Chiaramente, ogni formato ha i propri vantaggi e svantaggi comprare amoxil senza ricetta per effettuare un acquisto, non è necessario fornire la prescrizione medica.

Acne


Dr Noori Moti-Joosub Laserderm, Dunkeld/ DGMC


 Acne vulgaris is a self-limited disorder of the pilosebaceous unit that is seen primarily in adolescents. Most cases of acne present with a pleomorphic variety of lesions, consisting of comedones, papules, pustules and nodules. Although the course of acne may be self- limiting, the sequelae can be lifelong, with pitted or hypertrophic scar lifelong.


 Almost every teenager can experience acne to a certain degree during adolescent years.  Boys>girls  Tend to "grow out of it" in early 20s  Females can continue until post-menopausal



Hair follicle has a hair and sebaceous gland. The gland produces too much oil which becomes clogged with keratin, bacteria and cells.




 Excoriations (picked or scratched spots)  Erythematous macules (red marks from recently healed spots, mostly in fair skin)  Pigmented macules (dark marks from old spots, mostly in dark skin)  Normal physiological reaction in puberty  Disease of the ovaries ◦ Polycystic ovarian syndrome ◦ Benign or malignant ovarian tumors  Disease of the adrenal gland ◦ Partial deficiency of the adrenal enzyme 21 Hydroxylase ◦ Benign or malignant adrenal tumors  Disease of the pituitary gland ◦ Cushing's syndrome due to excessive adrenocorticotrophic ◦ Acromegaly due to excessive growth hormone production ◦ Adenoma of the adrenal gland especially prolactinoma  Obesity and the metabolic syndrome  Medication-phenytoin,steroids,barbiturates,OCPills  Patients with acne often have increased production of sebum, hence oily skin. This may be  High overall levels of sex hormones (mainly the androgen, testosterone).  Hyperandrogenism in females  Increased free testosterone because of low levels of circulating sex-hormone-binding-globulin (SHBG).  More active conversion of weaker androgens to stronger androgens such as dihydroxytestosterone (DHT) by the enzyme 5-reductase within the skin.  Higher sensitivity of the skin to DHT.  Mild: Comedones  Moderate: Papules, pustules  Severe: Nodules, cysts, conglobate lesions  Grade 1: Comedones only  Grade 2: Inflammatory papules  Grade 3: Pustules  Grade 4: Nodules, cysts, conglobate lesions  Unpleasant form of nodulocystic acne  Interconnecting abscesses and sinuses, which result in unsightly hypertrophic (thick) and atrophic (thin) scars.  There are groups of large macrocomedones and cysts that are filled with smelly pus.  It is occasionally associated with hidradenitis  Allergic reaction to P. acne  Abrupt onset  Inflammatory and ulcerated nodular acne on  Severe acne scarring  Fluctuating fever  Painful joints  Malaise (i.e. the patient feels unwell)  Loss of appetite and weight loss  Raised white blood cell count.  Infantile acne  Generally affects the cheeks, and sometimes the forehead and chin, of children aged six months to three years.  More common in boys and is usually mild to moderate in severity. In most children it settles down within a few months.  The acne may include comedones inflamed papules and pustules, nodules and cysts. It may result in scarring.  The cause of infantile acne is unknown.  It is thought to be genetic in origin.  Hormone abnormalities in older children with acne may be associated with the following conditions:  Congenital adrenal hyperplasia  Cushing's Disease  21-Hydroxylase deficiency  Precocious puberty  Androgen-secreting tumors  Acne can be effectively treated, but response is usually slow  Face washing-rock of management  Where possible, avoid excessively humid  Ultraviolet light helps  Abrasive skin treatments can aggravate  Try not to scratch or pick the spots  Important part of acne treatment  Wash face once or twice a day  Gentle cleansers  Foam cleansers best  Exfoliative cleansers can be used  Often not needed in acne  Do not dry skin out  Mattifying moisturisers  Often extra moisturisers needed with Isotretinoin treatment  Not necessary  Use non-alcoholic type  Often too oily  Use non-comedogenic types  Shade-seeking behaviour  Protective clothing  With Isotretinoin treatment, sun protection  Liquid foundation better than powders  Powders block pores  The more you use, the worse it is  Make sure adequately removed  Non-comedogenic  Wash affected areas twice daily with a mild cleanser and water or an antiseptic wash.  Acne products should be applied to all areas affected by acne, rather than just put on individual spots.  They often cause dryness particularly in the first 2-4 weeks of use. This is partly how they work. The skin usually adjusts to this.  Apply an oil-free moisturizer only if the affected skin is obviously peeling.  Anti-bacterial  Benzoyl peroxide 2.5-10% wash, gel, cream Gel: drying Cream: tolerant Wash: Chest and Back  MOA: kill bacteria, dry up oil, slough dead  Problem: dryness, irritation, flakiness  Erythromycin 4% and Zinc 1,2%  MOA: anti-inflammatory, kill bacteria  Problem: Resistance Gram negative  Adapalene 0.1% Cream: more tolerant  Tretinoin 0.1-0.25%  Isotretinoin 0.05%  MOA: Promote cell turnover, prevent plugging of hair follicles  Problems: dryness, irritation, redness, sun-  Oral or topical  Often in combination  Safe in pregnancy  MOA: unknown?? Immune-modulatory Anti-bacterial, anti-viral?  Problem: None  Sulfur compounds: 2% sulfur in UEA  Cost-effective  MOA: anti-bacterial, anti-parasitic, anti- fungal, anti-inflammatory  Problems: smell  Gel or cream formulations  MOA: anti-bacterial, anti-inflammatory  Problems: Dry skin, irritation  MOA: keratolytic agent (sloughing of dead  Problems: Irritation  Used for acne, wounds, infection, fungal  MOA: anti-bacterial, anti-viral, anti-fungal, anti-inflammatory  Problems: slower onset of action compared to benzoyl peroxide, sensitivity  Topical treatment plus Antibiotics  an adequate dose of antibiotic should be given for at least three months before deciding that a patient has failed to respond  after three months therapy then a reduction of acne lesions by 30-50 per cent should have occurred(pt assessment)  Good response? continued for a further three months and then the patient maintained on an appropriate topical regimen  Poor response to oral antibiotic therapy then an alternative antibiotic may be substituted  MOA: bacteriostatic, anti-inflammatory  First line – Tetracycline (no longer used)  2nd line- doxycycline (abdominal cramping, nausea, vomiting), minocycline(causes SLE), lymecycline (abdominal cramping)  Take with probiotic  Not to be taken with food  Warn females about vaginal thrush  Can have a flare when commencing treatment  MOA: bactericidal activity (2 agents).  Most effective due to lack of resistance (2  Can be effective on those who failed on tetracycline treatment (different sites of sebum production, less resistance).  S/E: GIT disturbance, drug reaction.  Must be a combination OCP (oestrogen and  Often regarded as an adjunctive therapy in  Indicated in PCOS, CAH, idiopathic hirsutism  Often combined with cyproterone acetate (25-100mg day 5-19)  MOA: reduces sebum production by an anti- androgenic effect. Mild Side effects:  Headaches  Breast tenderness  Often pass in a few months Severe side effects:  Thrombosis (minimally raised with the progesterone drospironone) Risk greatest in first year and as you get older. Over 35 years use a low oestrogen pill  Strokes  Heart attacks  History of thrombosis or cardio-vascular disease  Family history of blood clotting disease or abnormal clotting  Anti-phospholipid syndrome  Severe migraines  Hypertension, hypercholesterolaemia  History of thromboplebitis  Immobilisation  Results have not been consistent  hepatic and endometrial cancer  breast cancer in younger users, returns to normal 10yrs after stopping it  cervical cancer (? Increased sexual activity  Must be taken every day  Diarrhoea and vomiting decrease  Anti-epileptics, anti-virals may interfere with  No clear evidence that antibiotics interfere  Takes time to work  Family Planning Association of UK, safe to take OCP until 50yrs of age.  Weigh up benefits and risk factors  Many patients will be treated with oral  If this is not suitable, the following may be  High dose oral antibiotics for six months or  In females, especially those with polycystic ovary syndrome, oral antiandrogens such as OCP or spironolactone may be suitable long term. Systemic corticosteroids are sometimes used for their antiandrogenic effect.  Flutamide and finasteride also been reported to be of benefit in hyperandrogenic women, though not licensed MOA:  Reduces sebum secretion and shrinks  Anti-bacterial  Promotes normal keratinisation of hair follicle  Anti-inflammatory Side effects  Teratogenic  Dryness, nosebleeds, dry lips  Body aches and pains  Hair falling out  Staph carriage increased: boils etc  ?? Depression, mood changes  May fall pregnant 1 month after stopping  Blood tests: βHCG. LFTs (ALT, AST), Lipogram (Total cholesterol, triglycerides)  Repeat at 3 months  Dose: 0,5-1mg/kg/day  Cumulative dose: 120-150mg/kg  Low dose?  Take with biggest meal of the day  For greater efficacy bd dosing should be used  Cortisone on commencement  Sunlight is anti-inflammatory and can help briefly. Beware of skin cancer.  Cryotherapy  Intralesional steroid injections  Comedones can be expressed by cautery or  Microdermabrasion can help mild acne.  Lasers and light systems (blue light)  X-ray treatment-no longer recommended for acne as it may cause skin cancer.  Photo-dynamic therapy Topicals  Zinc and Erythromycin  Sulfur Oral meds  Erythromycin  Will resolve in 9-12months  Topical depigmenting agents can speed up  Fractionated lasers can resolve PIH in 3-5  Hypertrophic: I/L steroids Fractionated laser and rub steroid in  Atrophic HA fillers Fractionated laser CO2 laser Immediate referral indicated (within a day):  have a severe variant of acne such as acne fulminans or gram-negative folliculitis Urgent referral  have severe or nodulocystic acne and could benefit from oral isotretinoin  have severe social or psychological problems, including a morbid fear of Routine referral  At risk of or are developing scarring despite  have moderate acne that has failed to respond to treatment which has included two courses of oral antibiotics, each lasting  are suspected of having an underlying endocrinological cause for the acne (such as polycystic ovary syndrome) that needs

Source: http://www.blackignition.co.za/download/files_27/Galderma_Acne.pdf

Untitled

APPLICATION MANUAL 2016 09 GENER AL INFORMATION 86 Machines, Tools, and Aids 14 General Product Information 21 Swarovski Products and Suitable Application 100 Quick Assistance101 Swarovski Hotfix Selector 23 SOLDERING, PL ATING, AND STONE SET TING SEWING, EMBROIDERY, AND HAND APPLICATION 24 Machines, Tools, and Aids25 Suppliers 112 Product Overview 112 Machines, Tools, and Aids

journalofoptometry.org

Documento descargado de http://www.journalofoptometry.org el 08/10/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato. Genetic risk factors and age-related macular degeneration (AMD) Maryam Mousavi, Richard A. Armstrong Vision Sciences, Aston University, Birmingham B4 7ET, UK