Posted in Patient Information

Keratosis Pilaris

Keratosis pilaris is a very common harmless skin condition appearing as small, whitish bumps on the upper arms and thighs, especially of children and young adults. Individual lesions of keratosis pilaris begin when a hair follicle becomes plugged with keratin, a protein found in skin, hair, and nails.

Who’s At Risk

Keratosis pilaris can affect people of any age, any race, and either sex. It is more common in females.

Keratosis pilaris usually starts in early childhood (by age 10) and can worsen during puberty. However, it frequently improves or even goes away by early adulthood.

Keratosis pilaris can affect 50-80% of teenagers and up to 40% of adults. Many people have a family history of keratosis pilaris. A large number of individuals with ichthyosis vulgaris (an inherited skin condition characterized by very dry, very scaly skin) also report having keratosis pilaris.

Signs & Symptoms

The most common locations for keratosis pilaris include the following:

  • Backs of the upper arms
    • Fronts and sides of the thighs
    • Buttocks
    • Cheeks

Tiny (1-2 mm) white to gray bumps occur, centered in the hair follicle. Sometimes, a thin, red ring may surround the white bump, indicating inflammation. The bumps all look very similar to one another, and they are evenly spaced on the skin surface.

Rarely, people with keratosis pilaris may complain of mild itching.

Keratosis pilaris tends to improve in warmer, more humid weather, and it may worsen in colder, drier weather.

Self-Care Guidelines

There is no cure for keratosis pilaris, though its appearance can be improved. It is often helpful to keep the skin moist (hydrated) and to use mild, fragrance-free cleansers, with daily applications of moisturizer.

Creams and ointments are better moisturizers than lotions, and they work best when applied just after bathing, while the skin is still moist. The following over-the-counter products may be helpful:

  • Preparations containing alpha-hydroxy acids such as glycolic acid or lactic acid
    • Creams containing urea
    • Over-the-counter cortisone cream (if the areas are itchy) such as 1% hydrocortisone cream
Gold Bond rough & bumpy skin is an inexpensive cream which contains urea, lactic acid, and salicylic acid, all of which are helpful for keratosis pilaris.
Gold Bond rough & bumpy skin is an inexpensive cream which contains urea, lactic acid, and salicylic acid, all of which are helpful for keratosis pilaris.

Do not try to scrub the bumps away with a pumice stone or similar harsh material; these approaches may irritate the skin and worsen the condition.

Similarly, try to discourage your child from scratching or picking at the bumps, as these actions can lead to bacterial infections or scarring.

When to Seek Medical Care

Keratosis pilaris is not a serious medical condition and has no health implications. However, if self-care measures are not improving the appearance of the skin and it continues to bother your child there are some prescription options for treatment that could be considered.

Prescription Treatment Options

Treatments are aimed at controlling the rough bumps, not curing them. Keratosis pilaris bumps will come back if therapy is stopped.

Prescription treatments for keratosis pilaris sometimes include:

  • Prescription-strength alpha- or beta-hydroxy acids (glycolic acid, lactic acid, salicylic acid)
  • Prescription-strength urea
  • A retinoid such as tretinoin or tazarotene
  • High concentrations of propylene glycol
  • If the skin is itchy or inflamed, the short-term prescription strength topical corticosteroid to reduce the inflammation may be considered

Usually, consistent home use of over-the counter creams is enough to manage the symptoms of keratosis pilaris.

References

Posted in Patient Information

Eczema Home Treatment Plan

“The itch that rashes.”

Managing the symptoms at home can seem can seem daunting, but patients can take control of this condition with changes to the daily routine and a stepwise approach when symptoms worsen.

Prevention (do this every day, always):

Apply moisturizer twice a day.

  • Ointment – most effective, greasy, hard to apply. Won’t burn the skin if it is scratched and dry.
  • Creams – next most effective, thick.
  • Lotions – least effective, easiest to apply.

Apply the maintenance steroid cream once a week as a proactive treatment to prevent flares.

Avoid drying the skin when bathing

  • Shorter showers (not baths) are better.
  • Use cooler water, less than 104 °F (40° C).
  • Use a simple bar soap like a Dove bar. Fancy soaps have fancy chemicals.
  • Soap the Face, Armpits, Groin, Feet, Hands. Other areas do not need soap unless they are soiled or very dirty.

Minor flare – use your steroid every day!

  • Apply your regular steroid to all affected areas twice a day, Monday through Friday. Take a break on the weekend to ensure the steroid continues to be effective.
  • Continue to use moisturizers and avoiding long hot baths.

Severe flare – time for a stronger steroid!

  • Apply stronger steroid twice a day, again Monday through Friday.
  • As always, keep using the moisturizer, and maintain your normal skin therapies.
  • When symptoms improve you should work your way back to Prevention in steps. First treat as a Minor flare and only reduce your use of regular steroid when your symptoms are back under control.

Links

Topical Steroid Potency Chart: National Psoriasis Foundation

Posted in Procedures

Lipoma Removal

Equipment List

  1. Sterile gloves (1 pair)
  2. 15 Blade Disposable Scalpel (1)
  3. Iris Scissors, Straight (1 pair)
  4. Needle Driver (1 pair)
  5. Toothed Pickup (1)
  6. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1)
    • 4-0 Ethilon (1)
  7. 10 ml syringe (1)
  8. 18 gauge 1.5 inch needle (1)
  9. 27 gauge 1.25 inch needle (1)
  10. ChloraPrep 3mL stick (1)
  11. Alcohol Swabs (4)
  12. Sterile 4×4 gauze (5)
  13. Sterile 2×2 gauze (2)
  14. Paper Medical Tape (1 roll)
  15. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  16. Chux Pads (1)
  17. Formalin cups (as many cups as specimens)
  18. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)

Procedure Note

LIPOMA REMOVAL

The procedure was explained in detail and informed consent was obtained from the patient.  The area was prepped and draped in a sterile fashion, and infiltrated with _ mL of _% lidocaine with_ epinephrine for local anesthesia.  The lipoma was palpated superficially under the dermis.  An incision was made directly over the lipoma, and gentle blunt dissection was performed to free and then remove the lipoma.  The specimen was placed in specimen jar and sent for analysis.  Closure was performed with _ simple interrupted sutures using _ type of suture.  Petroleum ointment and a bandage were applied.  EBL was less than 1 ml.  Good hemostasis.  There were no complications.  Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound.  The patient voiced understanding.  Suture removal in _ days.
Posted in Procedures

Skin Biopsy

Equipment List

  1. Nitrile Exam Gloves (1 pair)
  2. Sterile Gloves (1 pair)
  3. 15 Blade Disposable Scalpel (1)
  4. Iris Scissors, Straight (1 pair)
  5. Needle Driver (1 pair)
  6. Toothed Pickup (1)
  7. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1) – absorbable for deep or layered repair
    • 4-0 Ethilon (1) – for skin closure
  8. Sterile Medium Drape (1)
  9. ChloraPrep 3 mL stick (1)
  10. Alcohol Swabs (4)
  11. Sterile 4×4 gauze (5)
  12. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise it is ok to have epinephrine. (1 vial with minimum 20 mL remaining)
  13. 10 ml syringe (1)
  14. 18 gauge 1.5 inch needle (1)
  15. 27 gauge 1.25 inch needle (1)
  16. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  17. Chux Pads (1)
  18. Formalin cups (as many cups as biopsy specimens)
  19. Paper Medical Tape (1 roll)
  20. Sterile 2×2 gauze (5)

Procedure Note

EXCISIONAL/INCISIONAL BIOPSY

The procedure was explained in detail and informed consent was obtained from the patient.  The area was prepped and draped in a sterile fashion, and infiltrated with _ ml of _% lidocaine with_ epinephrine for local anesthesia.  An elliptical cision was performed to remove the lesion, and the specimen was placed in specimen jar and sent for analysis.  Closure was performed with _ suture material.  Petroleum ointment and a bandage applied.  EBL less than 1 ml.  Good hemostasis.  There were no complications.  Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound.  The patient voiced understanding.  Suture removal in _ days.

Suture Removal Period

Face: 5-7 days

Neck: 7 days

Scalp: 10 days

Trunk & Upper Extremities: 10-14 days

Lower Extremities: 14-21 days

Sutures in wounds under greater tension may have to be left in place slightly longer.

Posted in Procedures

Skin Tag Removal

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Toothed pickup (1)
  3. DermaBlade (1)
  4. ChloraPrep swab 3 ml (1), or Alcohol swabs (many)
  5. Sterile 4×4 gauze (10)
  6. Band-Aid (as many as tags to be removed)
  7. DrySol (Aluminum chloride) (1)
  8. Sterile cup for DrySol (such as urine specimen cup) (1)
  9. Sterile cotton tipped applicators (CTA) (10)

Optional Items (may not be needed):

  1. 1% or 2% lidocaine (with epinephrine) (1 vial with minimum 20mL remaining)
  2. 10 ml syringe (2)
  3. 18 gauge 1.5 inch needle (2)
  4. 27 gauge 1.25 inch needle (2)
  5. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  6. Chux pads (3)
  7. Formalin cups (if needed for suspicious tags to be sent for pathology)

Procedure Note

SHAVE BIOPSY

Before the procedure began the risks and benefits were discussed, including the risk of bleeding, scarring, infection, or need to repeat the procedure.  Patient voiced understanding and desire to proceed.  Timeout performed (time documented on paper form).  

Acrochodon was grasped with pickups, then thin stalk was excised flat with DermaBlade.  Per patient request no anesthetic was used.  Aluminum chloride immediately applied to area to stop bleeding, then BandAid applied.  This was repeated for _ acrochordon which the patient desired removed.  Good hemostasis.  There were no complications.  Wound care and post-procedure warning signs were discussed.  Patient voiced understanding.
Posted in Procedures

Cryotherapy

Consent Form

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Liquid nitrogen (1)
  3. Ear speculums (1 each size)

Procedure Note

CRYOTHERAPY

Procedure was discussed with the patient including indications, risks, benefits, and alternatives.  Local post-procedure care discussed.  Side effects of treatment discussed.  All questions answered.  The patient opted to go forward with procedure.  Timeout performed.  The lesion was treated with light cryotherapy using cryo-cautery. The nozzle of the spray gun was positioned 1.0 to 1.5 cm above the skin surface and aimed at the center of the target lesion.  Liquid nitrogen applied until an ice field encompassed the lesion and the desired margin of _ mm.  Freeze thaw freeze technique was performed with complete thawing between cycles.  A total of _ lesions treated.  Patient tolerated procedure well.

Reference

https://www.aafp.org/afp/2020/0401/p399.html

Posted in Procedures

Abscess Incision and Drainage

Consent Form

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. 11 Blade disposable scalpel (1)
  3. Culture swab (1 swab)
  4. 1 Liter normal saline or sterile water (1)
  5. 60 ml (or largest available) syringe (1)
  6. Splash guard (1) if available
  7. Wash basin (1)
  8. Kidney basin (1)
  9. Forceps, curved (1 pair)
  10. Forceps, straight (1 pair)
  11. Sterile 4×4 gauze (10)
  12. Iodoform gauze (1 new bottle)
  13. Iodine swab sticks (3)
  14. Alcohol swabs (10)
  15. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise with epinephrine. (1 vial)
  16. 10 ml syringe (1)
  17. 18 gauge 1.5 inch needle (1)
  18. 27 gauge 1.5 inch needle (1)
  19. Exam-room sheet (1 sheet)
  20. Chux pads (10)

Procedure Note

ABSCESS INCISION AND DRAINAGE

Risks and benefits of the procedure were discussed, including the risk of bleeding, pain, the need for repeat procedure.  Patient indicated understanding and wished to proceed.  Timeout performed.

Area of concern was cleaned and draped.  Alcohol used to clean skin over area of injection.  Injected _ ml of _% lidocaine with epinephrine.  Area further swabbed with iodine swab sticks and allowed to dry.  Using scalpel performed linear incision over lateral aspect of of induration.  Drained _ ml of purulent fluid.  Probed wound for loculations and broke them down using gentle opening motion of forceps.  Irrigated wound with copious clean water.  Wound packed with _.  Covered with sterile dressing. 

Patient tolerated the procedure well with approximately _ ml of bleeding.

Instructed patient to follow-up in _ days for removal of packing.  Return immediately for fever, significantly worsening pain, spreading redness around the area, or other concerning symptom.
Posted in Patient Information

Hair Loss in Women

Originally Posted at:  Hair Loss in Women | Cleveland Clinic

Any girl or woman can be affected by hair loss, but it is more common in certain groups. Normal hair loss amounts to about 50-100 hairs per day. Causes of excessive loss of hair range from heredity to medical conditions to styling issues.

What are the symptoms or signs of hair loss in women?

  • Seeing more hair fall out daily either on your brush, on the floor, in showers, on your pillows, or on the sink.
  • Seeing noticeable patches of thinner or missing hair, including a part on the top of your head that gets wider.
  • Having smaller ponytails.
  • Seeing hair break off.

What is hair loss in women?

Hair loss in women is just that—when a woman experiences unexpected heavy loss of hair. Generally, people shed from 50 to 100 single hairs per day. Hair shedding is part of a natural balance—some hairs fall out while others grow in. When the balance is interrupted—when hair falls out and less hair grows in—hair loss happens. Hair loss is different than hair shedding.

The medical name for hair loss is alopecia.

Hair goes through three cycles:

  • The anagen phase (growing phase) can last from two years to eight years. This phase generally refers to about 85% to 90% of the hair on your head.
  • The catagen phase (transition phase) is the time that hair follicles shrink and takes about two to three weeks.
  • The telogen phase (resting phase) takes about two to four months. At the end of this phase, the hair falls out.

How common is hair loss in women?

Many people think that hair loss only affects men. However, it is estimated that more than 50% of women will experience noticeable hair loss. The most significant cause of hair loss in women is female-pattern hair loss (FPHL), which affects some 30 million women in the United States.

Who is affected by hair loss in women?

Any girl or woman can be affected by hair loss. However, it is usually more common in:

  • Women older than 40
  • Women who have just had babies
  • Women who have had chemotherapy and those who have been affected by other medications
  • Women who often have hairstyles that pull on the hair (like tight ponytails or tight braids) or use harsh chemicals on their hair.

What causes hair loss in women?

Family history (heredity):  Causes thinning of hair along the top of the head. This type of hair loss is female-pattern hair loss. (FPHL is also called androgenetic alopecia or androgenic alopecia.) This type of hair often gets worse when estrogen is lost during menopause.

Hair style: Causes hair loss when hair is styled in ways that pull on roots, like tight ponytails, braids, or corn rows. This type of hair loss is called traction alopecia. If hair follicles are damaged, the loss can be permanent.

Extreme stress or shock to the body: Causes temporary hair loss. This category includes events like losing a lot of weight, surgeries, illness, and having a baby. This type of hair loss is called telogen effluvium. It happens to hair in the resting stage.

Toxic substances, including chemotherapy, radiation therapy, and some medications: Cause sudden hair loss that can occur anywhere on the body. This type of hair loss is called anagen effluvium. It happens to hair in the growth stage. Sometimes, this type of hair loss can be permanent if the hair follicles are damaged.

Other medical conditions:
Alopecia areata is an autoimmune skin disease that causes patchy hair loss on the head and possibly other places on the body. It is usually not permanent.

What is the relationship between hair loss in women and menopause?

During menopause, you might see one of two things happen with your hair. You might start growing hair where you did not have it before. Or, you might see the hair you have start to thin. One cause may be changing levels of hormones during menopause. Estrogen and progesterone levels fall, meaning that the effects of the androgens, male hormones, are increased. Other factors, such as stress, your diet, and heredity, may contribute to hair loss.

The aging process may mean that some women experience female-pattern hair loss (FPHL). This is also called androgenetic alopecia or androgenic alopecia. This type of hair loss may get worse due to hormone changes.

During and after menopause, hair might become finer (thinner) because hair follicles shrink. Hair grows more slowly and falls out more easily in these cases. FPHL often means that thinning hair is centered at the crown and top of the head.

Your healthcare provider will do a thorough examination and take a detailed history to help you deal with changes in hair growth. You may be directed to have your iron levels or thyroid hormone levels tested. Your medications might be changed if what you take is found to affect hair loss or growth.

Antiandrogens might be prescribed for either excess hair (hirsutism) or for hair loss, but the studies on usage are not clear. For hair loss, minoxidil lotion or shampoo combined with antiandrogen drugs like spironolactone is one approach. Another is to use antidandruff shampoos with ingredients like ketoconazole and zinc pyrithione. You might also be told to try things that do not actually repair hair loss but do allow you to hide it.

If you are already taking hormone therapy (HT) for menopausal symptoms, you might see an improvement in the condition of your hair. However, HT is not recommended solely to treat hair loss.

Posted in Procedures

Wound Suture

Background

When done properly wound irrigation and repair can help prevent infection and speed recovery. Remember that large volumes of low pressure water should be used for irrigation. The water does not have to be sterile! The wound is already dirty, so clean water is enough! The best option is allowing the patient to wash it out in a sink with constantly running water. Repair can help to reduce the time it takes for the wound to heal, but may increase infection risk. Healing by secondary intent is ok when you have significant concerns about infection from a dirty wound. Finally, remember to check if a tetanus shot is needed!

Consent Form

Equipment List

  1. Nitrile Exam Gloves (1 pair)
  2. Irrigation Fluid: Access to a sink, or 1 L Normal Saline or Sterile Water (1)
  3. 60 ml (or largest available) Syringe (1)
  4. Splash Guard (1) if available
  5. Wash Basin (1)
  6. Kidney Basin (1)
  7. Iris Scissors, Straight (1 pair)
  8. Needle Driver (1 pair)
  9. Toothed Pickup (1)
  10. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1)
    • 4-0 Ethilon (1)
  11. Iodine swabs (5)
  12. Alcohol Swabs (4)
  13. Sterile 4×4 gauze (10)
  14. Sterile 2×2 gauze (5)
  15. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise with epinephrine. (1 vial)
  16. 10 ml syringe (1)
  17. 18 gauge 1.5 inch needle (1)
  18. 27 gauge 1.5 inch needle (1)
  19. Exam-room sheet (1 sheet) when necessary due to location of area to be sutured.
  20. Chux pads (5)
  21. Petroleum jelly (1 tube)
  22. Dermabond (1 tube)
  23. Steri Strips (3)
  24. Paper medical tape (1 roll)
  25. Coban roll (1)
  26. Band-Aid (1) if area is small enough to be covered by Band-Aid

Procedure Note

Wound examined to ensure no foreign bodies.  Wound irrigated with large volume of clean water prior to repair.  Risks and benefits of wound closure discussed with the patient including risk of infection and potential need to remove repair in the future.  Patient indicated understanding and wished to proceed with closure.  Anesthesia achieved with subcutaneous injection of _ ml of _% lidocaine with_ epinephrine.  Wound then closed with _.  Good tissue approximation and hemostasis achieved.  Return precautions discussed.  Patient instructed to return in _ days for removal of suture.

Tips

Posted in Procedures

Shave Biopsy

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Toothed pickup (1)
  3. DermaBlade (1)
  4. ChloraPrep 3 ml stick (1)
  5. Sterile 4×4 gauze (10)
  6. Sterile 2×2 gauze (about as many as expected biopsies)
  7. Medical paper tape (1 roll)
  8. 1% or 2% lidocaine (with epinephrine) (1 vial with minimum 20 ml remaining)
  9. 10 ml syringe (1)
  10. 18 gauge 1.5 inch needle (1)
  11. 27 gauge 1.25 inch needle (1)
  12. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  13. Chux pads (1)
  14. Formalin cups (as many cups as biopsy specimens)
  15. DrySol (Aluminum chloride) (1)
  16. Sterile cotton tipped applicators (CTA) (10)
  17. Petroleum ointment (1 packet)

Procedure Note

SHAVE BIOPSY

The procedure was explained in detail and informed consent was obtained from the patient.  The area was prepped in a sterile fashion, and infiltrated with _ ml of _% lidocaine with_ epinephrine for local anesthesia.  Forceps were used to elevate the lesion and a shave biopsy was performed with DermaBlade.  The specimen was placed in a specimen jar and sent for analysis.  DrySol solution was used for hemostasis. Petroleum ointment and a bandage were applied.  EBL was less than 1 ml.  Good hemostasis.  There were no complications.  Wound care and post-procedure warning signs were discussed.  Patient voiced understanding.