Homemade Skin Care Recipes

Skintervention Guide: Purely Paleo Skincare

The Skintervention Guide contains more than 200 pages of downloadable, Fully Digital information that will radically change the way you think about skincare, body care, and everything in-between. For just $37 the key to natural skincare and a beautifully radiant body is at your fingertips. Heal Acne, Eczema, Scarring, Skin, Hair, And Nail Problems Naturally! Great Skin And A Beautiful Body Starts From The Inside. A Guide To Paleo And Primal Nutrition, Digestion, And The Right Routine For Gorgeous Skin And Body. As an added bonus, youll receive two Extra downloads: Skintervention Guide Easy Recipes to kickstart your journey, and Skintervention Guide Resources where I share all my fave goodies (North America-based) to pamper your skin naturally. Not only that, but you receive lifetime updates to the guide And access to my password-protected Online resource guide! Thats over 200 pages of in-depth, quality content; Bonus Guides, online support, and a lifetime of updates! Heres what I will share with you: The nutrients you need for beautiful skin, lovely hair and a radiant bodyand where to find them. Unexpected super-foods that are critical for skin wellness (conventional wisdom not welcome!) Why almost everyone needs digestive helpand how to get it. How to get nutrients where they need to go. The best products on the planet for cleansing and nourishing the skin (hint: there are NO unpronounceable ingredients or unnecessary chemicals!) Alternatives to conventional makeup, hair dyes and hair care products. Strategies for improving cellulite and tips for smart intimate and feminine care. How to ditch toxins in food, in your body, and in your body care routine! Read more...

Skintervention Guide Purely Paleo Skincare Overview


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Author: Liz Wolfe
Official Website: purelyprimalskincare.com
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Leons Anti-aging Beauty Secrets

Leons Anti-Aging Beauty Secrets provides useful tips for women on anti-aging and skin care. This book reveals interesting ancient beauty secrets, talks about anti-aging diet, and provides easy-to-make natural recipes for home skin care. Learn how to use Essential and Carrier Oils to make your own Anti-aging Serums that rejuvenate, revitalize and brighten your complexion. Make your own Alpha Hydroxy Facial Masks to deal with Dull, Blotchy, Lifeless and Wrinkled Skin. Dont you want to know what women in other countries have been using for generations to keep themselves young and gorgeous? Discover the Anti-aging Secrets of women across the Globe. Learn how these easy Facial Exercises can reduce your Laugh Lines, Puffy Eyes, Wrinkles and improve your overall Skin Tone. Make Your own Eyelash Growth Serum using some Carrier Oils and get Longer, Darker and Thicker Eyelashes in less than a month. Learn Gemstone Therapy For Aging Skin and Make Your Own Gemstone Elixir. Read more...

Leons Antiaging Beauty Secrets Overview

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Antigen Identification

The antigens recognized by human tumor reactive T cells can be categorized according to their expression profiles in normal tissues and tumors. The differentiation antigens are limited in their expression in the adult primarily to one tissue type and are dominated by the melanocyte differentiation antigens (MDA), which represent gene products that are expressed in melanomas as well as normal skin melanocytes and retinal

Facial Acne in Adults

A total of 3,394 women completed the questionnaire of which 3,305 were useable. Prevalence of acne was 41 in adult women. In 17 of the cases, it was 'clinical acne' -with 6.2 inflammatory lesions as a mean - and in 24 'physiological acne' - with 1.3 inflammatory acne lesions as a mean. 97 and 94 , respectively, admitted that they used to scratch or squeeze their 'pimples'. 49 of women with 'clinical acne' had acne sequelae, i.e. scars and or pigmented macules. 34 of women with 'clinical acne' had not experienced acne during their adolescence. A premenstrual flare was recorded in 78 of women with 'clinical acne'. The adult females with acne reported a significantly more oily or mixed type than the non-acne group, sensitive skin was slightly more prevalent in the acne (71 ) and physiologic acne group (68 ) than in the non-acne group (64 ). The sensitivity of the skin to sun was no different among the 3 groups. Smoking, stressful lifestyle and professional occupation were not different...

Preoperative abnormalities

Delay in the relaxation phase of reflexes, dry skin, a husky voice, loss of the outer part of the eyebrows, and weight gain. In severe disease there is lethargy, bradycardia, hypothermia, and respiratory depression. Deposition of a mucinous substance causes thickening of the subcutaneous tissues producing a nonpitting oedema. Myxoedematous infiltration of the vocal cords and tongue can occur. Cardiovascular complications include ischaemic heart disease, bradycardia, pericardial effusion, and cardiac failure (Gomberg-Maitland & Frishman 1998). Neurological complications may involve carpal tunnel syndrome, polyneuritis, myopathy, and cerebellar syndrome.About 70 of patients have paraesthesia or sensory neuropathy. Psychiatric disturbances may predominate.

Treatment of eczema and inflammatory dermatoses

Dry skin tends to be itchy, so advise minimal use of soap. Emollients are used to soften the skin, and the simpler the better. Emulsifying ointment BP is cheap and effective but rather thick. By mixing two tablespoons in a kitchen blender with a pint of water, the result is a creamy mixture that can easily be used in the bath. A useful preparation is equal parts of white soft paraffin and liquid paraffin. Various proprietary bath oils are available and can be applied directly to wet skin. There are many proprietary emollients.

Management And Prognosis

Maintenance of adequate nutrition and hydration is of outmost importance. Parenteral nutrition is usually required because of the likely length of the disease and the undesirability of oral or nasogastric feedings. Adequate nutritional support can minimize weight loss, maintain electrolyte balance, and improve management of arrhythmias. Attention must be paid to skin care, and excretory functions must be monitored closely for urinary retention or serious constipation. Patients must be immunized with tetanus toxoid to prevent further disease. Tracheostomy may be required to prevent laryngospasm, which greatly increases the mortality rate of the disease.

Family Medical History

'In your family - that is, your parents, brothers and sisters - are there any health problems that seem to run through the family ' You may prompt with suggestion such as diabetes, hypertension, and skin problems. This gives you information about predisposition, especially with diabetes and skin problems, and helps with differential diagnosis and may be a contributing factor in the reason for the visit, as for example with impotence or recurrent vaginal candidiasis.

Skin and mouth problems

Many skin problems occur in patients with HIV infection (Box 4.5). These may represent exacerbations of previous skin disease, or a new problem. Identical skin conditions occur in HIV-negative persons. However, in the immunocompromised, these common conditions may be more severe, persistent and difficult to treat. Many minor opportunistic infections (Group IVC2) manifest themselves on the skin and in the mouth. Seborrhoeic dermatitis is frequently seen and usually presents as a red scaly rash affecting the face, scalp and sometimes the whole body. This condition often responds well to 1 hydrocortisone and antifungal cream.

Risk of progression and the value of surrogate markers

Patients who may need close monitoring include individuals whose CD4 count falls below 350 cells mm3, those with a rapidly declining CD4 count, those with a rising viral load and patients who are symptomatic as they may all be candidates for antiretroviral therapy. Patients who present with persistent constitutional symptoms, mouth or skin problems should be considered for antiretroviral therapy irrespective of CD4 count and viral load. These issues are discussed further in the chapters on treatment of infections and antiretroviral agents.

Changes In M0 Tsp1 Expression Levels Influence Tumor Neovascularization

Direct evidence implicating inflammatory M0 and or dermal dendritic cells in psoriatic angiogenesis are not as clear. However, Polverini and Nickoloff (unpublished data) have found that dermal dendritic cells isolated from psoriatic and symptomless skin as well as human monocyte-derived M0 and dendritic cells from normal skin when exposed to conditioned media from psoriatic keratinocytes potently express angiogenic activity, as one might predict. Interestingly, when TSP1 levels in these M0 or dendritic cells were examined and compared to dendritic cells derived from symptom-less or normal skin, TSP1 was virtually undetected. These observations therefore suggest that inflammatory M0 and perhaps dermal dendritic cells can be activated by psoriatic keratinocytes to express angiogenic activity and interfere with their ability to express sufficient levels of TSP1 that would enable them to counterbalance their heightened vasoproliferative activity.

Migration Of Dcs Cells In The Steady State For Tolerance Induction

A closer look into the cytoplasm of veiled cells shows that they are not traveling empty but carry antigens or apoptotic cells derived from the tissue from which they were originating. Many years ago, epidermal LCs were shown to contain melanosomes when emigrating from healthy skin (38), and, more recently, it was shown that this transport of melanosomes decreases in the absence of TGF- 1-dependent LCs (39). Mucosal LCs have also been reported to capture apoptotic epithelial cells in the vagina and cervix (40). In the rat afferent lymph draining from the gut, a subpopulation of DCs contains apoptotic material from their sentinel tissue, which is brought into the mesenteric lymph node (41). Self antigens are transported to the draining lymph node from the pancreas (42) and stomach (43). Also, cells undergoing apoptosis and entering the lymph node through the lymphatics can be captured by lymph node resident DCs for self-antigen presentation (44,45). As no foreign antigens are present...

The Harvesting Process

Clearly, it is important to distinguish between types of onions and their subsequent use for long- or short-term storage when interpreting the results of maturity-date trials. Local practice may vary according to whether optimum yield or a good appearance out of storage is the principal requirement. The timing of harvesting should be decided according to the importance of these considerations relatively early harvesting favours better skin retention while later harvesting maximizes yields.

Stump Preparation for a Prosthesis

Stump Crutch

Effective means of conditioning lower limb stumps and also of encouraging the patient psychologically. Thomas and Haddan, however, believed this was unnecessary in civilian practice, for a permanent limb could be fitted within a few weeks, and shrinkage countered by adding stump socks, and making a new socket if required, only needed for some 25 of amputees in the United States. Stump hygiene was vital by daily washing and change of socks, by exposure to fresh air as much as possible, by reducing friction and by using talcum or lanolin for dry skin.43

New Developments and Future Trends

Leukotrienes Inflammatory Mediators

Additional results have shown that the sebaceous gland expresses a number of different cytokines at steady state, without the influence of any external factors. Antilla et al. 104 showed that IL-1 is present in normal sebaceous glands and Boehm et al. 105 used in situ hybridization techniques to show that messenger RNA (mRNA) for IL-1a, IL-1P and tumor necrosis factor-a is present at multiple sites in normal skin including the sebaceous glands. Thus, while the presence of bacteria, most notably P. acnes, may stimulate upregulation of cytokine expression in sebaceous glands 106 , pro-inflammatory cytokines are expressed in these tissues in the absence of defined external influences.

Lumbar and sacral radiculopathy

Atrophy Paraspinal Muscles Image

Motor involvement following sacral herpes S 1 on the right side. The vesicles can no longer be seen. A Right sided gluteal weakness with loss of muscle definition on the right compared to the intact left side. B Discrete dry skin changes over the right half. C Note the skin over the plantar right foot, which appears to be wrinkled compared to left side (atrophy of the small foot muscles)

The Quest For Immortality

But so far, all attempts at physical rejuvenation have failed. Many such attempts date back to the turn of the early 1900s and involved the use of concoctions, potions, and even radioactive cocktails, often with disastrous results. One such concoction, popular in the 1920s, was Tho-Radia, a skin cream containing thorium and radium, two radioisotopes discovered by the great French physicist Marie Curie. The radioactive material was supposed to have an antiaging effect on the skin, but their use was abandoned when Curie and other scientists working with radioisotopes began having serious medical problems. Madame Curie developed cataracts, kidney failure, and a fatal leukemia, all from overexposure to radioactive materials.

Umbilical Artery In Adults

Alcohol Absorption Pics

Percutaneous alcohol absorption with resultant erythema and burns to the buttocks of a premature infant. During placement of an umbilical arterial catheter, alcohol or iodine may track down the sides of the abdomen and soak the underlying sheet. Evaporation is restricted from the skin in contact with the underlying sheet and this may result in irritation, erythema, and severe burns, especially in a premature infant with very sensitive skin. Figure 7.9. Percutaneous alcohol absorption with resultant erythema and burns to the buttocks of a premature infant. During placement of an umbilical arterial catheter, alcohol or iodine may track down the sides of the abdomen and soak the underlying sheet. Evaporation is restricted from the skin in contact with the underlying sheet and this may result in irritation, erythema, and severe burns, especially in a premature infant with very sensitive skin.

Incisional biopsy and punch biopsy

Skin Lines

This is suitable for larger lesions and is taken across the margin of the lesion in the form of an elipse. It is essential to include deeper dermis, as the significant changes in, for example, granuloma or lymphoid infiltrate may not be near the surface. An adequate amount of normal tissue should be included, so this could be compared with the pathological area and this also means there is enough normal skin to suture the incision together.

Preoperative management

Immediate management should also include attention to palliation and skin care, nutrition, physiotherapy, rehabilitation and overall patient morale. Surgical fistula patients are usually previously healthy individuals who entered hospital for what was expected to be a routine procedure, and end up with symptoms infinitely worse than their initial complaint. Obstetric fistula patients in the developing world are social outcasts. Whatever the cause, these women are invariably devastated by their situation. It is vital that they understand the nature of the problem, why it has arisen, and the plan for management at all stages. Confident but realistic counselling by the surgeon is essential and the involvement of nursing staff or counsellors with experience of fistula patients is also highly desirable. The support given by previously treated sufferers can also be of immense value in maintaining patient morale, especially where a delay prior to definitive treatment is required.

Picture Of Skin Dimpling

A pigmented skin dimple over the left shoulder. Normal skin dimples in general tend to occur in areas where the skin is relatively tightly bound to the underlying bony prominences. Figure 1.61. A pigmented skin dimple over the left shoulder. Normal skin dimples in general tend to occur in areas where the skin is relatively tightly bound to the underlying bony prominences.

Other Dermatologic Problems

Infants With Abnormal Big Head

The typical facies of hypohidrotic (anhidrotic) ectodermal dysplasia is seen in this infant. Note the alopecia, absent eyebrows and eyelashes, square forehead with frontal bossing, hyperpigmented wrinkles around the eyes, flattened nasal bridge, and large conspicuous nostrils. There are wide cheek bones with depressed cheeks, thick everted lips, a prominent chin, and the ears may be small and pointed. These infants have a thin dry skin, decreased sweating, decreased tearing, and abnormal dentition. The nails are defective in a large percentage of these patients in that they may be thin, brittle, or ridged. If the absence of the sweat glands is generalized, they may have recurrent fever in high environmental temperatures.

Sebaceous Glands in Acne

Pathogenesis Acne

It is generally accepted that sebaceous glands were not innervated and the peripheral nervous system has no effect on the sebaceous biology. Indeed, nerve fibers, as documented immunohistochemically using the general neuronal marker PGP 9.5, were rarely observed around the sebaceous glands in normal facial skin. In contrast, facial skin from acne patients shows numerous fine nerve fibers not only around but also within sebaceous acini 19 . Numerous nerve endings were also observed in close apposition to the sebaceous glands ultrastructurally. Such increase in the number of nerve fibers, some of which are even invading into sebaceous acini, may result from increased expression of NGF on the sebaceous glands of acne-prone facial skin since NGF is essential for the survival, development, differentiation and function of peripheral sympathetic and sensory neurons, and acts as a neurotrophic molecule stimulating the sprouting of nerve fibers also in the skin 20 . Immunohistochemical study...

Convex Triangular Foot Hallux Valgus And Quintus Varus

Foot Varus

The diabetes had been adequately controlled but the patient was already exhibiting signs of diabetic complications, such as background retinopathy and neuropathy. On examination, she had a right convex triangular foot, with an ulcer under the head of the fifth metatarsal head following callus formation at this site (Figure 3.15). She had symptomatic diabetic neuropathy, exemplified by a burning sensation in the feet, which was especially exacerbated at night peripheral pulses were palpable and the ankle brachial index was 1.0 bilaterally. Small muscle atrophy of the feet was noted, as well as dry skin and loss of feeling of a 5.07 monofilament vibration perception threshold was 30 V.

Necrosis and renal impairment

Fig. 6.9 A small split in dry skin on the border of the foot of a patient in end-stage renal failure treated with haemodialysis is becoming necrotic. Fig. 6.9 A small split in dry skin on the border of the foot of a patient in end-stage renal failure treated with haemodialysis is becoming necrotic. Necrosis can occur in diabetic renal patients with palpable pulses in the absence of severe peripheral arterial disease and in the absence of infection. An apparently small and trivial trauma such as a small split in dry skin (Fig. 6.9) or a tight nail sulcus will frequently lead to necrosis which then spreads (Fig. 6.10). Necrotic lesions often become rapidly infected in diabetic patients with renal failure.

Feckless patient with endstage renal failure

Causes of trauma included blisters from ill-fitting shoes, picking at dry skin, pulling off pieces of nail and being 'trodden on by a baby'. In the last episode she stubbed her toe while walking barefoot, did not report the injury and presented late to the renal unit with spreading cellulitis, wet necrosis and

The significance of skin disease

The skin is not only the largest organ of the body, it also forms a living biological barrier and is the aspect of ourselves we present to the world. It is therefore not surprising that there is great interest in skin care, with the associated vast cosmetic industry. The impairment of the normal functions of the skin can lead to acute and chronic illness with considerable disability and sometimes a need for hospital treatment.

The curing process

During curing, the thin outer layers of the bulb are dried to form one or more complete dry skins, which act as a barrier to water loss and microbial infection. Ideally, the dirty outer skins can be removed after storage to show a clean, intact, inner dry skin before retail sale. Even for fresh-market onions, at least one complete skin should be present.

Ovarian Ablation

For premenopausal women with receptor-positive disease, medical or surgical castration is also an effective approach to hormonal therapy. The endocrinologic effect of castration is achieved by two analogs of gonadotropin-releasing hormone, goserelin and leuprolide, which suppress follicle-stimulating hormone and luteinizing hormone, and thus estrogen production by the ovary.62,63 Either agent will achieve the same benefit as oophorectomy, that is, a 45 percent likelihood of disease regression or stabilization, but require parenteral administration on a monthly or tri-monthly basis. Side effects are limited to pain at the injection site and menopausal symptoms such as hot flashes, mood swings, and dry skin. Once disease progresses after either medical or surgical castration, the alternate approach has little chance of benefit. Obviously, castration by either technique can only be of benefit to pre-menopausal patients, where the ovary is the primary site of estrogen production.


On examination, she had findings of severe neuropathy (no feeling of light touch, pain, temperature, vibration or a 5.08 monofilament Achilles tendon reflexes were absent the vibration perception threshold was > 50 V in both feet). Peripheral pulses were weak and the ankle brachial index was 0.7. Dry skin and nail dystrophies were present. A superficial ulcer with a sloughy base was seen on the dorsum of

Surgical treatment

Freezing warts with liquid nitrogen is a rapid method of treatment. It is contraindicated in small children, since it is frequently associated with intense pain secondary to oedema under the nail bed. Application of a surface anaesthetic cream 1-2 hours prior to therapy does not help to reduce pain in the periungual region. Hyperkeratotic warts should be pared off before treatment to permit freezing of the deeper portions of the wart. Freezing takes 10-15 seconds using cryogen spray. A 1 mm halo ring should form in the normal skin surrounding the wart. Cryosurgery should be used with caution for warts on the proximal nail fold, since nail matrix damage is a common complication, with leukonychia, Beau's lines and onychomadesis. Irreversible matrix destruction with nail atrophy has been reported after overzealous cryosurgery.

Figure 545

These usually disappear before the patient presents to the doctor. Confluent eczematoid changes cover the skin immediately adjacent to the distal edge of the nail. The affected area is pink or of normal skin colour and densely studded with fine scales there is a clear margin between the normal and affected areas. The skin changes may extend to the dorsal aspect of the finger or toe, but usually only the finger tip is affected. The most striking and characteristic change is the hyperkeratosis beneath the nail tip. The nail plate is lifted up, deformed and often thickened. Commonly the deformity produced is asymmetrical and limited to one corner of the distal edge, or at least more pronounced at the corners of the nail. Pitting occurs in some cases rarely, transverse ridging of the nail plate is present. In most cases the condition resolves within a few months, but in some cases it may persist for many years, even into adult life.


There is ample clinical evidence suggesting that the nervous system such as emotional stress can influence the course of acne. We examined possible participation of cutaneous neurogenic factors including neuropeptides, neuropeptide-degrading enzymes and neurotrophic factors, in association with inflammation in the pathogenesis of acne. Immunohistochemical studies revealed that substance P (SP)-immunoreactive nerve fibers were in close apposition to the sebaceous glands, and that neutral endopeptidase (NEP) was expressed in the germina-tive cells of the sebaceous glands in the skin from acne patients. Nerve growth factor showed immunoreactivity only within the germinative cells. In addition, an increase in the number of mast cells and a strong expression of endothelial leukocyte adhesion molecule-1 on the postcapillary venules were observed in adjacent areas to the sebaceous glands. In vitro, the levels and the expression of stem cell factor by fibroblasts were upregulated by SP. When...

Neuropathic Ulcer

Diabetic Heel Ulcer

A non-infected neuropathic ulcer was noted under her left third, fourth and fifth metatarsal heads. Its dimensions were 3.5 x 4 x 0.4 cm, and it was surrounded by callus. A smaller neuropathic ulcer was also observed under her midsole (Figure 5.10). Claw toe deformity of her lesser toes, dry skin and desquamation of the tip of her third toe were also present. Under her Figure 5.10 Neuropathic ulcers under prominent metatarsal heads and on the midsole. Claw toes and dry skin are also apparent Figure 5.10 Neuropathic ulcers under prominent metatarsal heads and on the midsole. Claw toes and dry skin are also apparent


Saprolegnia lesions in channel catfish initially occur at the site of injury, containing a central zone of either necrotic skin, with fungal mycelia throughout the lesion, or, in more severe lesions, a necrotic core of sloughed tissue, which leaves a crater-shaped cavity (Xu and Rogers, 1991). In some lesions, the epidermis has been reported as completely sloughed, leaving the dermis exposed (Xu and Rogers, 1991 Bly et al., 1992). Adjacent tissue becomes infected following the spread of hyphae on the skin surface, and mucus cells present in normal skin are absent in the infected skin.

Local treatment

Lupus Erythematosus Treatment

Dithranol, obtained originally from the Goa tree in south India, is now made synthetically. It can easily irritate or burn the skin, so it has to be used carefully and should be kept from contact with normal skin as far as possible. For hospital treatment pastes are used and the lesions surrounded by petroleum jelly to protect the normal skin. Dithranol creams can be used at home they are applied for 30 minutes and then washed off. A low concentration (0-1 ) is used initially and gradually increased to 1 or 2 as necessary. All dithranol preparations are irritants and produce a purple-brown staining that clears in time. If used in the scalp dithranol stains red or fair hair purple. Emollients soften dry skin and relieve itching. They are a useful adjunct to tar or dithranol.


Nucleus Ambiguus Wallenberg Sendromu

Interruption of the descending autonomic fibers gives rise to a clinical condition called Horner's syndrome. In this syndrome, there is loss of the autonomic sympathetic supply to one side of the face, ipsilaterally. This leads to ptosis (drooping of the upper eyelid), a dry skin, and constriction of the pupil. The pupillary change is due to the competing influences of the parasympathetic fibers, which are still intact. Other lesions elsewhere that interrupt the sympathetic fibers in their long course can also give rise to Horner's syndrome.


Callus Formation

On examination, the patient had fever, severe diabetic neuropathy, and bounding pedal pulses. He had hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin. Callus formation superimposed on a neuropathic ulcer over his third metatarsal head was present a callus was also noted over his fifth metatarsal head. A superficial, painless, Figure 8.21 Superficial infected ulcer with purulent discharge under Lisfranc's joint. Callus formation is superimposed on neuropathic ulcer over the third meta-tarsal head with callus formation over the fifth metatarsal head. Hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin can be seen Figure 8.21 Superficial infected ulcer with purulent discharge under Lisfranc's joint. Callus formation is superimposed on neuropathic ulcer over the third meta-tarsal head with callus formation over the fifth metatarsal head. Hallux valgus, claw toes, prominent metatarsal heads, ony-chodystrophy and dry skin...

Infantile Acne

Infantile acne must be differentiated from acneiform eruptions due to topical skin care products (greasy oint-memts, creams, pomades, oils) applied by the parents (pomade acne) due to steroids (topical, oral, inhaled) and from skin contact, ingestion or inhalation of aromatic hydrocarbons with chlorine groups (chloracne) 1, 20 . Perioral dermatitis can mimic an IA, papules and pustules are present mainly periorally (95 ) and occasionally at the periocular area (44 ). It can be associated to kerato-conjunctivitis and vulvar lesions in female patients and usually occurs due to steroids. A family history is present in 20 of cases 21 .

Pes Cavus

On examination, peripheral pulses were bounding. She had severe peripheral neuropathy (no sensation of pain, light touch, temperature, vibration or 5.07 monofilaments) and dry skin. A high plantar arch due to pes cavus was noted, which was more apparent in the standing position. Mild hallux valgus, clawing of the toes, and callus formation over the inner aspect of the first metatarsal heads as well as at the tip of the second toe and the second metatarsal head bilaterally were observed (Figure 3.4). The patient had the callus removed, and the nails cut and she was educated in foot care. Suitable shoes and insoles were prescribed and she was advised to attend the foot clinic on a monthly basis for chiropody treatment.

Rectal pain

Anal tags are normal skin variation, and though they do not cause any symptoms or require treatment, sometimes they may be a clue to an underlying condition. As has earlier been stated, tags can be associated with Crohn's disease these tags are usually thick with a purplish appearance. Anal tags can occur as the result of a thrombosed external pile or may form the marked end to a chronic anal fissure.


Flutamide does not interfere with ovulation and is generally well tolerated. The only common complaint of patients given flutamide is dry skin, attributable to reduced sebum production. Liver toxicity is an uncommon, but potentially severe, risk with this drug (24). On the whole, from several points of view, flutamide is probably the best available antiandrogen drug. However, this drug should be used with caution for the treatment of hirsutism, and in these cases serum transaminases should be carefully monitored.

DNAR Orders

The attending physician should clarify both the DNAR order and plans for future care with nurses, consultants, house staff, and the patient or surrogate and offer an opportunity for discussion and resolution of conflicts. Basic nursing and comfort care (ie, oral hygiene, skin care, patient positioning, and measures to relieve pain and symptoms) must always be continued. DNAR orders carry no implications about other forms of treatment, and other aspects of the treatment plan should be documented separately and communicated to staff.

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