believe the current label provides a thorough explanation of the risks and benefits of these medicines.  Patient safety is of paramount concern to Novartis and Fujisawa and they are committed to working with the FDA to make sure that physicians and patients have the information they need to treat eczema safely and effectively. The clinical data in humans do not show any evidence of an increased risk of cancer. The Public Health Advisory referred to animal studies designed to look for cancer formation.  In one study in particular, animals swallowed very high doses of an experimental form of the drug (not the approved topical cream form) over a long period of time.  Some of those animals developed lymphomas.  The drug levels in these animals could not be achieved using Elidel or Protopic applied to the skin.  There has been no cause and effect shown between Elidel or Protopic and cancer in humans. Because Elidel Cream and Protopic Ointment are applied to the skin, very low amounts enter the bloodstream. In clinical studies, most blood levels of Elidel or Protopic were too low to measure. If you have further questions or concerns, please talk to your doctor. When you and your doctor find other treatments don’t work for you, there’s concern about risks of other treatments, or you simply can’t tolerate them, your doctor may prescribe Elidel or Protopic.  These are for adults and for children as young as 2.  The most common side effects are a feeling of warmth or burning where applied for the first few days; headache, cold-like symptoms, such as sore throat and cough; and rarely, viral skin infections.   As a Precaution, when using Elidel or Protopic you should avoid unprotected exposure to the sun or sun lamps.  Adapted from Novartis and Fujisawa informational Leaflets 6/05.

HAIR LOSS & HAIR COUNTS

 Normal Hair Behavior:  Each person is born with about 100,000 hair follicles on their head.  Hairs cycle through resting and growing phases.

•  1-9/10 are active growing (Anagen) hairs.  Anagen hairs grow for 5 to 6 years.
• 1-3/10 are resting (Telogen) hairs.  Telogen hairs rest for 3 to 6 months.
• Normal hair loss is 25 to 125 hairs per day.

INSTRUCTIONS FOR DOING A “HAIR COUNT”

1.  Obtain seven (7) envelopes.
2. Label day 1 thru 7.
3. Each day, indicate any treatments you did to your scalp on the envelope (shampoo, perm, etc.).
4. Count the hair lost that day and record on envelope.  You may include hair collected in the drain or on the comb, if they were clean to start with.  Don’t include hairs you pick up around the house.
5. Put hairs in envelopes.
6. Bring envelopes with you to your next appointment.

FRICTIONAL HAND DERMATITIS

1.  Avoid or minimize handling paper or cardboard as much as possible.  This includes regular white paper, file folders, newspaper, mail, cardboard boxes, books, etc.  When handling without gloves, try to avoid “sliding” fingers on paper.  Keyboards can also be a problem.
2. Wear tight fitting fabric/rubber or leather gloves that breathe when your hands will be exposed to any significant friction from paper, dust, money, or cardboard.  Keyboards can also be a problem.
   1. Put Tetrix or Cerave or Mimyx on IMMEDIATELY before you put these gloves on.  The inside of the gloves should build up a layer of cream.
   2. Gloves with rubber palms and fabric backs are usually in the gardening section
   3. Tight fitting leather or synthetic leather gloves, such as golf gloves are usually in the sporting goods section

3. Once hands are doing much better, can be less consistent about wearing the gloves
4. Follow the Soak and Smear Protocol to accelerate the healing of the hands when they are bad.  (See SOAK and SMEAR Protocol below).
5. Apply small amounts of Tetrix or Cerave or Mimyx after you wash you hands or get them wet.  Must be applied, at a minimum, after EVERY TWO exposures to water and/or soap.
6. Apply CeraVe Cream twice a day, don’t wash the hands for at least 30 minutes after applying CeraVe Cream.

 SOAK AND SMEAR  INSTRUCTIONS

1.  SOAK YOUR HANDS IN WARM WATER FOR AT LEAST 20 MINUTES.  This adds water to the deep skin; 20 minutes is necessary, the water won’t get deep enough in less than 20 minutes.
2. THEN IMMEDIATELY AFTER DRYING THE HANDS, APPLY CERAVE CREAM, THEN SMEAR A THICK LAYER OF PETROLEUM JELLY OVER THE CERAVE CREAM.  This puts a layer of oil on the surface to prevent the water that was just added from escaping.
3. IMMEDIATELY PUT ON COTTON OF JERSEY GLOVES OVER THE OINTMENT AND LEAVE THEM ON FOR AS LONG AS POSSIBLE, PREFERABLY OVERNIGHT.

 Waking up in the morning and getting a shower removes the oil and allows the water to start escaping from the skin.  To prevent this from happening, YOU MUST PUT ON CERAVE CREAM, EUCERIN PLUS INTENSIVE REPAIR CRÈME, OR NEUTROGENA NORWEGIAN FORMULA HAND CREAM within ONE Minute after drying the hands after showering in the morning.  YOU MUST RE-APPLY WITHIN ONE MINUTE OF DRYING THE HANDS EVERY TIME YOU WASH THEM THROUGHOUT THE DAY.

During the day, if your hands start to get dry, painful, and/or stiff, run them under warm water for long enough to make them soft and relieve the pain, then pat them dry, then immediately put on more of one of the above.  You can do this as often as necessary during the day.

Simplified Low Nickel Diet

GRAINS TO AVOID:  Whole wheat bread, multigrain breads, multigrain cereals, wheat bran, wheat germ, whole wheat pasta, oats, OATMEAL, buckwheat, seeds

VEGETABLES  TO AVOID:  BEANS, LENTILS, PEAS, SOYBEANS, SOY PRODUCTS, (TOFU, SOY SAUCE), bean sprouts, brussel sprouts, asparagus, broccoli, cauliflower, spinach, CANNED vegetables

FRUITS TO AVOID:  CANNED fruit cocktail, pears, bananas, CANNED fruits

MILK & DAIRY TO AVOID:  Chocolate Milk

 MEATS TO AVOID:  Shellfish, processed meats with fillers or coatings,  CANNED meats or fish

 OTHER SOURCES OF DIETARY NICKEL TO AVOID: 

1.   Chocolate and cocoa powder (especially DARK CHOCOLATE)
2.   All nuts (especially PEANUTS)
3.   Canned foods in general
4.   Stainless Steel Cooking vessels used for cooking acidic foods
5.   Vitamins containing nickel
6.   The first quart of tap water drawn from each faucet in the morning
7.   Black tea
8.   All seeds
9.   Commercial salad dressings

WAYS TO PREVENT YOUR BODY FROM ABSORBING THE NICKEL YOU EAT:

1.  Take vitamin C supplement with each meal
2.  Eat a high iron diet

Methotrexate (mtx) is a very effective drug for the treatment of psoriasis, arthritis and selected other skin diseases.  There are many side effects, however, some of which are made worse by other medications.  The following is a list of medications which may interact with methotrexate and must be avoided while taking methotrexate.

METHOTREXATE HINTS:

1. If nausea is a problem you may take folic acid 5 mg daily, available at most drug stores.

2. Remember Methotrexate (mtx) is to be taken only once weekly.  The laboratory studies, used to detect harmful effects of the mtx, are most informative when they are drawn well away from your last dose of mtx.  For example, if you take your medicine on Thursday, the best time to draw your blood would be late Wednesday or early Thursday before you take your next dose.

DEFINITION

Common findings of molluscum:

• Small skin-colored, dome-shaped bumps.
• A very common skin condition in young children.
• Commonly found on face, armpits, trunk and extremities.
• Can spread from one part of the body to another.
• They may be itchy.

 CAUSE

• Molluscum is caused by a virus.  Children acquire this type of infection through contact with other young children.

 COURSE

• The bumps will often clear in months, but sometimes not for years.
• They can become infected with bacteria, especially when scratched.  This bacterial infection causes surrounding red patches with or without pus draining from the center, or a yellowish crust may form.
• The bumps rarely may leave a chickenpox-like scar, with or without treatment.  Scarring is more likely with a secondary bacterial infection or if the child repeatedly picks at crusted scabs.

TREATMENT

1. Cantharone Liquid:  This liquid is an extract from the blistering beetle.  A drop is applied to the bump, avoiding surrounding skin.  A blister will form within 1 to 6 hours.  Check the treated areas hourly and wash Cantharone off with soap and water at the TIME OF FIRST BLISTERING, or after a maximum of 6 hours.  Blistering may also occur after this time.  Blisters should be slightly bigger than the area treated.  If excessive blistering occurs, call our office at that time.  After the blister breaks open, a scab will form.  Apply Bacitracin or Polysporin ointment to scabs daily and cover with a bandaid.  The crust will fall off within 1 week.  A temporary discolored spot may occur, this will fade to normal over time.
2. Cryotherapy:  Liquid nitrogen is another form of treatment.  It is a very cold        (-196ºC) liquid applied by Q-tip for about 5 seconds to each bump.  This may cause temporary discomfort.  Blistering usually occurs and is cared for as above.  This type of treatment is especially useful for areas around the eyes and nose.
3. Curettage:  A third way to remove these bumps is by scraping the bump off with a curette.  This method is usually reserved for persistent bumps that have not responded to other methods of treatment.
4. Aldara: Aldara is applied every other day, very sparingly, to the bump.  Aldara stimulates interferon, helping the body’s own immune system resolve the molluscum.

 FOLLOW-UP

Any temporary discomfort may be treated with Tylenol.

• Call our office if signs of infection occur:  increased redness, pus draining from bumps, swelling and/or increasing discomfort.

New bumps that were too small to be detected may appear after treatment.  Call to schedule a follow-up appointment if you desire these to be treated.

WHAT ARE SCABIES?

Scabies is a skin disease caused by an almost invisible “itch mite” called Scarcoptes scabiei.  This disease has plagued man for thousands of years and has recently been increasing in incidence.  It is acquired by close personal contact and is somewhat contagious.  It may spread rapidly among school children due to their close contact.  Only rarely, can it be spread by exchanging clothing or towels.  The mite does not “jump” from one person to another, and it does not survive more than a few days off the human body.

IS THERE A CURE?

Yes, and the treatment is effective.  The medicine prescribed should be used ONLY as directed and no more.  Usually the entire family is treated because of the contagious nature of the disease, even though all family members are not itching.

 WASHING CLOTHES

At the end of the applications of cream, change clothing and bed linen which has been used the previous three days.  Wash these clothes in HOT water and if possible, dry them in a hot dryer.  It is not necessary to boil clothing.  For blankets, have them dry cleaned, or simply place them in a closed bag for three days.  The mite cannot survive off the body for any longer time.

 ELIMITE CREAM

Apply a thin layer of cream or lotion to the entire body from the neck down to the toes – top of the head to the tip of the toes on children under two years of age.  Be sure not to forget finger webs, bottoms of feet, under fingernails, armpits, belly button, genitals, and groin.  Do not wash hands after applying.  Leave cream on overnight.  Shower or bathe to remove the cream.  At the time of the shower, wash clothing and bed linen used in the previous three days in the hot cycle of the washer.  Remember that itching may persist to a lesser degree for several weeks.  ALL individuals must be treated at the same time.

IVERMECTIN

Oral medication used for severe, resistant, or epidemic cases of scabies.  You are to take ______            tablets and repeat in one week.

• Do not shave your legs or use lotions the day of treatment.
• After sclerotherapy injections, patients should walk for 15 minutes and avoid high impact aerobic activity for 1 week.
• If the injected veins are deeper, an ace bandage wrap should be worn during the day for 2 weeks.
• If you have a lot of veins, or if your veins are thick, you may look worse after the initial treatment.  You may experience a darkening of the veins, especially the deeper and larger vessels.  Though this should disappear in time, the discoloration may fade but not completely disappear.
• Depending on the extent of involvement, usually a minimum of 3 visits 4 to 6 weeks apart is necessary for optimum results.

• The skin will feel tight (similar to the sensation of wearing a mask).  This sensation can be reduced by applying the recommended medication, which will also prevent cracking of the skin.  Begin facial washing 24 hours, 3 times a day, followed by the medicated ointment.
• You should also avoid excessive facial expressions to avoid creacking of the skin  prematurely.  This tightness may last 5 to 6 days.
• Your skin color will darken four to five shades prior to the beginning of the actual peeling process.  Some persons having naturally dark skin may appear very dark before the peel starts.  This is normal and the darkened skin will peel away once the peel process begins.
• Avoid contact with people who have cold sores or skin infections, and avoid any form of intimate contact that may cause irritation to your skin.
• Swelling of the face is expected with deeper peels, which are designed to improve scars and fine wrinkles.  More welling can be anticipated in the areas that were more wrinkled or scarred.  If the peel is very concentrated around the eyes, it is not unusual for the eyes to swell shut for a day or two.  Should this occur, cold compresses with a wet cloth saturated with ice water would offer comfort.  The ice compress may be applied four or five times per day.
• Usually you will begin to peel on the third or fourth day.  The peeling normally begins around the mouth and works its way into other areas.  Be extremely careful not to scratch your skin.
• Normally, a light peel is completed in approximately 10 days for the average person.  For those persons requiring deeper peels, an average of 12 to 14 days is required to complete the peel process.  The length of time required to complete the peel is reliant upon your own natural healing abilities.  Absolutely no one can speed up that process for you.  Some people heal rapidly while others must be patient with their healing process.
• After the peeling process has been completed, your face may remain red and may be sensitive to sun exposure for a few weeks.  The redness and sensitivity will subside, and once you are able to tolerate sunscreen, you will be able to resume all normal activities, however strict sun avoidance is recommended for one month.
• Within a few days after the peel is completed, you will be able to use makeup, if you wish.
• Take your antiviral capsules for the full course.

As soon as you can tolerate it, begin using your Acne medicine or Retin-A or hydroquinone and glycolic acid or Lac-Hydrin.

Noncomedogenic, and with broad-spectrum UVB and UVA protection:

• Water Babies Spectra 3-SPF 50.
• Coppertone Spectra 3-SPF 50.
• Hawaiian Tropic 45+, 50+
• Coppertone Faces, Oil Free 15, 30, 45
• Shade 45
• Neutrogena Sunblock 45.
• Neutrogena Healthy Defense 30
• Neutrogena Dry Touch 30
• Neutrogena Ultrasoft 30, 45
• Neutrogena Active Breathable 30 and 45.
• Neutrogena Oil Free Sunblock Stick

 UVA and a UVB protection:

• Coppertone Sport cream, spray, and gel 30, 48.
• Water Babies  Stick 30.
• Banana Boat Kids stick 30.
• Banana Boat Aloe Vera 30 lip balm.
• Bullfrog Superblock 40, 45.
• Banana Boat Kids Quick Block 45.
• Banana Boat Sport 30, 45.
• Coppertone Kids 45.
• Hawaiian Tropic 70+.
• Hawaiian Tropic ozone sport 60+.
• Baby Faces 60+

HANDS OR FEET

Mix a solution of 1 part of Psoralen 1% solution in 9 parts of water.   Soak hands and/or feet for 20 minutes, then expose to light.

After soaking, expose your hands and/or feet to the lights beginning with 30 seconds and increasing by 30 seconds each time.   Expose your hands and/or feet 2-3 times per week.

For the 24 hours following exposure, protect your hands and/or feet from sun exposure using gloves or socks or one of the suggested sunscreens.

Extreme caution to avoid excess light exposure must be used when treating with topical PUVA therapy.   If you have any questions, please call our office.

 SUGGESTED SUNSCREENS

*SPF = Sun Protection Factor (How many times longer you can stay in the sun without burning.)

**Looking for Avobenzone, Parsol 1789, Titanium Dioxide, or Zinc Oxide as an active ingredient.

WOUND CARE USING 0.25% ACETIC ACID (VINEGAR)

 Making Acetic Acid:

1. Boil 1 quart of water for five minutes.
2. Add ½ cup of WHITE vinegar.
3. Allow to cool.
4. Place in a clean jar that has been washed in hot soapy water and rinsed well or washed in the dishwasher.
5. Store in refrigerator and warm small amount to room temperature before use.

 Dressing:

1. Remove old dressing
2. Gently cleanse wound
3. Moisten clean gauze with the acetic acid solution
4. Apply zinc oxide ointment around the wound to protect the healthy skin (do not place directly on wound)
5. Cover the wound with the acetic acid gauze
6. Cover with dry sterile dressing
7. Change daily or as needed if there is a lot of drainage

PATHOLOGY INFORMATION:

Your biopsy or surgery specimen will be sent to a lab for processing into slides for the pathology physician to read.  The slides are then sent to the physician who reads them and prepares a report of results.  This physician may be located in Washington, Oregon, Pennsylvania, or another state depending on the type of specialization needed to read the slides.  You will see a separate charge sent to your insurance for the processing and pathology reading which is separate from your biopsy or surgery charge at our office.  If you have any questions about this when it comes through, please do not hesitate to call our office or the office of the reading pathologist directly.

 CARE OF BIOPSY AND SURGERY SITES:

1. Keep dressing clean and dry for about 24 hours.  After 24 hours, remove the dressing and shower or bathe normally.  Cleanse area once or twice daily with soap and water (any regular soap is fine) or warm salt solution (1/2 tsp. of table salt dissolved in one 8 oz. glass lukewarm water).  Pat dry after cleansing and cover the area with Polysporin ointment or Vaseline petroleum jelly and a Band-Aid or gauze until it is healed (usually 1 to 3 weeks).  If you have sutures, continue with a clean dressing every day until the sutures are removed by your doctor or nurse.  As the area heals, it may get a small (1-2 mm) red rim and look yellow in the center.  This is normal wound healing.
2. If there is any bleeding, apply direct pressure on area for 10-20 minutes.  Repeat if necessary.  If still bleeding after repeat pressure, call our office and ask to speak to the nurse or doctor for further instructions (360)413-8760.
3. If there is swelling and discomfort, you may use a cold pack or bag of frozen vegetables such as peas or corn over the area for 10 minutes every few hours.  You may also take acetaminophen (Tylenol) as directed.
4. For punch biopsy sites, gelfoam may be used.  This will dissolve on its own or fall out.
5. Avoid swimming, heavy lifting, heavy exercise, and sweating until the sutured wound has healed.  Watch for signs of infection (see below).
6. If you have not heard from us by about 2 weeks, you may call the office for your biopsy/pathology result.  Call the nurse line listed below to speak directly to the nurse or leave her a message.

 ALTERNATIVE DRESSING (DUODERM EXTRA THIN): 

Duoderm Extra Thin is found at medical supply stores, such as Kirk’s, or larger drug stores.  It comes in many different sizes of sheets.  Start with a clean, dry wound, cut the Duoderm to a size large enough to cover the wound along with some normal skin around it.  This will prevent leaks when bathing.  You do not need to use antibiotic ointment when using Duoderm.  Change the Duoderm every 2 to 4 days or sooner as needed.  When ready to change the dressing, remove the old Duoderm, wash the wound with soap and water, dry, and reapply a new piece if needed.  Wound fluid often collects beneath Duoderm.  This is expected and alright.  If the fluid drains, a new dressing should be applied.

 It is best to avoid exposure to sun on all surgery, biopsy, and liquid nitrogen areas for 4 months.  Newly healed skin is very sensitive to sunlight and will remain red if overly exposed to sunlight.  After the wound has healed, #15 or higher sunscreen can be used over the treated area for 4-6 months after surgery when exposure to sun is anticipated.

SIGNS OF INFECTION:  Swelling increasing after the first 36 hours, heat/fevers, excessive tenderness, pus drainage from the wound, expanding redness or red streaks.