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By: Jennifer Lynn Garst, MD

  • Professor of Medicine
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Musculoskeletal: Aseptic necrosis of femoral and humeral heads antibiotics for uti yahoo buy generic omnicef 300mg on line, calcinosis (following intra-articular or intra-lesional use) virus zeus generic 300mg omnicef with visa, Charcot-like arthropathy antimicrobial underwear mens generic omnicef 300 mg amex, loss of muscle mass antimicrobial wound cream for dogs discount omnicef 300mg with visa, muscle weakness, osteoporosis, pathologic fracture of long bones, postinjection flare (following intra-articular use), steroid myopathy, tendon rupture, vertebral compression fractures. Neurologic/Psychiatric: Convulsions, depression, emotional instability, euphoria, headache, increased intracranial pressure with papilledema (pseudotumor cerebri) usually following discontinuation of treatment, insomnia, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychic disorders, vertigo. Ophthalmic: Exophthalmoses, glaucoma, increased intraocular pressure, posterior subcapsular cataracts. The following adverse reactions have been reported with the following routes of administration: Intrathecal/Epidural: Arachnoiditis, bowel/bladder dysfunction, headache, meningitis, parapareisis/paraplegia, seizures, sensory disturbances. Miscellaneous injection sites (scalp, tonsillar fauces, sphenopalatine ganglion): blindness. It Should Be Emphasized that Dosage Requirements Are Variable and Must Be Individualized on the Basis of the Disease Under Treatment and the Response of the Patient. The dose for intra-articular administration depends upon the size of the joint and varies with the severity of the condition in the individual patient. The doses in the following table are given as a general guide: Size Examples Range of Joint of Dosage Knees Large Ankles 20 to 80 mg Shoulders Elbows Medium 10 to 40 mg Wrists Metacarpophalangeal Interphalangeal Small 4 to 10 mg Sternoclavicular Acromioclavicular Procedure: It is recommended that the anatomy of the joint involved be reviewed before attempting intra-articular injection. In order to obtain the full anti-inflammatory effect, it is important that the injection be made into the synovial space. Employing the same sterile technique as for a lumbar puncture, a sterile 20 to 24 gauge needle (on a dry syringe) is quickly inserted into the synovial cavity. The aspiration of only a few drops of joint fluid proves the joint space has been entered by the needle. Treatment failures are most frequently the result of failure to enter the joint space. If failures occur when injections into the synovial spaces are certain, as determined by aspiration of fluid, repeated injections are usually futile. The area around the injection site is prepared in a sterile way and a wheal at the site made with 1 percent procaine hydrochloride solution. The needle is left in place and the aspirating syringe changed for a small syringe containing the desired dose. When treating conditions such as epicondylitis, the area of greatest tenderness should be outlined carefully and the suspension infiltrated into the area. Care should be taken to avoid injection of sufficient material to cause blanching since this may be followed by a small slough. When a prolonged effect is desired, the weekly dose may be calculated by multiplying the daily oral dose by 7 and given as a single intramuscular injection. In pediatric patients, the initial dose of methylprednisolone may vary depending on the specific disease entity being treated. The recommended dosage may be reduced for pediatric patients, but dosage should be governed by the severity of the condition rather than by strict adherence to the ratio indicated by age or body weight. The usual dosage for patients with dermatologic lesions benefited by systemic corticoid therapy is 40 to 120 mg of methylprednisolone acetate administered intramuscularly at weekly intervals for one to four weeks. In acute severe dermatitis due to poison ivy, relief may result within 8 to 12 hours following intramuscular administration of a single dose of 80 to 120 mg. In seborrheic dermatitis, a weekly dose of 80 mg may be adequate to control the condition. Similarly, in patients with allergic rhinitis (hay fever), an intramuscular dose of 80 to 120 mg may be followed by relief of coryzal symptoms within six hours persisting for several days to three weeks. If a rapid hormonal effect of maximum intensity is required, the intravenous administration of highly soluble methylprednisolone sodium succinate is indicated. In treatment of acute exacerbations of multiple sclerosis, daily doses of 160 mg of methylprednisolone for a week followed by 64 mg every other day for 1 month have been shown to be effective. When these substances or their derivatives are injected intramuscularly or into joint spaces, their relative properties may be greatly altered. The chemical name for methylprednisolone acetate is pregna-1,4-diene-3,20 dione, 21-(acetyloxy)-11,17-dihydroxy-6-methyl-,(6,11) and the molecular weight is 416. Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt retaining properties, are used in replacement therapy in adrenocortical deficiency states. Their synthetic analogs are used primarily for their anti inflammatory effects in disorders of many organ systems. Dermatologic Diseases: Bullous dermatitis herpetiformis, exfoliative erythroderma, mycosis fungoides, pemphigus, severe erythema multiforme (Stevens-Johnson syndrome). Endocrine Disorders: Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; synthetic analogs may be used in conjunction with mineralocorticoids where applicable; in infancy, mineralocorticoid supplementation is of particular importance), congenital adrenal hyperplasia, hypercalcemia associated with cancer, nonsuppurative thyroiditis. Nervous System: Acute exacerbations of multiple sclerosis; cerebral edema associated with primary or metastatic brain tumor or craniotomy. Ophthalmic Diseases: Sympathetic ophthalmia, temporal arteritis, uveitis and ocular inflammatory conditions unresponsive to topical corticosteroids. Renal Diseases: To induce diuresis or remission of proteinuria in idiopathic nephrotic syndrome, or that due to lupus erythematosus. Reports of severe medical events have been associated with this route of administration. These serious neurologic events have been reported with and without use of fluoroscopy. General this product contains benzyl alcohol, which is potentially toxic when administered locally to neural tissue. Exposure to excessive amounts of benzyl alcohol has been associated with toxicity (hypotension, metabolic acidosis), particularly in neonates, and an increased incidence of kernicterus, particularly in small preterm infants. There have been rare reports of deaths, primarily in preterm infants, associated with exposure to excessive amounts of benzyl alcohol. The amount of benzyl alcohol in medications is usually considered negligible compared to that received in flush solutions containing benzyl alcohol. Administration of high dosages of medications containing this preservative must take into account the total amount of benzyl alcohol administered. Although initially sterile, any multidose use of vials may lead to contamination unless strict aseptic technique is observed. Particular care, such as use of disposable sterile syringes and needles, is necessary. In order to minimize the incidence of dermal and subdermal atrophy, care must be exercised not to exceed recommended doses in injections. Multiple small injections into the area of the lesion should be made whenever possible. The technique of intra-articular and intramuscular injection should include precautions against injection or leakage into the dermis. Injection into the deltoid muscle should be avoided because of a high incidence of subcutaneous atrophy. Rare instances of anaphylactoid reactions have occurred in patients receiving corticosteroid therapy. Cardio-renal Average and large doses of corticosteroids can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium. Literature reports suggest an apparent association between the use of corticosteroids and left ventricular free wall rupture after a recent myocardial infarction; therefore, therapy with corticosteroids should be used with great caution in these patients. Infections General Persons who are on corticosteroids are more susceptible to infections than are healthy individuals. Infections with any pathogen (viral, bacterial, fungal, protozoan, or helminthic) in any location of the body may be associated with the use of corticosteroids alone or in combination with other immunosuppressive agents. Do not use intra-articularly, intrabursally, or for intratendinous administration for local effect in the presence of acute local infection. Fungal Infections Corticosteroids may exacerbate systemic fungal infections and therefore should not be used in the presence of such infections unless they are needed to control drug reactions. Special Pathogens Latent disease may be activated or there may be an exacerbation of intercurrent infections due to pathogens, including those caused by Amoeba, Candida, Cryptococcus, Mycobacterium, Nocardia, Pneumocystis, and Toxoplasma. It is recommended that latent amebiasis or active amebiasis be ruled out before initiating corticosteroid therapy in any patient who has spent time in the tropics or in any patient with unexplained diarrhea. In such patients, corticosteroid induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia. Vaccinations Administration of live or live, attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids.

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Z-plasty is use A detailed analysis of the scar is paramount in the initial ful in changing the direction of the scar best antibiotic for sinus infection cipro buy omnicef 300 mg otc, increasing scar evaluation of the patient antimicrobial textiles 300 mg omnicef free shipping. A favorable scar is one that is nar length antibiotics for uti nhs order omnicef 300mg with mastercard, elongating a contracted scar bacteria battery omnicef 300mg lowest price, and shifting malpo row, well positioned along aesthetic subunit borders, and sitioned facial landmarks. Facial scars tend A particularly good use of Z-plasty is correcting trap to mature over time and typically continue to improve for door scars, also known as pin cushion scars. Traditionally, it has been advised to allow are formed by circular or semicircular scars, which, when scars to undergo that maturation period before pursuing they contract, tend to bunch the central soft tissue, cre any revision techniques. Correction of this involves plac iting favorable characteristics, earlier intervention after the ing small Z-plasties around the perimeter of the wound, first 60 to 90 days may be appropriate. There are a multi allowing for interdigitation of the flap with the surround tude of techniques to use when attempting to surgically re ing skin, and in effect, lengthening the circular con vise a scar. In addition, serial excisions can the same benefits are maintained as a single Z-plasty. How also be performed for a large scar that cannot be primarily ever, the resultant scar tends to be less noticeable be closed with a single definitive excision. This is most tage of the skins ability to stretch and slowly accommo useful in long scars, which require irregularization as well date over time. The classic Z-plasty is a z-shaped inci a scar less noticeable and better camouflaged. Unlike Z sion using the scar as a central member and 2 peripheral plasty, which is a transposed flap, W-plasty is an inter members of the z configuration both equal in length, form posed flap that does not create lengthening of the scar. In addition, it lengthens a con W-plasty is created by excising connected triangular units tracted scar by adding additional intervening tissue, which to break up the scar line in a regularly irregular fashion. A series of consecutive triangles are marked out along the amount of added length to the scar can be varied by the wound or scar edge. For example, angles be approximately 5 to 7 mm in length, with ideally 1 arm of 30° will provide lengthening of the contracted area by of the triangle drawn parallel to relaxed skin tension lines. A, A widened forehead scar; B, intraoperative excision and closure with running W-plasty; and C, final appearance at 6 months following W-plasty and dermabrasion. Geometric broken-line closure is a technique that creates an irregularly irregular scar using random geo metric figures as interposed flaps on each side of the excision. These geometric units are a series of squares, rectangles, and various shaped triangles placed in a random pattern. The geometry of the resultant scar is less detectable to the eye than the more predictable W-plasty. This technique is best suited for lengthier scars that traverse an aesthetic unit or broad flat sur faces such as the forehead and cheek. Like W-plasty, geometric broken-line closure is formed by interposed flaps without affecting length, as opposed to the trans posed flaps and resultant increase in length with Z-plasty. Scar irregularization techniques are typically followed by a second-stage local dermabrasion. A diamond fraise is used instead of a wire brush to Dermabrasion is a method of controlled superficial skin gain greater control of the instrument and to decrease ablation that is useful for smoothing out elevated scars the chances of abrading too deeply into the reticular and other skin contour irregularities. This not only provides a allowing the wound to re-epithelialize by the surround nerve block but also infiltrates the area, providing dis ing epithelium and underlining adnexal structures. Also, the time required to perform the cation between treated and untreated regions. Ideal candidates for dermabrasion are fair illary dermis will reveal small capillary loops easily skinned patients because there is a lower risk for dys identified by pinpoint bleeding. Some recom sion proceeds deeper, small parallel strands of white mend antiviral prophylaxis (eg, acyclovir sodium, 400 colored collagen can be appreciated, indicating the mg by mouth, 3 times daily, or valacyclovir hydrochlo appropriate depth. As mentioned previously, proceed ride, 500 mg by mouth, twice daily) against herpetic in ing deeper into the reticular dermis will lead to dam fections on all patients, regardless if they have a his age of the underlying adnexal structures, which are tory. This can lead to quires viable epidermal cells to establish infection, which unnecessary scarring. Overall, there was significant im hibits the degradation of bradykinin, a potent vasodila provement in the overall appearance of the treated scars 102 tor. Angiotensin-converting enzyme is present in tis at the 3 and 6-month follow-up examinations. They determined that both methods were of a renin-angiotensin system within human skin. This is left in place for human dermal fibroblasts suggesting its involvement in 48 hours, and after removal the patient is instructed 108 skin wound healing. Iannello et al pre after dermabrasion is posttreatment pigmentary sented 2 case reports using low-dose enalapril to treat alteration. The ery with enalapril (10 mg, once a day) and after 4 months thema is usually less of an issue for female patients, reported rapid improvement and eventual recovery of the since they can use makeup to cover up the area when keloid scar. After 6 months Overall dermabrasion is one of the oldest forms of re of low-dose enalapril therapy, there was marked im surfacing and is very effective at improving the cos 110 provement in the cosmetic appearance of the keloid. A, An acne scar of the nasal tip; B, following dermabrasion of the the major prostaglandin produced in the skin, derived nasal tip scar. This min to incisions were collectively able to show that it later corresponded to decreased collagen deposition and reduced skin scarring compared with the controls. One study in par hibitors on full-thickness incisional wounds using a mouse ticular showed significant differences in collagen model and was unable to show a significant effect on the organization, with the avotermin-treated scars more morphologic features of the wound. One group hyperplasia and keratinocyte proliferation during heal received avotermin at 50 ng/100 µL per linear centime ing, it appears to be dispensable for proper healing be ter and group 2 received avotermin at 200 ng/100 µL per cause of redundant mechanisms. They deter gesting that inhibition may cause delayed wound heal mined that avotermin at 200 ng/100 µL per linear cen ing. Of the avotermin-treated scar segments, involved in wound healing, including lymphocytes, neu 74% were histologically more similar to normal skin com trophils, macrophages, and fibroblasts. A con placebo in addition to an overall improved scar appear sistent difference has been demonstrated among the dif ance. The most recent of phase 2 clinical trials with avoter ferent isoforms between adult and fetal wounds. Intralesional 5-fluorouracil in the treatment of keloid without any further sequalae. Intralesionaltriamcinolonealoneorincom ties of itching, pain, or edema reported between the avoter bination with 5-fluorouracil for the treatment of keloid and hypertrophic scars. New combination of triamcinolone, 5-fluo rouracil, and pulsed-dye laser for treatment of keloid and hypertrophic scars. Intralesional5-fluo A number of therapeutic strategies have been developed rouracil in the treatment of keloids: an open clinical and histopathologic study. Sometimes despite bined intralesional 5-fluorouracil and topical silicone in prevention of keloids: one’s best efforts, an optimal outcome may not occur. Imiquimodappliedtopi tively with realistic goals clearly stated by the surgeon is cally: a novel immune response modifier and new class of drug. Postsurgical use of imiquimod 5% cream in aforementioned techniques can provide the surgeon with thepreventionofearlobekeloidrecurrences:resultsofanopen-label,pilotstudy. Failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids. Effect of Mederma on hypertrophic scar Author Contributions: Study concept and design: Thomas ring in the rabbit ear model. Analysis and interpretation of data: Thomas and Some ment for postsurgical scars. Intradermalbleomycininjectionsinto Online-Only Material: this article is featured in the normal human skin: a histopathologic and immunopathologic study. Bleomycin, an apoptosis mimetic drug that induces two types of cell death depending on the number of 1. Treatment of keloids and hypertrophic scars with dermojet sponse to intralesional steroid therapy. Silicone sheeting decreases fibroblast scars using early pulse dye laser treatments: a preliminary report. Occlusionregulatesepidermalcytokineproduction ser in the treatment of surgical scars starting on the suture removal day. Silicone sheet for treatment and prevention of hypertrophic scar: a Control of hypertrophic scar growth using selective photothermolysis.

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There is also a glossary at the end of the Handbook for scientific or medical words used frequently in the Handbook which would not be included in a standard English glossary virus 10 purchase omnicef 300 mg free shipping. Anaerobic exercise is a short burst of high intensity effort infection trichomoniasis order 300mg omnicef amex, such as a sprint for a bus antibiotic resistance hospitals discount omnicef 300 mg mastercard. However virus zone discount omnicef 300mg without prescription, only a small amount of glucose is present in the muscle cells and this is used up within a few minutes of anaerobic exercise. In people unaffected by McArdle disease, the process of converting glycogen into glucose requires several enzymes, one of which is called “muscle glycogen phosphorylase”. McArdle disease is caused by the lack of the muscle glycogen phosphorylase enzyme in muscle cells. In McArdle people, muscle glycogen phosphorylase is either absent or not functional. The short term lack of glucose causes tiredness and stiffness in muscles of McArdle people when they carry out anaerobic exercise (Rommel et al. A period of rest is necessary because these other methods are slower to produce energy than glycogenolysis (the method which normally involves muscle glycogen phosphorylase). This can lead to breakdown of muscle cells (rhabdomyolysis) and muscle cramps (contractures), both of which cause McArdle people to experience muscle pain. Following rhabdomyolysis, the components of the broken muscle cells are released into the bloodstream. The components of the broken muscle cells are transported through the bloodstream to the kidneys. Myoglobin is transported in the bloodstream to the kidneys, where it is removed from the body in the urine, resulting in dark red/cola coloured urine (known as myoglobinuria or proteinuria). A rare, but serious effect of extreme muscle damage is that broken muscle cells may block the filtration system of the kidneys, preventing them working, and resulting in kidney failure (Martin et al. McArdle disease is caused by the absence of the muscle glycogen phosphorylase enzyme (Mommaerts, 1956; Schmid et al. An enzyme is a protein which has a special function of changing or breaking down one compound to another. The muscle glycogen phosphorylase enzyme breaks down glycogen into glucose-1-phosphate. If a mutation occurs in the enzyme which prevents it from functioning, it will result in an inability to break down glycogen and its components to form glucose. The major symptom of every glycogen storage disease is an intolerance to exercise. Phosphorylase b kinase is essential for activation of the muscle glycogen phosphorylase enzyme. McArdle disease is named after Dr Brian McArdle, the British family doctor who first published a paper describing a patient with the disease. In 1951, Dr McArdle described a 30 year old male patient for whom light exercise caused pain in the muscles, and continued exercise led to weakness and stiffness. Pain during exercise would occur in any muscle in the body – the most noticeable being in the arms or legs. The pain would force the patient to stop and rest, but it was noted that after a period of rest, the patient was then able to exercise further. Dr McArdle realised that after exercise the lactate level of the patient did not increase as expected, and that glycogenolysis was incomplete. He also noticed that the patient’s muscles were very weak even though they had quite a large bulk. His astonishingly perceptive theory was that “it is the enzyme system that is at fault it seems that the patient has a disorder of carbohydrate metabolism during exercise a change took place in the muscle chemistry which effectively led to a breakdown in glycogenolysis” (McArdle, 1955). He tested the different enzymes involved in the breakdown of glycogen and identified the cause of the disease as the loss of the ability to produce glucose-1-phosphate, because muscle glycogen phosphorylase wasn’t functional. It may be called MacArdle’s, but this is incorrect because it is named after Dr Brian McArdle. This is my suggestion of how I would describe it to friends and family who haven’t heard of McArdle disease before: “Your muscles use glucose to provide energy to move. There isn’t much glucose in your muscles, so after a couple of minutes of vigorous (anaerobic) exercise, the glucose is all used up. There are also stores of glycogen in the muscle, and there is an enzyme called “muscle glycogen phosphorylase” which normally changes the glycogen into glucose, which gives the muscles more energy to continue to exercise. In people with McArdle disease, this enzyme doesn’t work, so the muscles run out of 15 energy and can’t get any more. If the McArdle people continue to exercise, the muscles basically “starve” and can be damaged. However, if the McArdle person rests for a short period, the muscles can get energy from glucose in the blood or from other sources, such as fat which is stored in the body. In the 60 years since Brian McArdle published the first paper describing McArdle disease, a lot of research into understanding McArdle’s has been done (as outlined in this Handbook). In the shorter term, there are some excellent specialists who are highly knowledgeable about McArdle’s and can offer up-to-date advice on diet and exercise for people with McArdle’s. The internet has also enabled people with McArdle disease to compare symptoms and advice and to provide support with others around the world through online patient support groups. Research into improving everyday life with McArdle’s is ongoing, including investigating whether other genes (phenotype modulators) may have an effect upon the severity of symptoms. In the longer term, many different avenues for treatment are being considered, including correcting the expression of muscle glycogen phosphorylase which contains a mutation, or replacing it with the brain glycogen phosphorylase enzyme. Children with McArdle’s have great difficulty in carrying out activities such as cross country running if their teacher does not allow them to rest and get into a second wind. Outside of school, many McArdle children and adults will have developed coping mechanisms to allow themselves to rest without other people noticing. These techniques could include frequently pretending to tie up their shoelace, stopping to look in shop windows, or pretending to use a mobile phone. Some McArdle people will have discovered the “second wind” phenomenon; they will have learnt that if they rest when they feel muscle pain, they are then able to continue to exercise for a much longer period of time. Some McArdle people will not have experienced the “second wind” phenomenon, but all are able to experience it if taught (Quinlivan and Vissing, 2007). Most McArdle people will have experienced contractures (stiff, contracted, enlarged muscles), often following more intense exercise. Examples of exercise which is likely to lead to contractures includes intense activity such as running for the bus, repetitive activity such as chewing or peeling potatoes, or an activity where the muscles hold the body in one place for a long time such as squatting or some yoga positions. Some McArdle people will have experienced dark red/cola coloured urine, which is particularly likely after a muscle contracture. Some McArdle people will have attended a hospital emergency department because of the cola coloured urine and contractures. McArdle people typically find that a very sedentary lifestyle makes it more of a struggle to perform any exercise. However, at the other extreme, intense exercise can make the muscles very painful, forcing the McArdle person to rest for many days while the muscles repair and recover. After this period of time, they may then find that exercise is harder and the muscles feel weaker than before. For most McArdle people, the symptoms remain similar throughout their life, although some muscle weakness may occur as they get older. The above description is a combination of information published by Quinlivan and Vissing (2007), Lucia et al. Taken from published papers (references in brackets) and personal communication with McArdle people (unreferenced). Exceptions include some reported cases of late-onset symptoms, which are discussed further in section 8. Differences in severity of symptoms have been reported, and possible explanations are discussed in section 9. Very common symptoms of McArdle disease (seen in almost all McArdle people): Exercise intolerance; muscles becoming tired very quickly and running out of energy (Lucia et al. Muscle pain during intense exercise will usually have existed since childhood (Quinlivan and Vissing, 2007). Some people with McArdle’s are able to experience a “second wind”: They will exercise gently to warm up, and rest when they feel pain. It should be noted that a “second wind” is unique to McArdle disease (Lucia et al. However, many McArdle people do not know how to get into a 18 second wind or do not realise that this is occurring unless guided through it by a family doctor or specialist (Quinlivan and Vissing, 2007).

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Often with oily skin virus jewelry 300 mg omnicef for sale, cells that should be shedding on a regular bacteria 0157 omnicef 300mg free shipping, daily basis are being held back virus living or not purchase 300 mg omnicef. The oil works as an adhesive virus zombie 300 mg omnicef free shipping, preventing the shedding skin cells from going where they are supposed to go—off the face. One way to keep pores from getting clogged is to help skin cells shed as freely as possible so they don’t get trapped inside the pore. The more you keep skin cells exfoliating in a normal manner, the less cell debris can fll up the pore. Another issue for oily skin with clogged pores is that the oil gland itself has a skin lining (epithelial lining). For some reason, this lining inside the pore can become thickened or misshapen and choke off and block the fow of oil out of the pore. Using exfoliants that can exfoliate the lining of the pore, thus restoring a more natural shape, can encourage a normal fow of oil and eliminate clogged pores. ExfoliaTing dry Sk i n the reasons for exfoliating dry skin are different from the ones for treating oily, blemish prone skin, though the objective is the same: removing dead skin cells that are not shedding normally. Skin can be dry for many reasons, including lack of moisture, a buildup of dead skin cells that don’t easily shed, and abnormal skin cells that adhere together in a way that prevents normal exfoliation and normal moisture retention. When this happens, the surface of the skin feels “greasy” or moist, and the underlying layer feels dry. This also allows moisturizers to more easily pen etrate the skin because there are fewer dried-up skin cells in the way to block absorption. Exfoliating helps the dead, surface-skin cells shed at a more normal rate, making room for the lower layers of newer skin cells. And for dry skin it is also helpful to effciently remove dead skin cells to reduce the chance of pores becoming clogged and creating blackheads and whiteheads. This thickened layer is your skin’s response to the damage caused by unprotected exposure to ultraviolet radiation from the sun. This thickened outer layer of the skin produced by sun damage causes skin to look dull and more wrinkled than it really is; it also adds a yellowish or gray tint to skin and reduces the ability of good skin-care ingredients to penetrate. Using effective topical exfoliants to remove this thickened, unattractive outer layer of skin can help skin feel smoother, look less wrinkled, have a healthier, more normal skin color, and reduce the chance of clogged pores. Though it is always imperative to use a sunscreen, it is even more so if you are regularly using an exfoliant of any kind. As I look over the material and research I’ve accumulated, from magazine articles and books on botanicals and herbal ingredients to medical and scientifc journals, as well as from interviews with dermatologists, oncologists, and cosmetics chemists, I am amazed at the depth of information available on skin and skin care. It is also mind-boggling to real ize how many thousands of products you can choose from when it comes to everything from cleaning the face, to protecting skin from the sun, moisturizing, fghting blemishes, or treating a large number of skin problems. You wouldn’t think that taking care of your skin could be so complicated or shrouded in such controversy, but the truth is, it is very complicated. Despite being such a small part of the whole body, the face has the lion’s share of topical problems, far more than those that take place from the neck down. Acne, wrinkles, sagging, sunburn, blackheads, dryness, rosacea, eczema, psoriasis, seborrhea, dry patches, swelling, and allergies, not to mention the impact of our concepts of beauty, are most evident on the face. There is a lot of money to be made if a cosmetics company can get a consumer to believe that their product(s) will make her more beautiful and do something to tackle one or more of those facial dilemmas. If a company can make the stuff sound utterly unique for the skin, even when it isn’t, the sales fgures rise astronomically. As complicated and emotional as skin care can be, the actual skin-care routines can be streamlined and concise. Yet the details in each category are tricky because there is a lot you have to unlearn and then relearn. By now you have an overview of what works (such as being gentle, using sun protection, exfoliating, and what antioxidants, skin-identical ingredients, and cell-communicating ingredients do). You also know what doesn’t (such as one special ingredient, jar packaging, eye creams, exaggerated claims, certain natural or exotic ingredients, and all essential oils) when it comes to cosmetics claims and various skin-care ingredients. If you’ve gotten this far in the book (and haven’t skipped chapters) you are also aware of how the cosmetics industry may be damaging your skin and what current research is reveal ing about optimal skin care. The next step is to arrange all these data in a way that helps you fnd an effective skin-care routine so you can stop wasting money on useless products that may be hurting your skin. This section reviews how those steps work, why they are important, and how the industry distorts their purpose or makes it diffcult to know what to choose. Cl e a n i n g t h e Sk i n No other aspect of skin care is quite as basic as this one. Cleaning the face sets the stage for everything else that will take place on the skin. More so than any other part of your skin-care routine, it is essential that the cleansing products you use be gentle. Over-cleaning or using cleansers that are too drying or that strip the skin are major causes of irritation, dry patches, and redness. Not cleaning the skin well enough can clog pores or leave a residue on the face that can prevent skin cells from sloughing off. Using a cleanser that leaves a greasy flm on the face can clog pores and prevent moisturizers from being able to be absorbed and do their job. It is essential to get this step right, and that means thoroughly, but gently, cleaning the face. My preference is to recommend that all skin types start with using a gentle, water-soluble cleanser. I’ve already explained how important being gentle is, but just to reiterate: Irritating and infaming the skin triggers a cascading chain reaction that can include increased oil production, faky dry skin, depletion of collagen, and other factors that “age” skin. However, wiping at the face is a problem because tugging on the skin damages the elastin fbers in skin, increas ing the potential for sagging, especially around the eyes. Washing your face with a water-soluble cleanser reduces pulling (the water cuts friction), and most if not all of the makeup is rinsed down the drain. Then if you still need a makeup remover it would only be for touch-up, causing minimal pulling. Using the right cleanser makes all the difference in the world because it determines how your skin is going to react to everything else you put on it. Greasing up your skin with a wipe-off, cold cream–type cleanser can clog pores and leave a flm on the skin, which means all the other products you put on will be sitting on top of that instead of being eas ily absorbed. Using a cleanser that is overly drying in the hopes of treating oily skin or blemishes absolutely won’t work. The irritation and barrier damage to skin impede healing, increase acne-causing bacteria in skin, and increase oil production because irritation stimulates oil production. Using a gentle, water-soluble cleanser is the best option for the entire face, and this is true for all skin types. It washes off makeup without leaving the face dry (like soaps) or greasy (like cold cream), or drying skin, as liquid cleansers can sometimes do; 2. It contains no obvious fragrance (even though the fragrance ingredients would quickly rinse off the face, any potential for needless irritation should be avoided), or abrasive, scrublike particles (scrubs should be used carefully and judiciously, not as part of cleaning the skin twice a day); and 3. It matches your skin type, meaning it should be more emollient for dry skin and provide more thorough cleansing (not drying and irritating) for oily/combination skin. Some cleansers on the market are labeled “water soluble,” but in actuality they need to be wiped off with a wet washcloth. If the cleanser must be wiped off with a tissue or washcloth, it need not be a problem but it would only be an option for someone with dry skin. Water-soluble cleansers are not only the gentlest way to clean the face, they are also the most effcient. Imagine splashing your face generously with (tepid) water, then massaging a water-soluble cleanser on evenly over your face, including the eyes, and then rinsing it off with more water, preferably with your hands. Second, when cleansers do contain some bells and whistles to make you think you’re getting something special, those ingredients would just be rinsed down the drain without ever getting a chance to be absorbed and provide a beneft on the skin. In my book Don’t Go to the Cosmetics Counter Without Me, 7th Edition, and on my Web site, Summary: Use only water-soluble cleansers that rinse off completely when water is splashed on the face, leaving the face with a clean, soft feeling that is neither dry nor greasy. Basic directions: Wash your hands frst and then splash the face generously, including the eyes, with tepid water (not hot or cold).

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