By H. Jack. California Pacific University. 2019.
What is the rate of adverse events after oral N-acetylcysteine administered by the intravenous route to patients with suspected acetaminophen poisoning? Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial cheap 50 mg caverta visa impotence bicycle seat. Improved outcome of paracetamol-induced fulminant hepatic failure by late administration of acetylcysteine buy caverta 100 mg cheap 2010 icd-9 code for erectile dysfunction. The temporal profile of increased transaminase levels in patients with acetaminophen-induced liver dysfunction. Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study. Although light consumption of ethanol may be associated with health benefits for some populations, heavy consumption increases overall mortality, especially mortality due to trauma, suicide, cirrhosis, and malignancies . Ethanol is estimated to contribute to nearly 90,000 deaths each year in the United States, with economic costs in excess of $200 billion per annum . The so-called toxic alcohols, namely, methanol and ethylene glycol, are usually involved in sporadic poisonings, often involving the accidental exposure of a young child to automotive or household products or the intentional suicidal ingestion of adults. Furthermore, multiple-victim poisonings can occur after recreational substitution for ethanol, during illicit manufacture of ethanol, or after the addition of other glycol products (see further discussion later). Ethanol use is a factor in about 8% of emergency department visits  and 10% to 50% of hospital admissions, and its projected economic costs due to job absenteeism and poor job performance are substantial. Chronic ethanol consumption can cause multiorgan system disease, nutritional disorders, and teratogenic effects. In addition to beverages (typically 4% to 50% ethanol by volume), ethanol can be found in a myriad of other things such as colognes, perfumes, mouthwashes, aftershaves, and over-the-counter medicinals. Ethanol is a small, slightly polar aliphatic alcohol with a weak electric charge and is miscible in water and lipids. It is postulated that ethanol influences multiple ion channels, possibly by causing subtle alterations in their tertiary structure or their dynamic interaction with cell membranes. The behavioral effects of ethanol may result from its ability to antagonize the excitatory N- methyl-D-aspartate–glutamate receptor and to potentiate the inhibitory γ-aminobutyric acid A receptor [4–7]. The precise role of these and other effects in producing intoxication, dependence, and withdrawal (see Chapter 126) is uncertain. Ethanol is readily absorbed from the gastrointestinal tract, with 70% occurring in the stomach and 25% within the duodenum . Acetate is linked to coenzyme A (acetyl-CoA), which can then participate in the citric acid cycle, fatty acid synthesis, or ketone formation . After acute ingestion, there is often an initial stage of paradoxical excitation because of release of inhibitions. For nontolerant individuals, a blood ethanol concentration as low as 20 mg per dL impairs driving-related skills involving perception and attention . At concentrations of 50 mg per dL, gross motor control and orientation may be affected, and intoxication may become apparent . Lethargy, ataxia, and muscular incoordination may be seen at serum levels of 150 mg per dL or greater, coma at approximately 250 mg per dL, and death with levels greater than 450 mg per dL [23,24]. Tolerant drinkers can achieve higher levels before developing similar symptoms, and survival has been reported despite a serum level of 1,500 mg per dL [11,25]. With acute consumption, the physiologic effects at a given serum level of ethanol have been noted to be less when ethanol concentrations are declining rather than when levels are rising (Mellanby effect). Compared with inexperienced drinkers, chronic drinkers experience diminished effects to a given amount of ethanol. Clinical Manifestations Patients may present with varying degrees of altered consciousness, including agitation, stupor, and coma. Diagnostic Evaluation the physical examination should be directed toward evaluation of the airway and a search for complicating or contributing factors such as trauma, infection, and hemorrhage. For patients with moderate-to-severe poisoning, laboratory studies including complete blood cell count; serum electrolytes, blood urea nitrogen, creatinine, glucose, ethanol, magnesium, calcium, and phosphorus level; liver function tests; prothrombin time; electrocardiogram; chest radiograph; arterial or venous blood gas; and urinalysis should be obtained as clinically indicated. Blood alcohol levels may be helpful to support the diagnosis, but it does not predict clinical severity or overall outcomes . If the level of consciousness is inconsistent with the serum ethanol level or does not improve over a few hours, the physician should reconsider the diagnosis of ethanol intoxication (Table 99. Management Patients with stupor or coma who cannot be aroused to a verbal (but not necessarily coherent) state or who have a poor respiratory effort should be intubated to ensure airway patency and to protect against pulmonary aspiration. Hypothermia, when present, is usually mild in the absence of environmental exposure and can be managed with warm blankets. A variety of interventions trying to increase ethanol clearance or decrease its effects are neither clinically useful nor recommended. Vomiting results in decreased intravascular volume and increased catecholamine levels that blunt insulin release  activate lipase and accelerate free fatty acid oxidation. The ketogenic pathway has the largest capacity and requires the least adenosine triphosphate for handling acetyl-CoA overload . Nutritional deficiencies impair acetyl-CoA conversion to triglycerides and its entrance into the citric acid cycle . A hyperchloremic metabolic acidosis has been observed among acutely intoxicated patients who have excreted β-hydroxybutyrate in their urine . The fruity odor of ketones may be detected along with Kussmaul’s breathing, dry mucous membranes, tachycardia, orthostatic hypotension, and poor skin turgor . Signs and symptoms of concomitant gastritis, pancreatitis, hepatitis, gastrointestinal hemorrhage, and vitamin and mineral deficiencies are often present. Laboratory studies should include those listed for acute ethanol intoxication plus serum ketones, lactate, and osmolality. At presentation, the predominant serum ketone is usually β-hydroxybutyrate because of the altered redox state, which results in falsely low serum ketones by the semiquantitative nitroprusside test for acetoacetate . The osmol gap may be elevated from glycerol, acetone, and its metabolites , even after correcting for the serum ethanol concentration [30,31]. The differential diagnosis of an anion gap metabolic acidosis includes lactic acidosis, salicylate poisoning, uremia, diabetic ketoacidosis, and intoxication from iron, ibuprofen, toluene, methanol, ethylene glycol, and diethylene glycol. The presence of more than mild tenderness on abdominal examination should prompt investigation for other pathology such as pancreatitis, hepatitis, sepsis, or pneumonia . Thiamine facilitates the entry of pyruvate into the citric acid cycle and protects against Wernicke’s encephalopathy . Hypophosphatemia may develop with increased glycolysis and carbohydrate refeeding and should be corrected with potassium phosphate [32,34]. Ingestions usually result from suicide attempts, intentional substitution of ethylene glycol for ethanol, or accidental exposure. Ethylene glycol itself causes little toxicity other than ethanol-like inebriation until it is metabolized in the liver into its toxic acid metabolites. Glycolic acid is slowly converted to glyoxylic acid, which in turn is converted to multiple metabolites, including oxalic acid [37,38]. It is uncertain which of these metabolites is most directly responsible for renal tubular toxicity, though recent studies suggest that internalization of calcium oxalate crystals by proximal tubule cells may be directly related to renal damage . The anion gap metabolic acidosis seen in ethylene glycol poisoning is due predominantly to elevated glycolic acid levels [37,40], although oxalic acid, glyoxylic acid, and glycoaldehyde may be more toxic .
Although can have negative effects on fetal development order 50mg caverta fast delivery erectile dysfunction treatment injection cost, birth the expression of the symptoms is presumed to be related outcome and child development discount caverta 100mg with mastercard erectile dysfunction causes young males. The clinical significance of postpartum blues is placenta and the postnatal environment. Depression during pregnancy Postpartum depression Depression has been reported in up to 10–15% of preg- nant women. It has been postulated that there may be poor social support and unintended pregnancy. Within the ‘hormone‐sensitive’ Screening guidelines for depression in adults were phenotype, the normal perinatal fluctuations of reproduc- updated in early 2016, which included screening recom- tive hormones potentially lead to abnormal responses in mendations for pregnant and postpartum women . In this group of sensitive women, hormo- ommended that screening takes place in healthcare set- nal fluctuations trigger affective dysregulation with the tings with ‘adequate systems in place to ensure accurate expression of depressive and anxiety symptoms. The most widely used screening measure utilized in within 1 month of childbirth . In reality, many women perinatal women is the Edinburgh Postnatal Depression who are depressed in the postpartum period had 180 Maternal Medicine depression during pregnancy, or develop it beyond the five other symptoms such as change in appetite or first postpartum month. Maternal suicide is a leading negative effects on infant and child development, the cause of death in postpartum women in some countries mother and the family. Suicidal and infanticidal idea- tion should be inquired about at postnatal visits. While anxiety disorders are often Children of depressed mothers have been reported to comorbid with one another, they differ with regard to have temperament difficulties, sleep problems and poor the stimulus or scenario that induces the fear or anxi- self‐regulation. With all the disor- development, behavioural inhibition, externalizing disor- ders, a defining feature is that the fear or anxiety is ders (such as conduct problems), poor emotion regula- excessive, out of proportion or persisting beyond the tion and altered cognitive function. The symptoms may not be attribut- depressive disorders, anxiety disorders, attention deficit able to the physiological effects of a substance, medica- disorder, conduct disorders and medical illnesses. The worries ity, low mood, tearfulness, irritability, interpersonal include a number of events or activities, and feel difficult sensitivity, anxiety, fatigue and confusion. In the general population, prevalence ranges Agoraphobia, defined as excessive fear or anxiety about from 1. The worries often involve not available in the event of developing panic‐like or pregnancy complications and fetal well‐being, maternal embarrassing symptoms, is often comorbid with panic wellness and partner illness. Postpartum, the panic disorder during pregnancy ranges between zero anxious thoughts often involve mothering skills and the and 54%, with unpredictable courses (worsening, improv- transition to motherhood, breastfeeding, finances, and ing or staying the same) that vary widely among studies. Medical conditions nancy anxiety was the strongest predictor of alcohol that should be considered in the differential for new‐ consumption in the prenatal period. These infants were withdrawn tional age, anaemia, isolated cleft lip with or without with lowered emotional tone. Compulsions are mindfulness training, relaxation techniques and psychoe- repetitive behaviours or mental acts that one feels driven ducation. The behaviours or acts are clearly excessive, to severe cases, weighing the risk of untreated maternal and are not connected in a realistic way to their goal of anxiety and its consequences for the developing infant preventing a dreaded event or situation. A panic attack is defined by an abrupt surge of meta‐analysis showed that prevalence increases as intense fear or discomfort, along with at least four other women progress from pregnancy to the postpartum symptoms such as accelerated heart rate, sweating, sensa- period, and that pregnant or postpartum women are tion of shortness of breath, chest pain, nausea, feeling approximately 1. During the postpartum period actual or threat of death, serious injury or sexual violence, there are often intrusive ego‐dystonic obsessional accompanied by recurrent intrusive symptoms for over a thoughts of intentionally or accidentally harming the month that include avoidance of stimuli associated with infant, fears of contaminating the infant resulting in the event, negative alterations in cognitions and mood repetitive washing, fears of infant death, compulsive associated with the event, and marked alterations in checking, compulsive ordering and avoidance of being arousal and reactivity. It is important to recognize that most post- prevalence may be as high as 24% for women at high risk partum women, greater than 65%, experience intrusive (racial minorities, teens, less educated, or poor) . A mother’s fear of viding psychoeducation, extra support, improving coping harming her infant and subsequent avoidance may hinder strategies and increasing the woman’s sense of control. Increasing data delivery, which is shared with the care team, and includes show that a poor early interaction between the mother her desires for pain control and medications and immedi- and infant can have long‐term detrimental effects on the ate post‐birth wishes. Fear of childbirth As many as 78% of women experience some fear of Summary box 14. The with approximately 30% of women experiencing an fear may result in less tolerance of pain during child- anxiety disorder during their lifetime. Congenital malformations Antidepressant medications during pregnancy Most recent studies report that prenatal exposure to anti- depressants does not increase the risk of major congenital Up to 10% of women take antidepressants at some point malformations. A more recent cohort study suggested that itself be associated with the adverse effect. Neonatal symptoms Miscarriage and birth outcome One of the most consistent findings with prenatal use of Studies of the risk of miscarriage with antidepressant antidepressants is an increased risk of neonatal symp- use in the first half of pregnancy have reported mixed toms that include respiratory distress , temperature results. An increased spontaneous abortion rate may instability, jitteriness, poor feeding, hypotonia and exist in women with depression who do not take an hypertonia, tremors, cyanosis and seizures. Several meta‐analyses have reported that antide- are generally mild, require minimal treatment and pressant use during pregnancy is associated with an resolve within the first month. Some studies suggest delayed ● Studies often do not control for underlying illness, motor development and motor control, and possibly comorbidities and associated behaviours. A potential long‐term consequence of exposure to anti- ● Possible increased risk of cardiac malformations with depressant medication during pregnancy is autism or paroxetine. Sertraline, paroxetine and exposure during pregnancy compared with exposure to nortriptyline have been reported to have low‐to‐undetect- maternal psychiatric disorder without medication . Fluoxetine and citalopram are more likely to have relative infant doses above 10% and have been asso- Recent studies have reported an increased risk of hyper- ciated with negative effects in case reports. Adverse effects tension and pre‐eclampsia with prenatal exposure to that may occur include poor feeding, irritability, colic, antidepressants. Recent reports have suggested a small increased capacity to metabolize the antidepressants. Psychiatric Problems in Pregnancy and Post Partum 185 Benzodiazepines Bipolar disorder Many women with mood and anxiety symptoms during Bipolar I disorder is defined by experiencing at least one pregnancy take benzodiazepines as sole agents or in lifetime manic episode, which is a distinct period of addition to antidepressants. Cohort studies of preva- abnormally and persistently elevated, expansive or irrita- lence rates of major malformations with benzodiaze- ble mood and abnormally and persistently increased pine exposure do not suggest an increased risk, but goal‐directed activity or energy. The symptoms must last case–control studies have suggested an increased risk of at least 1 week or any duration of time if hospitalization oral cleft with benzodiazepines as a class, and anal atresia is necessary. The concern with maternal impairment in functioning or necessitating hospitaliza- benzodiazepine use and breastfeeding is sedation in tion) and at least one major depressive episode . The risk of relapse is further increased both during pregnancy and after delivery if Non‐pharmacological treatments mood stabilizers are discontinued. Untreated bipolar ill- ness carries many of the risks evident with depressive Non‐pharmacological strategies may be the treatment of episodes: poor prenatal care, poor nutrition and health choice for depression and anxiety disorders in peripar- behaviours, substance abuse and suicidal ideation. In tum women who want to minimize fetal exposure to psy- addition, impulsive and poor judgement behaviours can chotropic medications, and can also be adjunctive complicate the pregnancy. Meta‐analyses of psycho- concluded that the risk of relapse in women with bipolar therapy modalities in pregnant and postpartum women disorders was 37% . Postpartum relapse rates were have suggested that psychotherapy is moderately effec- lower in patients using pharmacotherapy, particularly tive compared with usual care . Risk effective treatment with ‘small to none’ harms, noting factors for relapse are medication discontinuation, a that most studies have been conducted in postpartum previous postpartum mood episode or psychosis, unsta- versus pregnant samples .
Since sotalol has β-blocking properties order 100 mg caverta overnight delivery erectile dysfunction doterra, it is commonly used for these indications in patients with left ventricular hypertrophy or atherosclerotic heart disease caverta 100 mg visa zyrtec impotence. This drug can cause the typical adverse effects associated with β-blockers but has a low rate of adverse effects when compared to other antiarrhythmic agents. The dosing interval should be extended in patients with renal disease, since the drug is renally eliminated. It can be used as a first-line antiarrhythmic agent in+ patients with persistent atrial fibrillation and heart failure or in those with coronary artery disease. Because of the risk of proarrhythmia, dofetilide initiation is limited to the inpatient setting. Ibutilide is the drug of choice for chemical conversion of atrial flutter, but electrical cardioversion has supplanted its use. Initiation is also limited to the inpatient setting due to the risk of arrhythmia. Although voltage-sensitive Ca2+ channels occur in many different tissues, the major effect of Ca2+ channel blockers is on vascular smooth muscle and the heart. Both drugs show greater action on the heart than on vascular smooth muscle, but more so with verapamil. In the heart, verapamil and diltiazem bind only to open depolarized voltage-sensitive channels, thus decreasing the inward current carried by Ca2+. These drugs are use dependent in that they prevent repolarization until the drug dissociates from the channel, resulting in a decreased rate of phase 4 spontaneous depolarization. These agents are more effective against atrial than against ventricular arrhythmias. They are useful in treating reentrant supraventricular tachycardia and in reducing the ventricular rate in atrial flutter and fibrillation. Digoxin is used to control ventricular response rate in atrial fibrillation and flutter; however, sympathetic stimulation easily overcomes the inhibitory effects of digoxin. Intravenous adenosine is the drug of choice for converting acute supraventricular tachycardias. Adenosine has an extremely short duration of action (approximately 10 to 15 seconds) due to rapid uptake by erythrocytes and endothelial cells. Magnesium sulfate Magnesium is necessary for the transport of Na, Ca+ 2+, and K across cell membranes. Intravenous magnesium sulfate is the salt used to treat arrhythmias, as oral magnesium is not effective in the setting of arrhythmia. Most notably, magnesium is the drug of choice for treating the potentially fatal arrhythmia torsades de pointes and digoxin-induced arrhythmias. However, its main effect is to shorten repolarization and decrease the action potential duration similar to mexiletine. It is used to treat refractory atrial and ventricular arrhythmias, often in combination with other antiarrhythmic drugs. It is well tolerated with dizziness and constipation as the most common adverse effects. Which agent should be used to prevent life-threatening arrhythmias that can occur post myocardial infarction in this patient? None of the other drugs has been shown to be effective in preventing postinfarct arrhythmias. Current theory holds that a reentrant arrhythmia is caused by damaged heart muscle, so that conduction is slowed through the damaged area in only one direction. A drug that prevents conduction in either direction through the damaged area interrupts the reentrant arrhythmia. Class I antiarrhythmics, such as lidocaine, are capable of producing bidirectional block. The other choices do not have any direct effects on the direction of blockade of conduction through damaged cardiac muscle. The other options are used for rhythm control in patients with atrial fibrillation. Digoxin levels of 1 to 2 ng/mL are desirable in the treatment of atrial fibrillation. Digoxin levels between 748 1 and 2 ng/mL are more likely to exhibit negative chronotropic effects desired in atrial fibrillation or flutter. Cinchonism is a constellation of symptoms (blurred vision, tinnitus, headache, psychosis) that is known to occur with quinidine. All other options are adverse effects with amiodarone that require close monitoring. Which of the following coexisting conditions would allow for initiation of flecainide? Since flecainide can increase the risk of sudden cardiac death in those with a history of structural heart disease, only coexisting hypertension will allow for flecainide initiation. Structural heart disease includes left ventricular hypertrophy, heart failure, and atherosclerotic heart disease. Dronedarone increases the risk of death in patients with permanent atrial fibrillation or symptomatic heart failure. The drug is contraindicated in those with symptomatic heart failure or permanent atrial fibrillation due to an increased risk of death. Spasms of vascular smooth muscle may also impede cardiac blood flow, reducing perfusion and causing ischemia and angina pain. Typical angina pectoris is a characteristic sudden, severe, crushing chest pain that may radiate to the neck, jaw, back, and arms. Types of Angina Angina pectoris has three patterns: 1) stable, effort-induced, classic, or typical angina; 2) unstable angina; and 3) Prinzmetal, variant, vasospastic, or rest angina. They are caused by varying combinations of increased myocardial oxygen demand and decreased myocardial perfusion. Stable angina, effort-induced angina, classic or typical angina Classic or typical angina pectoris is the most common form of angina. It is usually characterized by a short-lasting burning, heavy, or squeezing feeling in the chest. Some ischemic episodes may present “atypically”—with extreme fatigue, nausea, or diaphoresis—while others may not be associated with any symptoms (silent angina). Atypical presentations are more common in women, diabetic patients, and the elderly. Classic angina is caused by the reduction of coronary perfusion due to a fixed obstruction of a coronary artery produced by atherosclerosis. Increased myocardial oxygen demand, such as that produced by physical activity, emotional stress or excitement, or any other cause of increased cardiac workload (ure 20. When the pattern of chest pain and the amount of effort needed to trigger the chest pain does not vary over time, the angina is named “stable angina. Unstable angina Unstable angina is chest pain that occurs with increased frequency, duration, and intensity and can be precipitated by progressively less effort. Any episode of rest angina longer than 20 minutes, any new-onset angina, any increasing (crescendo) angina, or even sudden development of shortness of breath is suggestive of unstable angina. Prinzmetal, variant, vasospastic, or rest angina Prinzmetal angina is an uncommon pattern of episodic angina that occurs at rest and is due to decreased blood flow to the heart muscle caused by spasm of the coronary arteries.
Fortunately discount 50mg caverta erectile dysfunction treatment pumps, most complications encountered are mild and spontaneously resolve without permanent sequelae purchase caverta on line impotence cure food. Mild complications from laser treatments include prolonged erythema and edema, acne eruptions, milia formation, and contact dermatitis. Severe complications include hypertrophic scarring, delayed onset hypopigmentation, ectropion, disseminated infection, and ocular injury. Nonablative lasers usually leave the skin intact and have milder complications compared to ablative lasers that create an open wound, which increases the frequency and severity of complications. Some of the most common and problematic adverse effects with lasers are associated with cutaneous thermal injury. Thermal injury can result in burns, scarring, and pigmentary changes (hyperpigmentation and hypopigmentation) and can occur with any laser. These patients have abundant epidermal melanin, which serves as a competing chromophore for lasers, increasing laser energy absorption and the risk of thermal injury. Use of aggressive laser parameters including short wavelengths, short pulse widths, small spot sizes, high fluences, and inadequate epidermal cooling are also associated with increased risk of thermal injury (Table 7). Use of checklists, such as the Preprocedure Checklists in each chapter of this book, is recommended to reduce the likelihood of laser complications from provider error. However, it should be noted that lasers are complex devices, laser–tissue interactions can vary with individual patients and even in the best of hands with the best technique, complications can occur. Hyperpigmentation, darkened skin coloration relative to surrounding skin, is a very common complication and has been reported with virtually every laser device. Hyperpigmentation usually resolves spontaneously over several months, although in rare instances it may be permanent. Hypopigmentation, lightened skin coloration relative to surrounding skin, is a less common but more significant complication than hyperpigmentation. Second degree burns extend into the dermis and are visible as erythema, edema and blisters that may rupture and form crusts or erosions. A keloid is defined as an abnormal scar that grows beyond the boundaries of the original site of skin injury. A hypertrophic scar is defined as a widened or raised scar that does not extend beyond the boundaries of the site of injury. An atrophic scar is a depressed well defined area, most commonly resulting from collagen destruction associated with inflammatory conditions such as cystic acne, or as a result of tension on a surgical wound. Interventions to prevent scarring are most effective at this stage and are reviewed in the Scarring section, Chapter 6. Scarring is a rare complication with the use of appropriate settings, but can result with any laser at sites that have been overtreated or burned, especially if healing has been complicated by infection or repetitive abrasion. Hypertrophic scarring is more common with laser treatments that create an open wound such as ablative lasers. Subtle textural changes commonly occur with Q-switched tattoo laser treatments due to epidermal injury from high absorption of laser energy by darkly pigmented targets. Recent use of isotretinoin, previous radiation therapy in the treatment area, and a history of keloid formation are also risk factors for hypertrophic and keloidal scarring. Certain areas of the body such as the lower eyelids, mandible, anterior neck and chest are more susceptible to scarring. Additionally, patients of Asian and African decent may have a greater predisposition to hypertrophic and keloidal scarring. Ocular injury is the most severe complication associated with laser use, and both patients and providers are at risk. These wavelengths can also be absorbed by the vitreous humor, forming ‘floaters’ that drift across the visual field. Wavelengths greater than 1100 nm are strongly absorbed by water in the cornea and can lead to corneal burns and cataract formation. Protective eye wear appropriate for the wavelengths used is essential for providers, patients, and personnel in the treatment room and is reviewed in Laser Safety. Most patients experience discomfort only when the laser pulses the skin, and this rapidly resolves once the pulse ceases. Structures in the midline of the face such as the lips, nose, and chin are more sensitive than the periphery of the face. While this is not usually problematic for women as makeup can be worn, erythema can be more of a concern for men. Erythema and edema are considered abnormal if they persist longer than or are more intense than routinely observed. Nonablative lasers generally have a shorter duration of postprocedure erythema usually lasting 3–4 days, ablative lasers have a longer duration of erythema, which can persist up to a few weeks or even months with deep nonfractional ablative resurfacing. Treated skin is vulnerable to irritation from various substances found in topical products such as preservatives and fragrances. Over-the-counter herbal and vitamin remedies such as vitamin E and aloe products are common causes of contact dermatitis. Herpes simplex eruptions are usually preceded by tingling and burning and appear as small vesicles on the lip (i. Prophylactic antiviral medications are given to reduce the occurrence in patients with a known history of viral infections in the treatment area. Bacterial infections are rare (apart from acne), and if they occur usually result from Streptococcus or Staphylococcus. Acne vulgaris infection due to Propionibacterium acnes is visible as erythematous papules and pustules and can occur following any laser treatment. Acne may be due to the laser treatment itself or postprocedure skin care, particularly with prolonged use of occlusive moisturizers. Impetigo is a superficial bacterial infection that can occur following treatments on the face and extremities; lesions progress from papules to vesicles, pustules, and crusts. The main pathogens are Staphylococcus aureus (methicillin-resistant Staphylococcus aureus is uncommon) and group A Streptococcus. Folliculitis is a superficial infection of hair follicles visible as small, erythematous papules and pustules that are less than 5 mm in diameter. Folliculitis most often occurs after vigorous exercise or shaving immediately following treatments and is due to S. Ablative laser treatments have the greatest risk of any infection as the skin is not intact posttreatment, and they have a greater risk of rapidly spreading. Furthermore, the appearance of infections in nonintact resurfaced skin does not always have the characteristic signs seen with intact skin. Tattoos and permanent makeup have concentrated ink pigments and treating over them with lasers that are not intended for tattoo removal can result in severe epidermal injury such as a full thickness skin burn (i. Hair growth structures are susceptible to thermal injury and reduction of hair growth can occur with most lasers, especially those that are absorbed by the melanin chromophore. In addition, when performing hair removal treatments, it is possible to reduce hair adjacent to the intended treatment area as hair follicles grow at angles to the skin.