skin; verruca 6 Management

Management
There is no single therapy is one hundred percent effective, and various kinds of therapy should be combined. Research on the effectiveness of therapy should take into account the possibility of spontaneous regression. Any decision taken therapy which must be made case by case basis based on the physician experience, patient selection, and implementation of evidence-based medicine. Immunocompromised patients may experience with verruca incomplete cleaning and verruca become resistant to therapy. Verruca left without treatment is a valid management option if the patient is acceptable, but plantar verruca cause pain and verruca the invisible hand and less influence on school activities or led to difficulties at work. Verruca in adults with a long duration of infection and in immunosuppressed patients have little chance to heal spontaneously and more difficult to be treated.
Verruca with different types and different locations require different therapies. Verruca on the face should not be treated with ointment verruca severe irritation because of the risk. Verruca Plana with Koebner phenomena with any destructive techniques can aggravate the disease. Most verruca can be treated by general practitioners and even by the nursing staff.
The main goal is verruca management:
(1) to eliminate verruca without recurrence
(2) without cicatrix's
(3) create a long-term immunity.
General principles of management verruca must see things as follows:
1. not all be eliminated verruca
2. indication to be removed are: pain, interfere with the activity, cosmetic factors, and the risk of malignancy
3. there is no treatment success rate is very high (about 60-70% net in three months)
4. immune response is an important factor in the net verruca. Immunocompromised individuals may not show the net verruca
5. the highest level of cleanliness for the management of a variety usually the younger people who have a short duration of infection.

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skin; verruca 5 Veruka and Malignancy

Diagnosis Banding
Verruca plantar must be distinguished from regions where lesions callositis waxy, thick, yellowish and there are no capillaries in the peel. Cron occur in places affected by pressure and are usually smaller and pain with blockage in the middle.
Veruka Plana should be distinguished liken Planus which shows a purplish and diskolorasi Wickham stria. Planus liken lesions usually associated with itching and certain mucosal lesions.
Nevus epidermal similar verruca digitata or verruca filiformis. Molluscum contagiosum lesions are white with papul seen umbilikasi or in the middle of the curve.

Verruca and Malignancy
Verruca benign in individuals imunokompeten almost never become malignant. There are a few reports of lesions that begin as verruca and later became squamous cell carcinoma is invasive. The combination of verruca periungual with genital HPV disease should be special attention.
Verukous many lesions occur in individuals with immunosuppression and in patients who receive organ transplants is about 50% of patients with renal transplants develop into verruca, five years after transplantation. Exposure to sunlight increases the incidence of lesions verruca and act as kokarsinogen. Changes displasi almost certainly happen and very little relationship between the clinical symptoms with the histological picture. The lesions are a particular form of the virus verruca, Keratosis Bowenoid or diesel or keratoakantoma or squamous karsinomata. Some types of HPV have been found in benign squamous lesions and malignant in patients with immunocompromise and a role in the initiation and progression of malignant processes.

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skin; verruca 4 diagnosis

Special forms

Epidermodysplasia verruciformis
Epidermodysplasia verruciformis is inherited disorder in which there are subtle defect-mediated immunity by cells and is an area of HPV infection and persistent. Lesion is very diverse forms, can be flat, resembling verruca lesions, macular hyperpigmentation, red, or atrophy, or plaque-like Pityriasis versicolor. Flat form and which resemble lesions frequently located in verruca extremities and face and a thicker plaque can mimic seboroik Keratosis. Lesions found to contain many types of HPV that cause verruca including Plana, but some types that do not cause disease in normal individuals. There is a risk of developing into squamous cell carcinoma of the skin exposed to the sun (sun-exposed).

Bowenoid papulosis
Also known as intraepitelial neoplasms of the vulva, penis, and anal (NIV, NIP, NIA). Bowenoid papulosis appears as a small papul, usually multiple, sometimes located on the surface of pigmented mucosa and skin in the anogenital region of both sexes. Usually found in young adults but no association of age and there is a strong relationship with HPV type 16 infection.

Focal epithelial hyperplasia
Also known as Heck's disease, is a rare benign lesions, which reduced noise without gender predisposition. Lesions characteristic of multiple noduler firmly bounded on the oral mucosa. The disease is usually found in native Americans and the Inuit in Greenland, is reported rarely found in other countries. HPV types 13 and 32 as an agent cause in patients with genetic predisposition.

Epithelioma carcinoma cuniculatum and verukosa
Epitelioma kunikulatum a squamous cell carcinoma appears as mass with a smooth consistency bulbus software on your feet. Multiple sinus open to the surface and when pressed, the lesions become like a giant plantar verruca, but the difference between rapid growth and local invasion.
Verukosa carcinoma developed in the cavum of oral and genital mucosal lesions, and look like cauliflower.

Diagnosis
Verruca diagnosis is established based on clinical examination but can also be supported by the histological picture of epidermal acanthuses with papillomatosis, hiperkeratosis, and parakeratosis with a protrusion and grooves in the middle of verruca. Dermis capillaries protruding and blood clot blockage. There are a wide keratinocytes with eccentric piknosis cell nucleus surrounded by a halo perinuklear (koilosit is characteristic of papilloma associated with HPV). HPV-infected cells had few granules and a lump of eosinophils keratohialin basofilik granules. Verruca Plana acanthuses only slightly and does not occur hiperkeratosis and parakeratosis or papillomatosis.
Characterization of HPV is very little done, but useful in some cases of genital verruca in children with suspected sexual abuse. Knowledge of the genotype of HPV in benign verruca therapy does not affect the election.

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skin; verruca 3 aetiology, histopatology, and classification

Aetiology
The virus causes fall into papilloma virus (group papova) diameter of 45 nm. Is a DNA virus replication occurs internuclear characteristics.
Histopathology
Verruca is-epithelial hyperplastic lesions. Happened here acanthuses irregulars and hiperkeratosis. Focal sections of cells that have the irregulars through vakuolisasi stratum granulosum and caused protrusion parakeratotik in Stratum corneum, which consists of material basofilik inclusions in the nucleus. Tues lower stratum spinosum and stratum basalis is not affected.

Classification and Clinical Symptoms
The disease has verruca clinical forms:
1. verruca vulgaris with variant verruca filiformis
2. verruca Plana juvenilis
3. verruca plantar
4. verruca akuminatum (Condyloma acuminatum)
5. special form
Verruca vulgaris (warts)
This form is most common in children, but also in adults and the elderly. Predileksi place mainly in the extensor extremities, although this could spread to other parts of the body including the mouth and nasal mucosa. These warts round, gray, or if lentikuler size confluention shaped plaque, rough surfaces (verukosa). With a stroke can occur throughout the scratch autoinokulasi (Koebner phenomenon).

Parent is also known wart at some point will cause warts children in large numbers. There are opinions that characterize the disease recover without treatment
Verruca vulgaris variant found in the face, eyelids, nostrils, and skin heads are shaped as a protrusion perpendicular to the surface of the skin and surface verukosa called verruca filiformis. The lesions are usually single, soft, thin, like yarn. Lesions in the scalp rather difficult to be eliminated because it can grow new lesions due to scratching or because the use of a comb.

Verruca Plana juvenilis
This verrruca size milier or lentikuler. Smooth or flat surface, same color of skin color or slightly brownish. Spread especially in the face and neck area, dorsum manus and pedis, wrists, and knees. There is also a Koebner phenomenon and includes diseases that can heal itself without treatment. The number of lesions can be very many. Mainly occurs in children and young people, although can also be found in the elderly.

Verruca plantar
These forms are in the soles of the feet, especially in areas experiencing stress. The form of the hard ring in the middle of a bit soft and yellowish color. Slippery surface due to friction and leading to pain during walking, which caused the suppression by the masses is in the middle of the ring.
There are two types of plantar Verruca:
• Solitary verruca a single verruca. Verruca its size is often increased and even multiply, forming satellite verruca.
• Verruca mosaic is a group of several small verruca that confluen in one place. Mosaic Verruca more difficult to treat than solitary verruca.

Condyloma akuminatum
Condyloma akuminatum is shaped skin disorder with surface-stemmed vegetation in the genital area predilection place. The disease is discussed separately.

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skin; verruca 2 definition and epidemiology

Definition
Hiperplasi epidermal Verruca is caused by human papilloma virus (HPV) a particular type. HPV genotypes are divided into separate based on DNA content. Different types of HPV that can infect both the stratum corneum squamous epithelium or mucous membrane layer that has no horns. Appearance of lesions is not only influenced by the type of virus but also by environmental factors and the host.
More than 100 types of HPV that infektion skin and mucous membranes have been identified. Types of HPV that infect the skin will develop into verruca vulgaris. Specific type of high-risk HPV that infect the mucosa tissue in the genital area has a carcinogenic effect. High-risk HPV is also found in the head and neck cancer that develops in the tonsils.
There is also a low-risk types of HPV that cause benign lesions in the genital area, such as genital verruca. Some types of HPV infect the skin and cause verruca at various locations in the body. HPV types cause benign growth, or papilloma on the vocal cords.

Epidemiology
Verruca the spread of cosmopolitan and transmission through skin contact or autoinokulasi. Higher risk of infection if the skin is not infected with HPV had an injury or in wet conditions (eg in the pool or in the general cleaning) and contact with the skin on verruca.
This virus can also spread to other parts of the body. For example, it can spread to verruca around nails, lips, and surrounding skin if we verruca often bite on the finger or the nail, or if we like to suck fingers with verruca. If you have the immune system bad, it can develop into a much verruca and difficult to remove (eg in AIDS patients, in patients undergoing chemotherapy, etc.).

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skin; verruca 1

A lot of people who have experienced infection Human Papilloma Virus (HPV) in their lives. One manifestation of this virus infection is a verruca / verruca or often referred to as warts or warts cuplak or in English.
Warts appear on the layer of the epidermis with a variety of forms. Verruca vulgaris, verruca plantar, verruca Plana, and Condyloma akuminuta are some clinical manifestation of HPV infection.
Prevalence of viral warts in the United States in children and adults was recorded between 3.9% to 4.9%. Another survey said the prevalence of this virus in the state located in the northern United States ranged from 3% in children, 20% in adolescents, 3.5% in adults aged 25-34 years.1 greatest incidence occurs at age 12-16 years and more attacking women than men.
Actually verruca warts or harmless, but sometimes not visible. Verruca that arise on the sole of the foot sometimes causes a sense sick.3 In one study says, verruca will recover spontaneously within two years without treatment in children 40% of patients.

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skin : scabies 10 conclusion

1. Scabies a contagious skin disease caused by infestation and sensitization to mites Sarcoptes scabiei hominis and product variants.
2. Scabies transmission can occur either directly or indirectly.
3. Scabies is the great imitator, where there are clinical symptoms which resemble to some other skin diseases. And lesions typical of this disease form, which papul itching or vesicle, and the presence of the tunnel (Burrow).
4. Scabies diagnosis can be established by a careful anamnesis (history of contact with other patients, pruritus nocturna), physical examination (lesions of the typical predileksi Glan  penis and scrotum in males and mammary areola in women), and also with laboratory tests appropriate (microscopic examination, the ink test, or biopsy tissue).
5. Permethrin 5% is still the treatment of choice of scabies current treatment.
6. The success of therapy and prognosis of healing depends on patient compliance in therapy, the patient's ability to maintain personal hygiene and environment, as well as extensive treatment in the family and the people who frequent contact with patients.

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skin : scabies 9 treat

Several types of treatment have been conducted since scabies first, but research on the ideal therapy scabies still do. According to Rikyanto (2001), the ideal skabisid is: 1. Should be effective against all stages of mites; 2. Should not cause irritation, hypersensitivity, and non-toxic; 3. No smelly or dirty, and no damage or color of clothing; 4. Easy to obtain and use (can be used by all ages), and also economical.
1. Sulfur presipitatum
This is a drug dosage longest antiskabies used. Celsus uses sulfur mixed in a special fluid for the treatment of early scabies in 25 AD Sulfur ointment is used in the preparation (2% - 10%) and is usually recommended to use ointment recommended 6%. It's easy: after a shower, sulfur ointment applied to the skin evenly throughout the body for two or three days - helped (Karthikeyan, 2005).
Sulfur ointment messy, rank, leaving marks on clothes, as well as in the situation is hot and humid, can stimulate the occurrence of irritant contact dermatitis. And the benefits of this preparation because it is cheap and is a major option in place - a place that requires treatment in a large scabies or economic reasons. Sulfur is recommended as an alternative therapy is relatively safe scabies in infants, children - children, and pregnant women.
2. Benzyl benzoate
Benzyl benzoate is a derivative of benzoic acid and benzyl alcohol are found in Peru and balsam of Tolu. These preparations are neurotoksik on mites. Dosage used in the form of emulsion concentration of 25% with 24-hour contact time without interspersed bath. In younger patients or in children - children, the dose can be reduced to 12.5%. Benzyl benzoate is very effective when used appropriately. Benzyl benzoate can cause irritant contact dermatitis on the face and scrotum. And the repeated use - dematitis repeated contact may cause allergies. Prohibited use of this preparation in pregnant and lactating women, infants and children less than 2 years. In developing countries with limited resources, benzyl benzoate can be used as an economical alternative in the treatment of scabies (Karthikeyan, 2005).
3. Krotamiton
Krotamiton (crotonyl-N-ethyl-o-toluidine) is used in the preparation or lotion kren 10%. Average - the average treatment success with krotamiton between 50% - 70%. Obtained best results when used twice daily for five days - joined after a bath and change clothes. This medication is not recommended in children - children. And its use in pregnant women who do not have enough information (Category C) (Karthikeyan, 2005).
4. Gamma benzene heksakloride (Lindane)
Gamma benzene hekaskloride is an insecticide. Wooldridge was first used to treat scabies in 1948. These drugs work on the CNS (central nervous system) mites and cause an increase eksitabilitas, convulsions, and death. Lindane 1% cream in the form of an effective dosage in the treatment skabies. Applied to use with dry skin and after 6 hours washed with soap, then be repeated again 1 week later.
Lindane became famous for not irritating and easy to use. But the side effects of this drug can not be excluded. On the use of excess (repetitive use - again and laundering more than 6 hours) can cause increased absorption of the drug, as well as use in neonates and infants as well as use in conjunction with the use of hair oil. This resulted in toxicity that causes such symptoms in the CNS, headache, dizziness, nausea, termor, disorientation, muscle weakness, convulsions, breathing failure, even death. Some who had reportedly also be abnormalities in the blood, such as AZ anemia, thrombocytopenia, and pansitopeni (Karthikeyan, 2005). Because the resulting side effects, so that this group can become the drug of choice in the second or third scabies treatment.

5. Permethrin
Permethrin is a synthetic of pirethoid and potent insecticide. Permethrin is very effective against mites with a low toxic effect on mammals. These drugs work by disrupting the exchange of Na + that regulate nerve cell membrane polarization mites. So that will happen inhibition of repolarisasi and resulting in paralysis of the nerve cells mites (Rikyanto, 2001). Permethrin is absorbed in small quantities only through the cutaneous layer, rapidly metabolized by enzymes in the skin, and is excreted through the urine. 5% permethrin cream in the preparation, applied to the entire body once a week for 2 weeks. Left pengolesannya effective in 8 to 12 hours, then washed to clean. This drug is the latest and most effective for the treatment skabies, so that the drug of choice. Permethrin is safe to use on infants over 2 months and in nursing mothers. According to Karthikeyan (2005), from several studies indicate that permethrin has a high cure rates than lindane and krotamiton. Permethrin did not cause side effects of allergies, and in cosmetics can be accepted. Mild burning sensation or smell may arise dreadful, sometimes also causes skin redness, and itching, but it was only temporary (Cordoro, 2008). And the factors that limit the use of this drug, that the price in terms of permethrin is the most expensive compared to other topical medications scabies.
6. Ivermectin
Ivermectin, a derivative of avermectin B, is almost equal to the macrolides, but without the antimicrobial action. How it works through the suppression of nerve impulse conduction in nerve-muscle synapse in the mites with stimulation of gamma amino butyric acid (GABA) from nerve endings and presinaps bind to receptors on postsinaps. Preparations ivermectin in capsule form at a dose of 3 mg or 6 mg. Feeding at a dose of 0.2 mg / kg single dose. When are repeated, preferably 7 - 14 days after the first delivery. The effectiveness of these drugs quite well with good healing and reduced the former - former pruritus. The drug is rapidly absorbed, metabolized in the liver and excreted through feces. Absorption can be improved if ivermectin eaten with fatty foods (Chosidow, 2006). Ivermectin is safe with side effects of a single dose was not significant. According to research conducted Meinking, et al (1995), giving a single dose of ivermectin is effective in treating patients who skabies on "healthy" and in some patients with HIV infection. Giving dikontrandikasikan in patients ivermectin sensitive and allergic to these drugs, patients with CNS disorders. Also this drug is not indicated in pregnant and lactating women, children under 5 years old or weighing less than 15 kg.
Ivermectin therapeutic potential of scabies choice. To further topical ivermectin began to be used in the skabies therapy.
In patients skabies krustosa and also patients with HIV, treatment is needed for a long time. Giving peroral sufficient ivermectin to treat scabies effective, but require multiple doses and in combination with the drug and can be added topical to keratolitik existing hiperkeratosis (Karthikeyan, 2005).
Some problems that can arise in therapy. According to Karthikeyan (2005), among other problems that remain itch feels post-therapy, and treatment failure. Persistent itch can be reduced by giving antihistamines or topical steroids delivery / oral (Cordoro, 2008). And treatment failure can occur because of: providing an inappropriate, inadequate provision, reinfestasi, and reinfection.

Prognosis
With proper diagnosis and appropriate treatment and adequate, the prognosis of recovery from scabies infection quite well. In imunokompromise patients can increase the risk of scabies krustosa, where it will affect the prognosis.

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skin : scabies 8 Management

Management
Generally divided into antiskabies drug topical medications and oral medications. Scabies treatment as important in making the right diagnosis. The main therapy is a drug - skabisidal topical medications. Some of the things considered in patients handling, among others (Karthikeyan, 2005):
• definite diagnosis
• Medical treatment is appropriate
• Provide drug evenly throughout the body.
National guidelines recommend that treatment be done in the whole body's skin, without exception. Give more attention to areas where there are tunnels or mites that often arise (Anon, 2007).
• Treat all people close or frequent contact with patients.
• Provide medical explanations given verbally and in writing to the patient.
• Treat secondary infection exist.
• Do control over one and four weeks after treatment
• Wash clothes and bedding after treatment is completed.
In addition patients should also be informed about how the use of drugs skabisid. Some things that need to be informed and advised in patients (Karthikeyan, 2005):
• Starting with a regular shower and dried to perfection later.
According to Webster (2007), bath with warm water may increase the systemic absorption of most drugs can trigger scabies and irritation reactions.
• Topical treatment given to certain lubricated the entire skin.
In the areas under the fingernails, can be assisted by lubricate nail brush or a small toothbrush (Webster, 2007).
When will wash their hands or other body parts during treatment, then afterward must re lubricated in the area (Anon, 2007).
• Treatment is best done at night before bed.
• Better for people with children - children remain at home until treatment is complete. And the baby needs more attention so as not to lick the drug spread (Anon 2007).
• Avoid touching the mouth and eyes with his hand directly.
• In women who are breastfeeding, before feeding the nipple should be cleaned from the existing topical medications, to then return after feeding lubricated (Anon, 2007).
• Change underwear, clothes, sheets, and pillowcases and washed the next day.
Clothing, towels and bed linen should be washed with a washing machine at a temperature of 50o C or above after starting treatment. It is expected to kill the mites that may exist. For clothes that had not been washed, should be stored in a plastic bag for 72 hours to accommodate these mites to death. Another alternative is to kill mites on clothing or sheets with iron with a high temperature, dry cleaning, or put in dryer with a high temperature for 10 - 30 minutes (Anon, 2007)
• The itching will still feel in a few days, but do not need to repeat the treatment performed.
• Each person in the house or close and frequent contact with patients should be treated in the same time.
• Control back to the treating doctor in a week.

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skin : scabies 7 Examination Support

1. Laboratory
On microscopic examination, expected to be found in the mites, either in the form of adults, larvae, or eggs through the skin scrape. The procedure of the microscopic examination through the skin is scrape (Cordoro, 2008):
- Mineral oil dripping on the glass object. Then with a scalpel blade no. Spoon curette 15 or 7 mm, after it is applied to the oil, carried out at scrape skin lesions found, mainly primary lesions, such as vesicles, papul, and tunnels. Avoid the occurrence of bleeding.
- Results scrape was then placed on an object glass and covered with glass for the deck and then examined on a microscope with magnification 400 x.
scrape skin can be done over and over again for more help in finding scabies (in various stages) or product (skibala, broken eggs). In scabies krustosa patients, may be added potassium hydroxide (KOH) to dissolve the keratin that is the skuama, but required a more thorough examination.
To find the existence of the tunnel (Burrow) on the skin, can be known by the following test (Cordoro, 2008):
- Test the ink; tip ink pen / ink dripped on the suspected area of the tunnel there. The ink is then going to fill the tunnel, unlike the surrounding area. The ink is cleaned out with alcohol. This method is useful in children - children and patients with a very small tunnel.
- Alternative ink tests (using tetracycline ointment) is an alternative topical tetracycline in ink testing. After smeared with tetracycline and cleaned with alcohol, the suspected area was examined under Wood's lamp. Tetracycline is left in the tunnel would cause flourensi yellowish color. This method is preferred because it is colorless and tetracycline skin area can be examined more widely.
Other laboratory tests can help diagnose include scabies (Binder, 2006):
- Increased levels of IgE and eosinophils in the blood.
- The health center can do a complete examination videodermatoskopi, epiluminens microscopy, and DNA amplification by PCR (polymerase chain reaction) using the ELISA method (enzyme-linked assay Immunosrbent).
2. Histopathology
Histological examination of scabies enough to determine a diagnosis, although there are a variety of arthropods reaction. If found in a tunnel, then the mites, larvae, eggs, and can be identified in skibala stratum korneum. Infiltrates of the superficial skin layer and a deeper, composed of lymphocytes, histiosit, mast cells, and eosinophils. Sometimes also obtained spongiosis and vesicle eksositosis composed of eosinophils and neurofil.
In scabies krustosa indicates massive hiperkeratosis stratum korneum with mites in large numbers and in various stages. Sometimes psoriasiform hyperplasia was also found under a layer of the epidermis with focal epidermal spongiotik and mikroabses. Dermis layer, chronic inflammatory infiltrates seem superficial and deep with some interstitial eosinophils (Cordoro, 2008).

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skin : scabies 6 diagnosis

According to Handoko (2007), the diagnosis can be established if scabies found 2 of the 4 cardinal signs as follows:
• Proritus nokturna, means itching at night. This is caused by mites that activity was higher in the more humid conditions and higher temperatures, and it happened at night.
• Attacking a group of human beings. Where scabies not only suffered by the patient, but also about the entire family or transmitted to people - the closest.
• The discovery of the tunnel (kunikulus) in place predileksi lesions. Tunnels are usually white or gray - gray, straight line or curved - curved, with the average length - average 1 cm, and at the end of the tunnel is often found in vesicles, papules, or pustules.
• The discovery of mites, both in the form of eggs, larvae, or adults. This is the most diagnostic points.
From the clinical manifestations described above, which includes the classic scabies, still there are many forms - a special form of which can be found skabies (Rikyanto, 2001):
1. Scabies on the net (clean scabies)
Usually very hard to find the tunnel. Lice are usually lost due to bathe regularly.
2. Scabies in infants and children
Scabies lesions in children can be about the entire body, including the entire head, neck, palms, soles of the feet, and often secondary infection of impetigo, so that the tunnel ektima rare.
3. Scabies which is transmitted by animals
Sarcoptes scabiei canis variants can infect humans who work closely with these animals, such as farmers and pastoralists. Mild symptoms and will heal themselves when away from the animals - these animals and bathe with clean (Maskur, 2000).
4. Scabies nodular
Nodules due hipersensivitas reaction. The place is often subject to male genitalia, groin and axilla. Lesions that arise can stay a few weeks to several months, even up to a year despite having received anti scabies (Maskur, 2000).
5. Scabies incognito
Topical medication or systemic steroids may mask the symptoms and signs while scabies infestations remain. In contrast, treatment with topical steroids which can also cause long lesions intensified. This may be caused by the decline in cellular immune responses.
6. Scabies lying in bed (bed-ridden)
Patients with chronic diseases and elderly people who are forced to stay in bed may suffer a lesi limited scabies.
7. Scabies krustosa (Norwegian Scabies)
Eritrodermi picture Lesi form, accompanied skuama generalized, erythema, and nail dystrophy. There are many Krusta, this form easily transmitted because the population is very high Sarcoptes scabiei and itching is not prominent. Often occurs in older people and people who suffer from mental retardation (Down's syndrome), low skin sensation (leprosy, and tabes dorsalis syringomelia.

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skin : scabies 5 Clinical Symptoms

Clinical Symptoms
Diagnosis of scabies be enforced from history (anamnesis) and physical examination on patients, especially the history of infestations of scabies, family history, and contact with previous patients. Classic manifestations of itching scabies includes a comprehensive and extraordinary and increasingly intense itching at night.
Scabies different distribution of lesions in children and adults. In adults, lesions are usually found on the flexor of the arm, between - between fingers, back of legs, armpits, elbows, hips, back and genital area. Papul the itching and vesicles can be found on Glan scrotum and penis in males and breast (areola) in women is a characteristic of the lesion scabies. Lesions in infants and children - children grow more in the head, face, neck, palms, though it may also spread in other regions (Cordoro, 2008).
Presence of nodules and the tunnel (in the armpits or genital area) is a typical picture of scabies, but can also not be found. Secondary lesions that are not specific, such as excoriate, eczema, or impegtinasi, may be found in patients (Chosidow, 2006).

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skin : scabies 4 pathogenesis

Pathogenesis
Skin disorder that occurs from scabies was not only due to mites, but also by patients themselves, which is due to do scratching.
Mites (Committee) to move into the top layer of skin by removing the protease enzyme that can be thinned stratum korneum. They live from damaged tissue rather than blood sucking. Skibala (feces) are left behind when he passed the epidermis, forming lesions clinically shaped tunnel liner. Skibala causes sensitization of the skin, causing itching complaints (Cordoro, 2008).
The incubation period varies skabies, there are a couple of weeks and even months - months without showing symptoms. Sensitization of the mites will take approximately 4 to 6 weeks after the first mite infestations. Infestations of this first hipersentivitas reaction type IV, which is a reaction to the mites, eggs or skibala of these mites (Maskur, 2000). At this moment arises that resembles the skin disorder dermatitis with the finding papul, vesicles, hives, etc., which can occur with erosion scratching, ekskoriasi, krusta, even a secondary infection (Rikyanto, 2001).
At the time of this onset, the patient can infect at least within one month before being diagnosed with skabies. This means that transmission can occur in anyone who had contact with patients.
Scabies mites can not fly or jump away, but they can travel with average speed - average 2.5 cm / min in the warm skin. At room temperature with sufficient humidity, mites can survive 36 to 48 hours and still have the ability to infect and make a tunnel lesions (Chodisow, 2006). Was at a temperature of 20o C, the mites become immobile, but still can survive for a longer time (Cordoro, 2008).
Scabies transmission can occur either directly or indirectly. Direct transmission is due to skin contact with the skin (skin to skin contact). Because it did, it can be classified in scabies sexually transmitted diseases. According Chodisow (2006), from studies ever of the risk factors scabies transmission through sexual intercourse, that people at high risk for infection scabies on people - people who often relate the same sex (homosexual) or who frequently change - change partners. But there is no evidence that can be transmitted scabies with HIV.
Indirect transmission usually occurs through objects - objects related to the patient as the bedding, clothes, towels, pillows, and so forth.

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skin : scabies 3 etiology

Etiology
Scabies caused by Sarcoptes scabiei. Sarcoptes scabiei including the phylum Arthropoda, class Arachnida, order Ackarima, Sarcoptes super family. Sarcoptes scabiei derived from the Greek, which means that sarx koptein meat and that means cutting, and also from the Latin word meaning scratched scabere (Cordoro, 2008). Scabies who attack people of Sarcoptes scabiei variety hominis. In addition there is S. scabiei others, such as the goats and pigs. Sarcoptes scabiei var hominis was found by Italian biologist named Diaconti Cestoni in the 18th century (Handoko, 2007).
In morphologies S. Mites Scabiei is small, oval, convex back and abdomen flat. Mites are translucent, white, dirty, and no eyes. Female mites have a larger size than males, it ranges from 0.3 to 0.4 mm, where the male mites only about half the size of it. Form of adult mites have four pairs of legs, two pairs of front legs as a means to stick, and two pairs of legs on females both ends with hair, was on the third leg of male couples end up with hair and a fourth as a adhesive (Handoko, 2007).
Movement of mites in the skin causing a very itchy feeling and led to similar reactions with allergic reactions. Produced eggs produce allergic response that causes itching feeling better (Morgellons, 2007).
Skabies only occurs when there is S. scabiei males and females into the skin. After a copulation, S. scabiei males will die and the females will continue to live. Then the female mites enter the skin and create a tunnel (tunnel) in the stratum korneum speed from 1 to 5 mm / day. In these tunnels female mites will lay eggs 3 to 4 eggs a day until you reach number 40 or 50 grains. Fertilized female forms can live a month. Eggs will hatch, usually within 3 - 5 days. And the larvae have three pairs of legs. After 2 - 3 days, the larvae become nymphs with 4 pairs of legs. Life cycle from egg to adult form takes between 8 to 12 days. Adult mites will come out of the tunnel to find his partner (the event usually occurs at night). If mites are not in the skin, so he can live in clothing, sheets, or towels for 2 or 3 days, so in this period that may arise reinfection (Rikyanto, 2001).

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skin : scabies 2

Definition
Scabies is a skin disease due to mite infestations and sensitization Sarcoptes scabiei hominis and product variants on the body (Siregar, 2005).

Synonym
Human Skabies often also called scabies (gudikan), Ampera disease, itching Agogo, budukan, the Itch, Seven-Year Itch, intense pruritus, nocturnal pruritus (cakmoki, 2007).

Epidemiology
It is estimated that an epidemic or pandemic of scabies occurred in 30-year cycle. However, because scabies not a disease that routine in the recording, and the information there is also wide - types, making it difficult to ensure the incidence of scabies. Several years epidemic ever reported 1919-1925, 1936-1949, and 1964-1979. Scabies also is a disease found in tropical and subtropical regions. High prevalence figures in the Aborigines in Australia, in South America, and in some developing countries around the world (Binder, 2006). And in developing countries, can appear as scabies epidemic cases in the hospital, nursing home, or at primary health facilities (Karthikeyan, 2005).
Although scabies often occurs in a younger population, but actually scabies can attack all ages, all races, all socioeconomic levels, and with equal probability between men and women. The spread scabies not directly related to one's hygiene, but more related to poverty and population density (Binder, 2006).

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skin : scabies 1

For ordinary people, the term zoonoses is still a foreign thing. But basically, have a sense as zoonotic animal diseases that can be transmitted to humans. One of them who is still an issue in the scabies skin health. Scabies is not a disease in animals, but a disease affecting humans caused by animal parasites. Scabies in humans is an infestation of disease is very itchy skin caused by parasitic infection, in this case of mites (committee).
Scabies cases spread throughout the world is estimated at 300 million cases per year. Scabies can appear in men or women, at all ages, all ethnicities, and also at all levels of socio-economic life (Chosidow, 2006). More than 2500 years ago, has become scabies skin problems in humans. At first, the Romans used to indicate the limits scabies the itchy skin disease. Aristotle discussed the "lice in the flesh" contained in a vesicle. In the 17th century, precisely in 1687, Giovanni Cosimo Bonomo explain the disease caused by mites (Committee) is. This is a disease in humans for the first time unknown causes due to the typical (Binder, 2006).
Currently, scabies restriction leads to skin lesions caused by mites (committee) this. Enforcement scabies early diagnosis is still difficult, inadequate treatment of the patient, and the environment suspected as the main cause of this disease developing. Clinical scabies closely resembles the other skin diseases, so often associated with other skin diseases it. This often led to late diagnosis.

Scabies is widespread health problems, can strike all ages, and socioeconomic groups. Delay in diagnosis and treatment and low education about a very important role to scabies prevalence of these scabies. Worldwide prevalence estimated 300 million cases per year. Average - the average prevalence was higher in children - children and individuals with an active sexual activity than other groups. According Chosidow (2006), from a study in the UK, scabies show a high prevalence in the population of these cities and are women and children - children. Scabies This is more common in the rainy season than the summer. Patients with such a weak condition in leprosy, and patients with immune low condition (immunocompromissed) as in the case of post-transplant, HIV disease, and elderly patients are at high risk of this disease.

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treat melasma : 10 Conclusion

Hiperpigmentasi skin is a problem that many patients found the therapy to look for cosmetic reasons. Hiperpigmentasi interference that often complaint patients hiperpigmentasi is melasma and post-inflamasi. Melasma is hipermelanosis which usually occurs in areas affected by the sun.
The cause of melasma is ultraviolet rays, hormonal, drug, genetic, race, cosmetics, pregnancy and idiopathic. Pathogenesis melasma associated with many different fields of science, such as biology, biochemistry, pathology, and patofisiologi process pigmentasi skin, both at the cellular level, biomolekular, skin and tissue. In addition, knowledge of the pathogenesis is very important to establish the diagnosis and treatment
Melasma diagnosed only with clinical examination. To determine the type of melasma, Wood-ray examination is done. While the examination histopatologik only done in some cases.
Hiperpigmentasi treatment in general and in particular melasma, usually because of cosmetics, for their own lesi never give subjective complaints.
In addition to the curtain and use the sun to prevent melasma, the use of cream containing tretinoin, kojik acid and acid azeleat has showed improvement of melasma. Sometimes recommended for chemical peels or use a steroid cream topical. In the case of a heavy, laser treatment can be used to eliminate hiperpigmentasi.

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treat melasma : 9 handling

Handling
Melasma is an aberration in a difficult therapy. Pigment in melasma increased gradually, and it also requires a long time. Cases and chronicles recurrent and may often occur in people who are often exposed to sunlight exposure. All light waves from the sun, including visible spectrum can cause the occurrence of melasma.
Hiperpigmentasi treatment in general and in particular melasma, usually because of cosmetics, for never giving lesi subjective complaints.
Some of the actions of prevention are:

a. Avoid the sun. This is usually done with conventional ways, such as wearing a hat with a wide or paying or using screen sun (sunscreen)

b. Stop the use of contraceptives.
In addition to the curtain and use the sun to prevent melasma, the use of cream containing tretinoin, kojik acid and acid azeleat has showed improvement of melasma. Sometimes recommended for chemical peels or use a steroid cream topical. In the case of a heavy, laser treatment can be used to eliminate hiperpigmentasi.
Pandhi research conducted to evaluate the comparative treatment topikal in melasma treatment. Melasma from 50 patients taken at random, divided into 5 group (10 people per group). Evaluation of drug treatment of clobetasol propionate 0.05%, 0.025% tretinoin, hydroquinone 2%, benzoil peroxide 5% and glycolic acid 10% show the effectiveness of each drug. Effectiveness of drugs is highest clobetasol (80%).
Research other states that have the alpha hydroxyl acid is the right choice in the treatment of melasma suitable for Asian and Latin skin. Research that is conducted Satiti success kojik acid cream 2% can be used as alternative therapy melasma. Melasma can be difficult cured, melasma pigment form slowly and it is slowly.
Topikal range of treatment for melasma, including:

a. Hidroquinon
Hidroquinon is a chemical that impedes hydroxyphenolic so tyrosinase conversion decreased DOPA into melanin. Hidroquinon can be applied in the form of a cream or mixed with a solvent solution. Concentration allowed in the United States is 2%, without a prescription that is used for concentration of 4% or higher again. Hidroquinon related to the effectiveness of the degree of concentration but the side effects that occur along the increased concentration increased.
Other mechanisms that may be the way destructs, melanosit, melanosom degradation, and prevent DNA and RNA synthesis.
Hidroquinon used in the form of a cream-colored with a concentration of 2-50%. Cream is used at night, with the curtain in the afternoon sun. Generally appear to improvements in 6-8 weeks and followed up to 6 months.
Concentration that causes excessive skin irritation, reaction phototoksik with hiperpigmentasi post inflamasi and okronosis eksogen irreversible. Monobenzil ether causes vitiligo-like leukoderma a good lokalisata and general.Selain that, in hipopigmentasi can occur around the treated area. After the termination of the use hidroquinon, often relapse.

b. Retinoat acid (retinoic acid / tretinoin)
Acid retinoat 0.1% mainly used as additional therapy or a combination. Cream is also used at night, because during the day can occur fotodegradasi. Now retinoat acid is used as monoterapi and obtained a clinical improvement, although it take a while.
Retinoid trusted to work by increasing the turnover limit keratinosit and delivery melanosom to keratinosit. Major side effects of tretinoin is skin irritation, deskuamasi, photosensitive temporary and hiperpigmentasi paradoksikal. Combination with or without tretinoin corticosteroid topical has been promoted.
0,05-0,1% tretinoin pigmentasi with the transcript tirosinase hamper the functioning sintesis melanin. Tretinoin melasma can be effective in reducing the duration of 24 weeks. Tretinoin have any side effects, namely hiperpigmentasi secondary, and eritema irritation. Retinoid that can be used, among other adaphalen, tazarotene and isotretinoin topikal.

c. Azeleat acid (azeleic acid)
Azeleat acid is a drug that is safe to use. Azeleat acid treatment with 20% for 6 months to give good results. Side effects that can happen is feeling hot and itchy. There are no reports fototoksik reaction and fotoalergik on the use of acid azeleat.
Azeleat acid mechanism of action is not fully understood. Reduction DNA synthesis and cellular energy production mitokondria is the resistor in melanosit. Unlike hidroquinon, acid azeleat only work on melanosit the hiperaktif skin and does not affect the normal function melanositnya.
In a research report azeleat acid is as effective as with the hidroquinon 4% and without side effects. Acid azeleat combination with tretinoin or 0:05% 15-20% glikolat acid can accelerate the skin bleaching. Side effects that can happen is pruritus, eritema lightweight, and taste burnt.

d. Acid kojik
Kojik acid produced by fungus Aspergillus oryzae, and can prevent tirosinase. In the research found that a combination of acid kojik 2% with hidroquinon 2% more effective than the acid glikolat combined with hidroquinon 2%. Other research comparing glikolat acid 5% with 4% or hidroquinon acid kojik 4% for 3 months. -Combination before the combination is effective to reduce the hiperpigmentasi in 51% patients. Acid kojik can help patients hiperpigmentasi that does not fit with the other therapy.

e. Agent depigmentasi other
Depigmentasi other agents that have been examined in the treatment melasma is a 4-N-butylresorcinol, phenolic-thioeter, 4-isopropylcatechol and acid askorbat.

f. Combination therapy
Combination therapy is more effective than the use of one type of product. The cause of melasma is not fully known, so that combination therapy can be more effective for different degrees of therapy hiperpigmentasi one kind of product that is only effective on one hiperpigmentasi degrees.
The addition of tretinoin can increase the pigmentasi and keratinosit proliferation by preventing the oxidation of hidroquinon and improve epidermal penetration. Furthermore, the addition kortikosteroid topikal can reduce irritation and prevent melanin synthesis because cell metabolism will decrease. Combination hidroquinon 5%, tretinoin 0.1% and 0.1% had dexamethason known since 1975, with the name and formula Kligman. This formula is often used as combination therapy for melasma in the world.
Of a multicenter study, using random and double blind control trial showed that a combination of new hidroquinon 4%, tertinoin 0.05% and fluosinolon asetonid 0.01% (Tri-Luma, Galderma) that the result is better than other combinations with 2 or more products / agencies where 77% patients showed total recovery. The clinical, indicated a significant increase in the minimum and maximum of 4 weeks for 8 weeks. Side effects that is common is a mild local irritation, eritem.

g. Specific therapy in pregnancy
Melasma therapy in pregnant women should be done after the birth. This is because, melasma to be more resistant to treatment because of factors such as spark hormones during pregnancy is still high. Then, therapy is also beneficial because it does not become predileksi occurrence melasma also increased after birth and the most important therapy for melasma is kontraindikasi pregnancy.

In addition to the treatment used topikal, the systemic treatment can also be done include:

a. Askorbat acid (vitamin C)
Vitamin C has the effect of oxidation of melanin into the form of a reduction of melanin color is bright and prevent the formation of melanin to alter DOPA into DOPA quinon.

b. Glutation
Glutation form of reduction is sulfhidril compound (SH) that can potentially prevent the formation of melanin to the road to joining Cuprum (Cu) from tirosinase.

Special measures for melasma therapy can also be used as therapy options, among others:

a. Peel chemical
Peel chemical treatment can help hiperpigmentasi aberration. peel chemical smear done with acid glikolat 50-70% for 4-6 minutes should be done every 3 weeks for 6 times. Before the chemical peel, first given sour cream glikolat 10% for 14 days.

b. Surgical laser
Surgery using the laser Q-switched Ruby laser and Argon. relaps can occur. Hiper-treatment techniques pigmentasi with laser Qight amplification by stilulated emition of radiation) is a development of the current. Laser work monokromik emit high intensity, coherent source of energy that diabsorpsi by water, hemoglobin and melanin in the skin, to the kromophor. Absorpsi energy kromophor damage. Wavelength laser and set the lead in penetration and target kromophor.
Based on the spectrum absorpsi melanin, laser Q-switched ruby (694 nm) laser is an appropriate treatment for lesi hiperpigmentasi. Side effects of laser treatment including not feeling comfortable, redness, swelling, and hiperpigmentasi post-inflamasi. Patients should always be a spot test before treatment is done in full.

c. Intense Pulse Light (IPL)
Derivat of treat laser is Intense Pulsed Light (IPL), in pulsasi berintensitas with high wavelength (515 -1200 nm), which emanated by the light energy delivered to the skin. IPL energy is released to the dermis and diabsorpsi by kromophor. IPL has shown that work well for medical treatment for lentigines but melasma is not yet appropriate expectations. IPL treatment side effects are pain, local irritation and hiperpigmentasi post-inflamasi.

Prognosis
Melasma often disappear after a few months termination contraceptives, hormonal replacement therapy or after the birth. Melasma may relapse again if pregnant or use drugs that can spur melasma.
Melasma type dermis may take longer than the type of repair for epidermis because there is no effective treatment for the pigment in the dermis. Source of pigment from the epidermis is the dermis. Therefore, if the melanogenesis epidermis can blocked for some time, not pigment dermis and fill will slowly peter out. resisten cases and relapse often occurs and has been the prevention of contact with the clear sunlight to total no more needed.

Read More - treat melasma : 9 handling

treat melasma : 8 diagnosis

Melasma Diagnosis
Melasma diagnosed only with clinical examination. To determine the type of melasma, Wood-ray examination is done. While the examination histopatologik only done in some cases.

Melasma Diagnosis Letter
a. Addison Disease
Addison disease is a disease caused insufiensi adrenal, where the increase occurred between kortikotropin and MSH, which is marked by symptoms that are often not typical, such as stiff-stiff, weak, anoreksia, Nausea, stomach aches, Gastroenteritis, diarrhea and emotions that are not stable. Insufiensi adrenal is triggered by infection or destructs autoimmune nonspecific on the adrenal gland. Diseases that often cause infection of Addison disease is tuberculosis. There is destructs cortex adrenal cause feedback inhibition hypothalamus gland and anterior pituitary lost, the consequences kortikotropin sekresi ongoing. Kortikotropin MSH and progenitor of both components is the same hormone. When kortikotropin parsed from prohormon, together with the MSH released. Consequences arising hiperpigmentasi crimson / bronze (Bronze hyperpigmentation) that way.
b. Drug induced photosensitivity is kutaneus disease as a result of the combination of chemical reaction and light, where the actual exposure of one of them does not cause disease. This disease is usually because of drugs or chemicals or systemic topical.
c. Discoid lupus eritematous (LED) is a disease that attacks the system connective and vascular caused autoimmune process and the interaction between genetic factors and immunologic, virus infection and hormonal. LED going on which The speck in the skin eritematosa and atrophy without ulserasi. Deviation localise usually symmetrical in the face, ears or neck.
d. Hiperpigmentasi post-infection occurs after inflammation of the skin. Aberration is very common and tend to settle on the dark skin. The clinical hiperpigmentasi can be found following the pattern and distribution of skin disease.
e. Efelid aberration is a form of skin The speck-The speck of black or brown in areas exposed to sunlight. It was revealed that familial factors are autosomal dominant, and usually occurs in the summer. Localization on the face, neck, shoulder, back and hands.
f. Ookronosis the pigment in the dermis hill that often occur because the stack metabolite hidrokuinon in the dermis.

Read More - treat melasma : 8 diagnosis

treat melasma : 7 Laboratory examination

Melanin can be seen in the epidermis or dermis using Wood rays (wavelength 340-400 nm). Epidermal pigment will changed when examined with Wood rays are not in the dermal pigment. In the dermal, will melanin appear black blue. On someone with dark brown skin-black, with checks ray lesi Wood does not appear on the patient so that this referred to as type intermediet.
Usually there is no specific laboratory examination for melasma. Tiroid inspection functions can be done if there are indications. Examination with the Wood-ray can help in determining the location of pigment in the epidermis or dermis. In the case of some pigment found in both locations.

According Supardiman (2007) support the examination can be done on people with melasma are: 6
1. Histopatologik examination. With histopatologik examination, can be 2 types hipermelanosis, namely:
a. Epidermal Type: increase the amount of melanin found mainly in the suprabasal layer of basalt and, sometimes in the stratum spinosum to stratum korneum. Cells that contain melanin is concentrated melanosit, cell-cell layer and suprabasal basalt, keratinosit cells and stratum korneum. In most cases, a number of melanosit not increased. Nevertheless, melanosit appear larger, more dendritic and more active.
b. Dermal type: there is makrofag bermelanin around the blood vessel in the dermis and the top down. At the top of the dermis there is a focus infiltrat.
2. Electron microscope examination. Electron microscope examination provides a description ultrastruktur melanosit in the basalt layer increases.
3. Examination with the Wood-ray (wavelength 340-400 nm). Examination with the Wood-ray can be divided into 4 types, namely:
a. Epidermal type: lesi see more color contrast
b. Dermal type: lesi color contrast does not increase
c. Type mix: lesi have increased the contrast, there is not
d. Type not clear: the Wood-ray, lesi not become clear, whereas with the usual ray clearly visible. Usually occurs in people with dark brown skin color, where the Wood lamp examination does not localise pigment.

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treat melasma : 6 Clinical symptoms

Melasma does not cause symptoms in addition to changes in skin color but the big problem may be cosmetic.
Melasma usually attack the women, only 1 out of 20 suffered by men. Melasma generally occur between ages 30 to 40 years. Melasma occurs in many people with darker skin.
Lesi melasma be a young makula brown or dark brown, with a boundary edge is not strictly regular. Lesi on dermal type melasma colored grayish or bluish. Predileksi often on the cheek and nose, called the fact pattern. Pattern found in the mandibular chin. While the pattern sentrofasial about the temple, forehead, eyebrow and top lip. A pattern that is rarely found on the border with arms which looks down on women who use progesterone and native American Indian.

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treat melasma : 5 Classification

According Supardiman (2007), melasma classified based on the clinical picture, the examination with Wood-ray examination and histopatologis.
1. Based on the clinical picture:
a. Form sentrofasial areas include the forehead, nose, the medial cheek, nose and chin down (63%)
b. Continuous forms of covering the nose and cheek lateral (21%)
c. Mandibular form covering mandibular region (16%).
2. Based on the examination with the Wood-ray
a. Epidermal type. On the type of melasma is more clearly visible with the Wood-ray diffraction compared with normal.
b. Dermal type. Type dermal rays Wood with no visible color contrast compared with the normal ray.
c. Type mixture. On the type of mixture, it appears some locations more clearly, while the other is not clear.
d. Type considered difficult because of dark skin color. This type of radiotherapy Wood, lesi become unclear. Differences in types this is the means of therapy. Dermal type more difficult than treated epidermal type.
3. Based on the examination histopatologis
a. Melasma type epidermal. Type of brown epidermal generally. Melanin mainly found in the basalt layer and supra basal. Sometimes there is melanin in the stratum corneum and stratum spinosum.
b. Melasma type dermal. Dermal type blue brown. In the dermal type macrophage melanin found around blood vessel in the dermis and the top down. In addition, at the top of the dermis there is a focus infiltrate.

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treat melasma : 4 Etiology and Patogenesis

Etiology melasma until now has not been definitely known. According Supardiman (2007), factors that are considered causative role in the occurrence of melasma is patogenesis:

1. Ultraviolet rays.
Spectrum sun damage this cluster sulfhidril in the epidermis which is the enzyme tirosinase resistor with the binding of the enzyme Cu ion is. Ultraviolet rays cause the enzyme tirosinase not dihambat again, so that drive the process of melanogenesis.
Other mechanisms that cause sun exposure can cause melasma is the ultraviolet ray radiation can cause cell membrane lipid peroksidasi so that the generated free radicals stimulate melanosit to release melanin. Curtain especially to block the solar UV-B radiation (290-320 nm) is not satisfactory because there is a wavelength that is longer on the UV-A rays and visible radiation (320-700 nm) have the nature melanosit stimulated to produce melanin.

2. Hormonal
Hormone estrogen, progesteron and MSH can stimulate the formation of melasma.
Hormones have an important role in the human body. On the mask of pregnancy is known in terms obstetrik. Certain mechanisms of melasma because of the pregnancy has not been known. Estrogen level, progesterone, and Melanosit Stimulating hormone (MSH) generally increased in the third trimester. However, in nulipara with melasma, and MSH estrogen level does not increase. Then, the occurrence of melasma because the use of oral contraceptives and diethylstilbestrol used for prostate cancer therapy has also been reported. In the research, women who get menopause will progesteron experiencing melasma, while women who got estrogen not only suffering from melasma, so that it can be proved that progesterone a role in the occurrence of melasma.
One study found that patients with the disease tiroid suffering from melasma. A report of cases also reported that melasma can occur in patients who have experienced emotional stress because of increased MSH produki by hipotalamus.

3. Drugs
For example difenilhidantoin, mesantoin, klorpromasin, sitostatik and minosiklin can cause the occurrence of melasma. Drugs in this collectedthe top of the dermis layer and can stimulate cumulative melanonogenesis.

4. Genetic
Reported cases of family around 20-70%. Genetic factors is a major occurrence of melasma. This occurred mainly in women than men. A person with brown skin and the young sun exposure will increase the excess occurrence of melasma. More than 30% of patients have melasma history of the family who suffered the same aberration. Identical twin trends have also been reported suffering from melasma.

5. Race
Melasma many found in the Hispanic and the dark skin color.

6. Cosmetics
Use of cosmetics that contain perfume, coloring matter or materials that can cause fotosensitivitas which can lead to the emergence hiperpigmentasi in the face if exposed sun.

7. Certain conditions, such as pregnancy and hormone replacement therapy during menopause.

8. Idiopatik.

Pathogenesis melasma is not yet clear, many factors that are considered causative role in pathogenesis melasma.
According Supardiman (2007), pathogenesis the occurrence of melasma involves many factors, such as:

1. Increased production of hormones or because melanosom because ultraviolet rays. Melanosom this increase can also be caused pharmacology materials such as silver and psoralen.

2. Retardation in Malphigian cell turnover. This condition can occur because drugs sitostatika.
Pathogenesis melasma associated with many different fields of science, such as biology, biochemistry, pathology, and patofisiologi process pigmentasi skin, both at the cellular level, biomolekular, skin and tissue. In addition, knowledge of the pathogenesis is very important to establish the diagnosis and treatment.

Read More - treat melasma : 4 Etiology and Patogenesis

treat melasma : 3 Epidemiology

In the case of melasma comparison between women and men is 24: 1, especially visible in the fertile with age women Exposure history directly affected the sun. Highest incidence at age 30-44 years, whereas according to Montemaro in 2001, 90% of cases occurred in melasma women, if any clinical symptoms in men and histologisnya same.
Research conducted by Goh and Dlova 1999 in Singapore, the ratio of melasma among women and men of 21: 1.
Melasma is a big problem for the East Asia, with skin type III or IV that is equal to 90%. Although the exact number of incidents in some countries is not known, but in East Asia is reported that the patient came to the clinic every year by the skin of 0.25 -40%.

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treat melasma : 2 Definition

Melasma is hipermelanosis which usually occurs in areas affected by the sun. Melasma derived from the Greek, which means the weld while cloasma black comes from the word cloazin, which means to be green, so that melasma more appropriate terminology is used to hiperpigmentasi in the face.
Melasma or khloasma is often called a hiperpigmentasi The speck that is often found in the region face the second cheeks, forehead, chin, mouth up, and can be extended up to the neck. Color can vary from brown to black youth and does not regularly shaped. Size also varies. Lesi usually symmetric, especially when the cheek, while spreading like a mask.
Synonyms of melasma is chloasma which sometimes used to describe the occurrence of melasma during pregnancy. On pigmentasi pregnancy can also occur in general, and often arise in the linea alba becomes a linea nigra, the areola mammae, and on the genitalia area eksterna. Hiperpigmentasi this is happening because of the increased level in the blood so that MSH stimulation occurred melanosit activity, is also estimated to increase estrogen and progesteron role in this interference pigmentasi.

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treat melasma : 1

Human skin color is a combination of several kromofor, the melanin that gives color brown, which gives oksihemoglobin red, which gives deoksihemoglobin blue carotene and the color orange-yellow. Melanin is the component that contributes most dominant color in the skin, so that interference is caused mainly by pigmentasi not have melanin pigment.
Melanin produced by cells melanosit located in the stratum basalis epidermis. Production of melanin occurs in the melanosit and then distributed to keratinosit around melanosit it. Main function of melanin is to absorb ultraviolet radiation. Differences in skin color of different races is not determined by the number of melanosit but depend on the metabolic activity melanosit, the size and shape melanosomnya the organela forming melanin.
Hiperpigmentasi skin is a problem that many patients found the therapy to look for cosmetic reasons. Hiperpigmentasi this is the result of deposisi melanin in the skin caused by increased synthesis or increased the number of melanosit. The many changes color depending on the location of melanin in deposisi. Hiperpigmentasi interference that often complain from patients hiperpigmentasi is melasma and post-inflamasi. These conditions have a major impact because the changes will affect the color of the face someone in the psychological, social life, and confidence.
Hiperpigmentasi determine the cause is very important in the approach to therapy. Based on history and clinical findings of patients, causes hiperpigmentasi likely due to post-inflamasi factors, drugs,
photosensitive agents, ultraviolet rays or systemic disease (eg, Addison disease, liver disease, pregnancy, tumor pituitari). So that the treatment interruption pigmentasi this can succeed, the agent must be determined and it is managed well.
Beauty is not only seen from the outside, but beauty is in support of the creation of a person to appear beautiful. Beauty also need to be outside, because of the line with the age, beauty could be someone outside the pale. One difference that can change the skin of someone's appearance is melasma.
To date, the melasma is still a problem in both the cosmetics and the skin disease in the clinic, this is because handling a difficult and requires a long time.

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surgical epidural hematom: 9 conclusion

Hematoma epidural is one of the cases emergency the need to obtain strict control because it can cause permanent disability and life threatening if not get the handling of the operation. Hematoma occurred in the space between the dura mater and the bottom tabulation of the skull bones.
Typical symptoms of hematoma epidural, namely the existence of lucid interval, where there is conscious phase between phases is not aware. And enforcement of the diagnosis based on clinical findings and of the scanning head to this day is still the gold standard for diagnosis support HED.
Action surgical evacuation can be done after the volume and location based on the results of head CT scan.
When you get the handling right and appropriate, the prognosis of patients with hematoma epidural is very good and can recover as usual.

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surgical epidural hematom: 8 Complications & Prognosis

Complications
Many complications may arise from the case of HED. When the brain herniasi, arterial - arterial anterior and posterior brain can be stopped, for the next infark can cause the brain (Ullman, 2006).
In some cases, patients with HED behavior changes can occur after several hours to days after injury. In addition, when handling and do not get adequate, then patients with HED may vegetative status or even death (Price, 2006).

Prognosis
After the blood clot is taken, for the next patient is treated in the ICU room, in which control more secure. Sometimes necessary to use ventilator patients are conscious and able to breathe by itself. Rating neurology the frequent important to determine the degree of awareness. Particular treatment may be given to reduce interference and maintain brain pressure remained stable intrakranial (Anonymous, 2004).
Mortality figures for patients who do not have a comma before surgical action is 0 and about 10% for patients with disabilities and 20% for patients in a coma in (Price, 2006).
Although the results obtained up to 0% for mortality figures and 100% for the outcome with good function, but the overall number of patient mortality with HED around 9.4% - 33%, average about 10%. In general, the motor examination before the operation, GCS score, pupil reaction, and closely associated with its outcome in patients with acute HED when they can be saved (Ullman, 2006).
As important to remind that the healing of the injury is very long and gradual. It is important also to get enough rest and adequate nutrition while waiting for the process of healing.

Read More - surgical epidural hematom: 8 Complications & Prognosis

surgical epidural hematom: 7 conduct operation

Most of the hematoma epidural is a surgical emergency and must be evacuate as soon as possible. Because brain hematoma epidural under generally quite normal, every effort made to reduce the pressure as soon as possible to prevent brain damage. Outcome of surgery for the hematoma epidural is very dependent on the patient's clinical condition prior to evacuation operative. When clot large, or there is doubt on the extent of brain damage underneath, it is recommended to make craniotomy flap wide standard. In the case where the hematoma epidural clearly limited to one Regio and where there is not accompanied by subdural bleeding on the CT scan appears, flap craniotomi a small modification can be used (Saanin, 2007).
HED with volume of 30 ml, 15 mm thickness and require surgical evacuation action because almost most of the patients with the HED of this kind shows that the level of awareness and poor showing signs - signs lateralisasi (Ullman, 2006).
Location is also an important factor in determining the operative. Hematoma in the Temporal, if the size or spread, can cause herniasi and cause disorients more quickly. HED in the posterior fossa, which is sometimes associated with the dissolution lateral sinus venosus, which requires surgery take action - the heart because the available space is very limited (Ullman, 2006).
In the period before the CT scan, the exploration drill often do, especially if the patient has shown symptoms lateralisasi or deorientasi quickly. Now, with a fast scanning techniques, such as how this is rarely done (Ullman, 2006).
Some circumstances be indicative actions Explore the drill hole (Price, 2006):
 intrakranial Hypertension instability with a heavy hemodinamik
 Alerts - sign herniasi start to appear
Not available  nerve surgeon for immediate consultation
 Trepanasi (or laying of the drill) should be done after consultation with the surgeon nerve, if possible, after residing in the central health.
 land or air transport is too long
Procedure in taking action to make the drill hole according to Price (2006) include:
 Make a deep hole, but not exceed, the broken bones in the skull or from the area indicated CT scan.
 If no CT scan, wimble placed on the side where the pupil is more dilatasi, 2 fingers to the anterior to the ear tragus and 3 finger over it.
In research conducted by Liu, et al in 2006, explained that with the evacuation drill holes and drainage with negative pressure is safe and effective for handling emergency the HED because trauma.

Read More - surgical epidural hematom: 7 conduct operation

surgical epidural hematom: 6 handling and therapy

Handling of HED depending on various factors. Side effects that may occur in the brain due to the mass by, among others, structural distortion, herniasi that threatens life, and increased pressure intrakranial (Ullman, 2006).

Two options in the handling of patients, namely 1. operative action immediately, and 2. initial observations, a conservative, and strict clinical supervision. HED notes that the speed has to be knowledgeable more quickly disbanding hematoma subdural, and patients have a very strict control, if steps taken conservative will (Ullman, 2006).
Not all cases get HED acute surgical action immediately. If lesi existing small and patients neurologist in good condition, with the supervision of the patient examination neurological the frequent be reasonable. Scanning the development can be done to assess the size of hematoma enlargement in the deorientasi. When it was found that increasing the size very quickly, then further surgical action is indicated (Ullman, 2006).

handling prehospital
According to Price (2006), actions taken prior to reaching the health center immediately control the situation - the situation can quickly threaten the lives and provide therapy suportif early. ABC control is the cornerstone that must be remembered. Then needs to be done vena access, the provision of oxygen, and strict supervision. Kristaloid per the provision of IV fluids to maintain blood pressure remains adequate. In addition, can also be done intubasi and sedative drugs, drugs neuromuskular appropriate resistor protocol.
- Use lidokain 1 mg / kg IV BB premedikasi as to prevent increased pressure intrakranial done intubasi time (Argyle, 1996).
- There are several responses about the increased mortality in patients with head injury Moderate to heavy intubasi done before in the hospital compared with patients in diintubasi Emergency Installation (IGD).
- Heating Ventilation mask the face with a good technique can be more beneficial for the brain injury compared with intubasi pre-hospital

handling in emergency intalasi
According to Price (2006), handling up to when the Installation of Emergency Access vena others, giving oxygen, strict supervision, and the liquid kristaloid important to maintain blood pressure remains adequate. This is the first step in handling the patient until after the health center.
Intubasi using Rapid Sequence Induction (RSI), which generally includes the use of lidokain, brain protective agent sedation (eg, etomidate), and agents neuromuskular resistor as premedikasi. Lidokain have a limited effect on the situation like this, even to this day can be spelled without the risk. Premedikasi using fentanyl may also be able to increase the pressure intrakranial. Intubasi should be done after the examination neurologik basis to facilitate oksigenisasi, to protect the roads of breath, and when necessary can be done hiperventilasi.
30o elevate the head of the bed is put back after, or with the reverse Trendelenburg's position to reduce pressure and increase the flow of intrakranial back vena.
Giving manitol 0.25 - 1 g / kg IV BB after consultation with the surgeon if the nerves of the average arterial pressure - average (MAP) greater than 90 mmHg with a sign - a clinical sign of increased pressure intrakranial ongoing. Manitol can decrease the pressure intrakranial (with a decrease in brain edema in osmotik) and viskositas blood, where it can improve blood flow to the brain circulation and oxygen. Fluid must be replaced and should be avoided hipovolemia (urin monitor output produced, it is better when using a down Catheter).
Hiperventilasi to the partial pressure of CO2 ( PCO2 ) 30 - 35 mmHg can alleviate signs - signs herniasi or increased pressure intrakranial, nevertheless, it is still controversial. A decrease in PCO2 should be - the heart that is not too far ( < 25 mmHg). Hiperventilasi given if it appears a sign - a sign of increasing pressure intrakranial progress and continue on sedation, paralisis, diuresis osmotik, and if possible serebrospinal fluid drainage. How to reduce pressure intrakranial with vasokonstriksi hipokarbi and decrease the risk of hipoperfusi cell death and the injury.
Phenytoin may decrease the incidence of spastic post-trauma, although it does not mean a strain on the go or a persistent disturbance.

medication
Some classes of drugs that can be given as a therapy or to prevent further occurrence of side effects (Price, 2006):

Group Diuretik Osmotik
Manitol (Osmitrol) given to maintain serum osmolalitas < 320 mOsm so that it can prevent the occurrence of kidney failure. Dose in adults is 0.25 to 1 gr / kgBB IV, and the dose for children in accordance with the calculation of body weight on the adult dose. Contraindicate of the drug among other drugs of this history hipersensitif before, anuria, the heavy congestion tuberculosis, dehydration weight, bleeding intrakranial of the active, progressive damage to the kidneys, sistolik blood pressure < 90 mmHg. The drug is given to the safe in pregnant women.

Group Antiepilepsi
Phenytoin (Dilantin) therapy is an option to profilaksi strain. Dose pemberiannya in adults is 17 mg / kgBB IV are mixed in with the NS infus no faster than 50 mg / min, and dose to the child - the child in accordance with the calculation of body weight of adult dose. This class can not be given to patients who have a history hipersensitif before, there is sinoatrial block, sinus bradikardi, AV block 2 and 3 degrees, or in patients with Adam-Stokes syndrome. The drug is not safe when given to women in situations that are pregnant.

Read More - surgical epidural hematom: 6 handling and therapy