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The homoeopathic physician in his private practice seldom gets to see and to treat an eruption of itch spread over a considerable part of the skin and coming from a fresh infection effective 150 mg cleocin acne quick treatment. The patients on account of the intolerable itching either apply to some old woman discount 150 mg cleocin mastercard skin care 9 year old, or to the druggist or the barber 150 mg cleocin otc skin care vitamins, who buy cheap cleocin 150 mg skin care jobs, one and all, come to their aid with a remedy which, as they suppose, is immediately effective (e. Only in the practice of the barracks, of prisons, hospitals, penitentiaries and orphan asylums those infected have to apply to the resident physician, if the surgeon of the house does not anticipate him. Even in the most ancient times when itch occurred, for it did not everywhere degenerate into leprosy, it was acknowledged that there was a sort of specific virtue against itch in sulphur; but they knew of no other way of applying it, but to destroy the itch through an external application of it, even as is done now by the greater part of the modem physicians of the old school. So also the most ancient physicians, like the moderns, prescribed for their itch patients baths of warm sulphurous mineral water. Such patients are usually also delivered from their eruption by these external sulphur remedies. But that their patients were not really cured thereby, became manifest, even to them, from the more severe ailments that followed, such as general dropsy, with which an Athenian was afflicted when he drove out his severe eruption of itch by bathing in the warm sulphur baths of the island of Melos (now called Milo), and of which he died. Epidemion, which has been received among the writings of Hippocrates (some three hundred years before Celsus). Internally the ancient physicians gave no sulphur in itch, because they, like the moderns, did not see that this miasmatic disease was, at the same time and especially, an internal disease. They only gave it in connection with the external means of driving away the itch, and, indeed, in doses which would act as purgatives, - ten, twenty and thirty grains at a dose, frequently repeated, - so that it never became manifest how useful or how injurious this internal application of such large doses, in connection with the external application, had been; at least the whole itch-disease (psora) could never be thoroughly healed thereby. The external driving out of the eruption was simply advanced by it as by any other purgative, and with the same injurious effects as if no sulphur at all had been used internally. For even if sulphur is used only internally, but in the above described large doses, without any external destructive means, it can never thoroughly heal a psora; partly because in order to cure as an antipsoric and homoeopathic medicine, it must be given only in the smallest doses of a potentized preparation, while in larger and more frequent doses the crude sulphur* in some cases increases the malady or at least adds a new malady; partly because the vital force expels it as a violently aggressive remedy through purging stools or by means of vomiting, without having put its healing power to any use. After assuming that a drug, which in a normal state of health causes the symptoms a, b, g, - in analogy with other physiological phenomena, produces the symptoms x, y, z, which appear in an abnormal state of health - can act upon this abnormal state in such a way that the disease-symptoms x, y, z, are transformed into the drug symptoms a, b, g, which latter have the peculiar characteristic of temporariness or transitoriness; he then continues: Ò This transitory character belongs to the group of symptoms of the medicine a, b, g, which is substituted for the group of symptoms belonging to the disease, merely because the medicine is used in an extraordinarily small dose. Should the homoeopathic physician give the patient too large a dose of the homoeopathic remedy indicated, the disease x, y, z may indeed be transformed into the other, i. If a very large dose is given, then a new often very dangerous disease is produced, or the organism does its utmost to free itself very quickly from the poison (through diarrhoea, vomiting, etc. This in time passes away, when the psora again lifts its head, either with the same morbid symptoms as before, or with others similar but gradually more troublesome than the first, or with symptoms developing in nobler parts of the organism. Ignorant persons will rejoice in the latter case, that their former disease at least has passed away, and they hope that the new disease also may be removed by another journey to the same baths. They do not know, that their changed morbid state is merely a transformation of the same psora; but they always find out by experience, that their second tour to the baths causes even less alleviation, or, indeed, if the sulphur-baths are used in still greater number, that the second trial causes aggravation. Thus we see that either the excessive use of sulphur in all its forms, or the frequent repetition of its use by allopathic physicians in the treatment of a multitude of chronic diseases (the secondary psoric ailments) have taken away from it all value and use; and we may well assert that, to this day, hardly anything but injury has been done by allopathic physicians through the use of sulphur. I know a physician in Saxony who gained a great reputation by merely adding to his prescriptions in nearly all chronic diseases flowers of sulphur, and this without knowing a reason for it. This in the beginning of such treatments is wont to produce a strikingly beneficent effect, but of course only in the beginning, and therefore after that his help was at an end. Even when, owing to its undeniable anti-psoric effects, sulphur may be able of itself to make the beginning of a cure, after the external expulsion of the eruption, either with the still hidden and latent psora or when this has more or less developed and broken out into its varied chronic diseases, it can nevertheless be but rarely made use of for this purpose, because its powers have usually been already exhausted, because it has been given to the patient already before by allopathic physicians for one purpose or another, perhaps has been given already repeatedly; but sulphur, like most of the antipsoric remedies in the treatment of a developed psora that has become chronic, can hardly be used three or four times (even after the intervening use of other antipsoric remedies) without causing the cure to retrograde. The cure of an old psora that has been deprived of its eruption, whether it may be latent and quiescent, or already broken out into chronic diseases, can never be accomplished with sulphur alone, nor with sulphur-baths either natural or artificial. Here I may mention the curious circumstance that in general with the exception of the recent itch-disease still attended with its unrepressed cutaneous eruption, and which is so easily cured from within* - every other psoric diathesis, i. It is, therefore, not strange, that one single and only medicine is insufficient to heal the entire psora and all its forms, and that it requires several medicines in order to respond, by the artificial morbid effects peculiar to each, to the unnumbered host of psora symptoms, and thus to those of all chronic (non venereal) diseases, and to the entire psora, and to do this in a curative homoeopathic manner. It is only, therefore, as already mentioned, when the eruption of itch is still in its prime and the infection is in consequence still recent, that the complete cure can be effected by sulphur alone, and then at times with but a single dose. I leave it undecided, whether this can be done in every case of itch still in full eruption on the skin, because the ages of the eruption of itch infecting patients is quite various. For if the eruption has been on the skin for some time (although it may not have been treated with external repressive remedies) it will of itself begin to recede gradually from the skin. Then the internal psora has already in part gained the upper hand; the cutaneous eruption is then no more so completely vicarious, and ailments of another kind appear, partly as the signs of a latent psora, partly as chronic diseases developed from the internal psora. In such a case sulphur alone (as little as any other single antipsoric remedy) is usually no longer sufficient to produce a complete cure, and the other antipsoric remedies, one or another according to the remaining symptoms, must be called upon to give their homoeopathic aid. The homoeopathic medical treatment of the countless chronic diseases (non-venereal and therefore of psoric origin) agrees essentially in its general features with the homoeopathic treatment of human diseases as taught in the Organon of the Art of Healing; I shall now indicate what is especially to be considered in the treatment of chronic diseases. Of course everything that would hinder the cure must also in these cases be removed. But since we have here to treat lingering, sometimes very tedious diseases which cannot be quickly removed, and since we often have cases of persons in middle life and also in old age, in various relations of life which can seldom be totally changed, either in the case of rich people or in the case of persons of small means, or even with the poor, therefore limitations and modifications of the strict mode of life as regularly prescribed by Homoeopathy must be allowed, in order to make possible the cure of such tedious diseases with individuals so very different. A strict, homoeopathic diet and mode of living does not cure chronic patients as our opponents pretend in order to diminish the merits of Homoeopathy, but the main cause is the medical treatment. This may be seen in the case of the many patients who trusting these false allegations have for years observed the most strict homoeopathic diet without being able thereby to diminish appreciably their chronic disease; this rather increasing in spite of the diet, as all diseases of a chronic miasmatic nature do from their nature. Owing to these causes, therefore, and in order to make the cure possible, the homoeopathic practitioner must yield to circumstances in his prescriptions as to diet and mode of living, and in so doing he will much more surly, and therefore more completely, reach the aim of healing, than by an obstinate insistence on strict rules which in many cases cannot be obeyed. The daily laborer, if his strength allows, should continue his labor; the artisan his handiwork; the farmer, so far as he is able, his field work; the mother of the family her domestic occupations according to her strength; only labors that would interfere with the health of healthy persons should be interdicted. The class of men who are usually occupied, not with bodily labor, but with fine work in their rooms, usually with sedentary work, should be directed during their cure to walk more in the open air, without, on that account, setting their work altogether aside. The physician may allow this class the innocent amusement of moderate and becoming dancing amusements in the country that are reconcilable with a strict diet, also social meetings with acquaintances, where conversation is the chief amusement; he will not keep them from enjoying harmless music or from listening to lectures which are not too fatiguing; he can permit the theatre only exceptionally, but he can never allow the playing of cards. The physician will moderate too frequent riding and driving, and should know how to banish intercourse which should prove to be morally and psychically injurious, as this is also physically injurious. The flirtations and empty excitations of sensuality between the sexes, the reading of indelicate novels and poems of a like character, as well as superstitious and enthusiastic books, are to be altogether interdicted. All classes of chronic patients must be forbidden the use of any domestic remedies or the use of any medicines on their own account. With the higher classes, perfumeries, scented waters, tooth-powders and other medicines for the teeth must also be forbidden. If the patient has been accustomed for a long time to woollen under-clothing, the homoeopathic physician cannot suddenly make a change; but as the disease diminishes the woollen under-garments may in warm weather be first changed to cotton and then, in warm weather, the patient can pass to linen. Fontanelles can be stopped, in chronic diseases of any moment, only when the internal cure has already made progress, especially with patients of advanced age. The physician cannot yield to the request of patients for the continuation of their customary home-baths; but a quick ablution, as much as cleanliness may demand from time to time, may be allowed; nor can he permit any venesection or cupping, however much the patient may declare that he has become accustomed thereto. But if both parties are able and disposed to it, such an interdict is, to say the least, ridiculous, as it neither can nor will be obeyed (without causing a greater misfortune in the family). No legislature should give laws that cannot be kept nor controlled, or which would cause even greater mischief if kept. If one party is incapable of sexual intercourse this of itself will stop such intercourse. But of all functions in marriage such intercourse is what may least be commanded or forbidden. Homoeopathy only interferes in this matter through medicines, so as to make the party that is incapable of sexual intercourse capable of it, through antipsoric (or anti- syphilitic) remedies, or on the other hand to reduce an excitable consortÕs morbidity to its natural tone. The poor man can recover health even with a diet of salt and bread, and neither the moderate use of potatoes, flour-porridge nor fresh cheese will binder his recovery; only let him limit the condiments of onions and pepper with his meagre diet.
In on a culture plate and incubated for up to two rare cases cleocin 150mg for sale skin care natural remedies, people may not show symptoms for days to allow the bacteria to multiply proven 150 mg cleocin acne keloid, but the several months order cleocin 150mg without prescription acne 9dpo, but whether or not infected indi- test’s sensitivity depends on the site where it was viduals are exhibiting signs or symptoms generic cleocin 150mg visa skin care routine, they can harvested. About 90 percent of the time, cervical spread the infection to sex partners unless they samples detect infection if one exists. A throat culture can be used to determine Most commonly, symptoms are a yellowish whether a patient has pharyngeal gonorrhea. If white or yellow-green discharge from the vagina gonorrhea is present in the male or female genital or penis and/or painful or difﬁcult urination. Men tract, its presence can also be diagnosed with a sometimes have swollen testicles that are painful. Rectal infec- Complications tion results in anal itching, discharge, and painful Although the cervix is usually the site of infection, bowel movements. Women suffer the endocervix, with secondary infection of the rec- most serious complications; these can include tum or urethra. Early symptoms of gonorrhea can ectopic pregnancy, infertility, and pelvic inﬂamma- be mild, and many infected women have none tory disease. Sometimes, a woman’s early symp- female reproductive organs that affects about 1 mil- toms of gonorrhea are mistaken for a bladder or lion American women every year—is the most seri- vaginal infection. Increased levels of ﬂu- infection, blindness, or a serious blood infection in oroquinolone-resistant gonorrhea were being the infant. Immediately after a baby is born to a mother could have acquired the disease in Hawaii, other who has gonorrhea, the doctor can prevent eye Paciﬁc islands, or Asia, where this same resistance is infection (ophthalmia neonatorum) by putting silver common. That would point to treatment for these nitrate or another medication into the baby’s eyes. In men, a complication of gonorrhea is the Also, gonorrhea is beginning to show resistance to painful condition of the testicles called epididymitis. Gonorrhea and treated if infected, even if no symptoms occur, can also affect the prostate and cause urethral scar- and these individuals should be screened for other ring that makes urination difﬁcult. That gonorrhea are: limiting the number of sex part- means that new antibiotics and drug combinations ners, not alternating partners, and practicing absti- must be used to treat resistant strains. When the possibility of infection occurs, see In fact, it is now common for doctors to encounter a doctor and avoid sexual contact until you have gonorrhea strains that are resistant to penicillin, been treated and have responded to treatment. Be so this common antibiotic is no longer used for aware that gonorrhea can even occur in the throat gonorrhea treatment. A person who experiences antibiotics, one of the most effective of which is burning during urination or has a discharge or ceftriaxone, injectable by the doctor in one dose. The sexually orally as a single dose are cefixime, ciprofloxacin, active person who is reluctant to inform partners and ofloxacin. One caveat, however: patients 18 that he or she has gonorrhea should remember gum disease 69 that this disease has very serious complications venting gonorrhea. In ordinary circumstances, a fam- National Committee for Quality Assurance, is a set ily member of the patient acts as health care of measures that are used to evaluate the quality proxy/advocate automatically. Each year, care, which differs from the traditional fee-for- the United States spends about $1. Not surprisingly, civil rights 56 percent reduction was seen in the incidence of groups were soon up in arms about this. Both pelvic inflammatory disease in the year after human rights and public health authorities were intervention. Congress then directed place to place, depending on where an individual Health and Human Services to produce a new list lives. Also, hemophilia A hereditary blood defect (in one’s choice of health resources often depends on males) that slows the clotting of blood and some- ability to pay and on the patient’s use of public times makes stopping bleeding very difficult. The charity facilities or others that are covered by her hemophiliac lacks a protein necessary for blood or his individual health insurance, Medicare, or clotting; for this reason, the individual bleeds Medicaid. The speciﬁc goal in respect to sexual behavior is to increase the number of adolescents who abstain hepatitis A Hepatitis A is a virus that is infectious from sexual intercourse or use condoms if they are and contagious and produces inﬂammation of the sexually active. Hepatitis A, B, and C can cause acute infec- adults, the goal is to increase the use of condoms tions, but B and C can become chronic. Besides these aims, Healthy People 2010 has 28 Cause total focus areas with numerous objectives. The Typically, hepatitis A infection is person-to-person agenda can be viewed on the Web: http://www. Helms Amendment Enacted in 1987, this law One gets hepatitis A by ingestion of infected sought to prohibit people from entering the United fecal matter. Many people get hepa- Doctors often encourage their patients to take titis A by eating food that was prepared by some- advantage of the immunization for hepatitis A, one who did not wash his or her hands thoroughly especially for international travel. Many health after a bowel movement and thus had feces experts believe that children who live in high-dis- remaining on the skin. This virus is easily trans- ease-incidence areas should be immunized, along mitted via food contaminated during preparation. The virus gets into the mouth infected person, which accounts for 12 to 26 per- or on food during preparation. Other associations are 11 to 16 per- have been outbreaks of hepatitis A among gay men cent in day care centers; 4 to 6 percent in that some believe may have been caused by this international travel; 2 to 3 percent via food or kind of transmission. Native American number of sexual partners a man has, the more reservations and Alaskan Native villages have a likely he is to contract hepatitis A. Also, a woman high rate of hepatitis A: about 30 to 40 percent of who engages in the sexual practices of oral–anal or the children are infected by age ﬁve, and almost all digital–anal contact is at increased risk of contract- in the community are infected by the time they ing hepatitis A. Young children rarely have atitis A vaccinations for homosexual men at age symptoms, but adults usually do. If someone does have antibodies, these confer pro- Treatment tection against getting the infection again. A per- If someone does contract hepatitis A, a physician son who has a negative result on a blood test but usually recommends rest, fluids, and medication has good reason to suspect infection should repeat to counter nausea. In people with liver problems, hepati- interest is the fact that some individuals whose tis A can be very serious. In some cases, a person blood shows evidence of having had this disease in with hepatitis A does not recover strength com- the past were never aware that they contracted or pletely for several months. The blood test result can turn up negative if the Cause individual has recently been infected. A liver One way that hepatitis B is contracted is via sexual biopsy may be necessary to determine stage of intercourse, especially anal. A test that measures liver function can- transmitted by drug addicts’ sharing of needles, by not be used to rule out hepatitis infection. If a per- vertical transmission (mother to child), and in son proves to be a hepatitis B carrier, a blood test health care environments. The more sex partners a for hepatitis D (delta hepatitis) should be done, person has, the more likely she or he is to get hep- because this can only occur in someone who has atitis B.
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The skin often becomes infected with ● Eczema craquelée (asteototic eczema) occurs Staphylococcus aureus cheap cleocin 150 mg visa skin care 1920s, which may play a role in particularly on the legs of elderly subjects with very relapses order cheap cleocin on line acne 101e. There is a susceptibility to virus dry skin and is marked by a red rash with a ‘crazy infections cheap cleocin 150mg visa skin care kemayoran, including multiple viral warts buy generic cleocin pills skin care logos, mollusca paving’ pattern. The major beneﬁts and most patients can be managed condition is stubbornly persistent, but potent with a combination of emollients and topical corticosteroids may assist. Antimicrobial agents housewives and those who work with their may also be helpful. Allergic contact dermatitis is due to the ● Seborrhoeic dermatitis occurs on hairy sites and development of delayed hypersensitivity to a ﬂexures or on the central trunk. Common signs are particular chemical substance such as nickel, severe dandruff and scaling, pink areas in the facial neomycin or a rubber additive in a few exposed ﬂexures. It appears ● Venous eczema occurs on the lower legs of elderly to be due to overgrowth of the normal follicular individuals with venous hypertension. In some, it ﬂora and is often seen in the immunosuppressed seems to be due to allergic contact dermatitis to (e. Sites affected Psoriasis affects the extensor aspects of the trunk and limbs preferentially. The nails are often affected and may show the so-called thimble pitting, sep- aration of the nail plate from the nail bed (onycholysis), subungual debris, brown- ish-black discolourations and deformities of the nail plate (Fig. Flexural lesions, which occur in some patients, are most often seen in the major body folds in the elderly, especially in those who are overweight. The moistness of the ﬂexural areas plate with pitting and decreases the scaling and produces a moist and glazed appearance (Fig. The face is not usually severely affected in psoriasis, although the scalp margin, paranasal folds and retroauricular folds are quite often involved (Fig. Psoriasis sometimes appears at the site of a minor injury such as a scratch or a graze (Fig. This reaction, known as the isomorphic response or the Koebner phenomenon, mostly occurs when the psoriasis is in active spreading phase. The development of a skin disorder at the site of injury is characteristic of psoriasis, but is also seen in lichen planus (see page 144) and discoid lupus erythematosus (see page 79). It has been claimed that the 130 Psoriasis disorder is less common in African and Asian groups, but detailed ﬁgures are not available. It seems less of a problem in the Japanese and other Asian populations, but may be becoming more frequent with the trend to Westernization. There are two main peaks of incidence, the ﬁrst of which is in the second half of the second decade of life. Recently, it has been recognized that psoriasis may also occur for the ﬁrst time in the seventh decade. In general, the younger the age of onset, the worse the outlook as far as frequency, severity and persistence of the disease are concerned. Psoriasis is a life-long disorder subject to unpredictable remissions and relapses. Single episodes are uncommon and in the most frequent variety an episode in the teenage years is followed by a series of attacks, each lasting weeks or months, in the succeeding years. With one parent affected, there is an approxi- mately 30 per cent chance of a child being affected. With both parents suffering from psoriasis, the chance that a child will develop the condition rises to 60 per cent. Non-identical twins have an approximately 20 per cent chance of both being affected, and the concordance rate for identical twins seems to be in the order of 70 per cent. Recent research indicated that, although no one gene is responsible for the disease, the direct inheritance of ‘susceptibility genes’ is necessary for its development. On the scalp, the most frequently seen disorder to be mistaken for psoriasis is seb- orrhoeic dermatitis (see page 114), although this usually affects the scalp diffusely rather than in distinct plaques. Lichen simplex chronicus (see page 119) of the scalp typically presents with a red, scaling patch on the occiput, which can look very psoriasis-like. The intense itching and licheniﬁed surface should serve to dis- tinguish the two disorders. On the legs, raised, round, red, scaling psoriasiform patches often turn out to be Bowen’s disease in the elderly, or discoid eczema. Superﬁcial basal cell carcinoma lesions are sometimes several centimetres in diameter and quite psoriasiform in appearance, but have a ﬁne, raised, ‘hair-like’ margin. Often, it develops some 2–4 weeks after an episode of tonsillitis or pharyngitis, mostly due to beta-haemolytic 132 Psoriasis Figure 9. It behaves like an exanthem, as the characteristically ‘drop’-sized lesions develop suddenly (Fig. Napkin psoriasis Infantile napkin dermatitis (see page 229) sometimes takes on a very psoriasis-like appearance and typical psoriatic lesions develop on the scalp and trunk. Erythrodermic psoriasis Psoriasis sometimes progresses to generalized skin involvement. Typical plaque- like lesions disappear, the skin is universally red and scaly and the condition is known as erythrodermic psoriasis. Patients who are seriously ill suffer from: ● heat loss, and are in danger of hypothermia because of the increased blood supply to the skin ● water loss, leading to dehydration because of the disturbed barrier function of the abnormal stratum corneum ● a hyperdynamic circulation, because effectively there is a vascular shunt in the skin; when the patient’s myocardium is already compromised because of other factors, there is a danger of high output failure ● loss of protein, electrolytes and metabolites via the shed scales and exudates; patients may develop deﬁciency states. Pustular psoriasis Most dermatologists consider this to be a manifestation of psoriasis, although there are some who believe it is a separate disorder. It seems probable that pustu- lar psoriasis is indeed a type of psoriasis, with exaggeration of one particular com- ponent of the disease (see Pathology below). Palmoplantar pustulosis Patients with palmoplantar pustulosis develop yellowish white, sterile pustules on the central parts of the palms and soles (Figs 9. Older lesions take on a brownish appearance and are later shed in a scale at the surface. The affected area can become generally inﬂamed, scaly and ﬁssured and, although relatively small areas of skin are affected, the condition can be very disabling. The disorder tends to be resistant to treatment (see below) and is subject to relapses and remission over many years. Generalized pustular psoriasis This is also known eponymously as Von Zumbusch disease, and is one of the most serious disorders dealt with by dermatologists. In its classical form, attacks occur suddenly and are characterized by severe systemic upset, a swinging pyrexia, arthralgia and a high polymorphonuclear leucocytosis accompanying the skin disorder. The skin ﬁrst becomes erythrodermic and then develops sheets of sterile pus- tules over the trunk and limbs (Fig. Sometimes, the pustules become conﬂuent so that ‘lakes of pus’ develop just beneath the skin surface. In other areas, there is a curious type of superﬁcial peel- ing without pustules forming. They can usually be brought into remission by modern treatments (see below), but are subject to recurrent attacks. Other forms of pustular psoriasis Occasionally, pustules may develop after strong topical or systemic corticosteroids have been used and then abruptly withdrawn. Other rare variants of pustular psor- iasis include: ● acrodermatitis continua, in which there is a recalcitrant pustular erosive dis- order on the ﬁngers and toes around the nails and occasionally elsewhere ● pustular bacterid, in which sterile pustules suddenly appear on the palms, soles and distal parts of the limbs after an infection.
Treatment Visible hair surface Internal changes Tensile strength shampooed hair Shampoo Intact f-layer Surfactant deposition Very slight decrease No increase in Small increase in with increasing cysteic acid metal content discount 150mg cleocin with mastercard skin care products for rosacea, esp purchase discount cleocin line acne quistes. There are order cleocin pills in toronto tazorac 005 acne, however buy generic cleocin 150 mg on-line skin care natural remedies, a number of clinical markers that will point the clinician to poor cosmetic practices. Trichorrexhis Nodosa Investigation: When numerous ﬁbers are affected, small white spots are easily seen on the hair with the naked eye and can be conﬁrmed with a hand lens. Transmitted or plane polarized light microscopy shows characteristic focal burst along the ﬁber or brush breaks where the node has parted. Additional observations should be made of the apparently normal parts of the ﬁber to rule out any predisposing conditions, such as pili annulati or pili torti, that may previously have gone unnoticed. While it is important to exclude any underlying pathology or metabolic changes, it is unlikely that a patient who previously had normal hair will have developed signiﬁcantly weaker hair. It must be remembered that where trichorrhexis nodes appear toward the tips on longer ﬁbers, that part of the hair was actually formed many months before the patient pre- sented with trichorrexhis nodosa. However, the combination of insults and insufﬁcient care may result in catastrophic ﬁber damage. In order to understand 26 Gummer the severity of a patient’s cosmetic regimen it may be useful to measure the distance from the scalp to the ﬁrst onset of trichorrhexis nodosa as an indication of how long the best part of the ﬁber can withstand the current level of trauma. It is probable that a chemical (permanent wave) or thermal (tongs) insult is indicated in the process. The current fashion trend for per- fectly straight hair has spawned a number of treatments and straightening irons that claim to be good for the hair. The author has observed an increase in trichorrhexis nodosa among young females who are seemingly “wedded” to their straightening irons. Bubble Hair Investigation: Routine light microscopy, or a hand lens, reveals swelling and honeycomb-like structures at the broken, distal end of the ﬁber (5). Very small (~5 micron) dome-like protrusions on cuticle scales are com- mon on normal hair, though difﬁcult to see by light microscopy, and should not be confused with bubble hair. The patient presents with a single episode of claimed hair loss that may affect either the whole of the scalp or one of more poorly deﬁned areas. When associated with a speciﬁc chemical treatment, hair breakage often begins several days after the causative procedure. Investigation: True hair loss from the follicle rarely, if ever, occurs due to cosmetic prac- tices. Routine light microscopy of the shed ﬁbers normally shows a fracture or trichorrhexis nodosa brush break at the proximal end. The distal end can present either as damaged, or often as a clean scissor cut, particularly when a haircut has preceded a chemical treatment. Matting or Tangling Even hair in perfect condition is prone to tangling, especially when wet. Severe tangling or matting, which may be impossible to unravel, can occur in hair approaching shoulder length or longer and is an indication of both poor hair condition and poor handling of the hair. Progressive damage, subsequent to chemical treatments, makes ﬁbers higher in friction and rougher to the touch. The best approach is to advise on a high quality cut and counsel on the time it will take to regrow the hair. Matting that requires a patient to present to a clinician is a single catastrophic event. It will suddenly occur and may, or may not, coincide with a change in cosmetic products. However, the patient may have had some degree of pre-warning with small tangles or knots appearing at the ends of their hair during routine shampooing and grooming. These are typical in chemically damaged hair and appear to be “understood” by most consumers. Matting typically affects a single loca- tion but involves many, many adjacent ﬁbers and hence may have extensive involvement on the head. The site of matting is invariably at the back of the head and typically occurs during the washing or conditioning step and only when the hair is wet. The location is due primarily to the difﬁculty in reaching and handling the hair when shampooing, such that the hair is piled up leading to massive ﬁber-to-ﬁber interactions. Investigation: Matting is always obvious to the naked eye and requires no further inves- tigative techniques. However, it is possible that there is no history of such treatments as even poorly Evaluation Techniques 27 handled normal hair will mat. The actual matting event is unlikely to be related to any particu- lar product use. The principal question to ask is, “What additional value does the investigation bring to the diagnosis and treatment of the patient? Each patient represents a consumer group adopting typical habits and practices, all of which may be considered “normal” for that individual but will have a deﬁnite and visible impact on the hair. An appreciation of the patient as a consumer is essential before further analysis is undertaken. This section is designed to explore the available techniques in order of “usefulness” to the clinician. An important point to remember is that nature has produced in hair a highly cross-linked protein sample that is easy to harvest in quantity. It does not require additional ﬁxation and is easily stored and transported in plain envelopes. The use of forceps to pluck the hair can easily squash the ﬁber lead- ing to apparent ﬂat sides or indentations on the ﬁber. Longitudinal ridges or “ﬂutes” are often found on normal hair, but one should always be concerned about focal indentations. Pulling hair ﬁbers will cause the cuticle to “stand up” giving the impression of higher levels of damage when viewed by techniques such as scanning electron microscopy. Although this may be unavoidable, parallel, cut sam- ples can be used to provide a truer picture of the hair surface (Fig. During sampling, both the hair bulb and the proximal end of the shaft may be damaged. One should only consider the bulb to be dystrophic if the hair attached to the bulb is malformed. A normal hair shaft will derive from a normal bulb and should indicate that a bulb abnor- mality was induced during sampling. Damage to the proximal shaft, still within the follicle, appears as rolled-back cuticle scales caused as the hair cuticle is pulled against the opposing inner root sheath cuticle. The speed of the pluck and the number of ﬁbers with attached outer root sheaths will affect the num- ber of ﬁbers showing this damage. The soft scales are pulled past the opposing inner root sheath cuticle causing them to roll backwards. Light Microscopy A number of techniques are included within the category of light microscopy.