Immunologic and Inflammatory - Meriel Espanilla

INTRODUCTION The body is equipped with a complex system that protects and defend the body from invasion by any foreign object or foreign cells The immune system functions as the bodys defense mechanism Immunity bodys specific protective response from foreign materials which can cause infection Antibody CHON of the globulin and are classified according to their structure and functions (Ig GEAMD) circulates in the plasma to attack antigen and render it harmless Antigen or Immunogen regards as foreign/potentially dangerous I. MAJOR PARTS OF IMMUNE SYSTEM 1. Bone Marrow found in bones 2. WBC/Leukocytes produced in bone marrow 3. Lymphoid tissues a. Thymus gland b. Spleen c. Lymph nodes - axillary - cervical - inguinal d. Tonsils e. GUT associated lymphoid tissue f. Bronchial associated lymphoid tissue g. Genital associated lymphoid tissue Major Components of Immune System 1. BONE MARROW 2. WBC aka LEUKOCYTE - NV: 4,500-11,000/cu mm *Granular Leukocytes or Granulocytes - because of the granules present in the cytoplasm (gel like substance) a. Neutrophil / Polymorphonuclear Leukocytes - Their nuclei have multiple lobes - First to arrive at site of inflammation - Helps in phagocytosis b. Eosinophils - defend against parasites and participate in allergic reactions, pulmonary infections and dermatologic infections (eg. Anaphylaxis) - inc. during stress c. Basophil - release heparin and histamine into the blood and participate in delayed hypersensitivity reactions - inc. during stress *Non-granular Leukocytes 1

Immunologic and Inflammatory - Meriel Espanilla

a. Monocytes -

function as PHAGOCYTIC CELLS; macrophages

b. Lymphocytes - role is related to humoral and cell mediated responses

b.1 B-lymphocytes = Bursa of FABRICUS - bursa fabricus: can only be found in birds - Bursa: seen in joints; small sac of fibrous tissue lined with synovial membrane -synovial membrane: contains synovial fluid - arthritis if no lubricant *Bursa Fabricus = equals to bone marrow in humans b.2 T-lymphocytes - maturation occurs in Thymus - long term immunity for life - thymosin = hormone in thymus gland; for the maturation of T-lymphocytes T-Lymphocyte are categorized into: a. T-cytotoxic Cells or Cytolytic cells or CD8 b. T-helper Cells or CD4 (clusters of differentiation) - involved in the regulation of cell-mediated immunity and the humoral antibody response - involves in ingestion and killing of microbes and parasites, in allergic response FYI: NK Cells (Natural Killer Cells) - these are not T or B cells but are large lymphocytes with numerous granules in the cytoplasm - involved in recognition and killing of virus-infected cells, tumor cells, and transplanted grafts - fights cancer cells Bone Marrow Lymphoblast (Lymphocyte) Bone Marrow Maturation B-Lymphocytes Regulator T Cells Helper T Cells Suppressor Cells Plasma Cells Antibodies Humoral Response Cellular (Cell Mediated) Response Thymus Effector T cells Cytotoxic Cells

Memory Cells

OTHER COMPONENT OF IMMUNE SYSTEM (Lymphoid Tissue) 1. Thymus Gland - located in the mediastinum (space in between the thorax) and reaches peek development during childhood - but remnants persist till old age 2

Immunologic and Inflammatory - Meriel Espanilla

- function atrophy - endocrine gland (ductless) secretes hormones for maintenance of T-cells 2. Lymph Nodes - resident macrophages present in the nodes which has a phagocytic action - swelling of lymph nodes = diagnostic sign of infection 3. Tonsils - located at the back of the mouth and consist of lymph tissue which helps fight off infections I. Characteristic/Properties of Immune System (IS): 1. Recognition able to distinguish the self from non-self and destroys the non self 2. Specify our IS forms specific body protection 3. Memory unique ability to remember dangerous foreign substances that enter the body 4. Our IS can develop into a disease: IS with hypoactive response immunodeficiency eg.AIDS IS with hyperactive response immunopathology eg. Hypersensitivity IS with incompetent response autoimmune disease eg. Systemic Lupus Erythematusos IS with suppressed respone immunosupression eg. d/t medication / Tx (chemotherapy or CA drugs) II. GENERAL TYPES OF IMMUNITY/PROTECTION 1. NATURAL (Innate) - non specific immunity present at birth - provides non specific response regardless of invaders composition 4 Mechanisms of natural immunity a. WBC ACTION - Aka leukocytes which participate both in natural and required immunity; more of cellular response; T lymphocytes 2 types of leukocytes a. Granular L or Granulocytes (showD3) Functions: release chemical mediators (histamine, bradykinin, prostaglandin) when there is invasion Histamine compound associated with mast cells which is a mediator of inflammation which causes characteristic skin reaction such as flushing, flare, and wheal Bradykinin dilates blood vessels Prostaglandin dilates blood vessels and also mediates process of inflammation NV WBC/Leukocyte: Neutrophils Eosinophil Basophil Lymphocyte Conventional Units 4,500-11,000/cu mm 45-73% 0-4% 0-1% 20-40% SI Units 4.5-11x10^9/L #fraction: 0.45-0.73 #fraction: 0.00-0.04 #fraction: 0.00-0.01 #fraction: 0.2-0.4

Increased Neutrophil - acute infection, trauma, surgery, leukemia, malignant disease Decreased Neutrophil - viral infection, bone marrow suppression, primary bone marrow disease Inc Eosinophil - allergy, parasitic disease, subacute infections 3

Immunologic and Inflammatory - Meriel Espanilla

Inc Basophil

increase in presence of stress, meds (Myroxine and adenocorticotropic hormone/ACTH)

- acute leukemia, trauma, surgery Dec Basophil - allergic reactions, corticosteroid Inc Lymphocytes - viral and bacterial infections Decreased lymphocytes - SLE, immunodeficiency (AIDS), aplastic anemia Monocytes - NV: 2-8% or 0.02-0.08 Increased monocytes - viral, collagen, infection, and hemolytic disorders Decreased monocytes - corticosteroids, rheumatoid arthritis, HIV infections b. INFLAMMATORY RESPONSE ^major function of natural IS, releases chem. Mediators bradykinin, prostaglandin, * chemical mediators assist this response by: minimizing blood loss walling off the invading organism and activating phagocytes promoting the formation of fibrous scar tissues regeneration of injured tissue c. PHYSICAL and CHEMICAL BARRIERS P- includes intact skin and mucous membranes which prevents pathogens from gaining access to the body ^eg. Cilia of respiratory tract along with coughing and sneezing C- mucous enzymes in tears and saliva, substances in sebaceous and sweat secretions ^sebaceous-found in skin that secretes fatty substances called SEBUM d. IMMUNE REGULATION - involves balance and counter balance - a successful immune response eliminates the responsible antigen - research on IMMUNOREGULATION holds the promise of preventing graft rejection body in eliminating cancerous or infected cells 2. ACQUIRED IMMUNITY (Adaptive immunity) - acquired during life but not present at birth ^ develops as a result of prior exposure to antigen ^ through immunization or vaccination ^ char of IS memory 1. T-cell activation - the cell-mediated response occur 2. B-cell activation - includes effector mechanism wherein maturation and production of antibodies occur

and histamine

and aiding the

Immunologic and Inflammatory - Meriel Espanilla

stem cell through process of lymphoblast go to thymus for maturation and differentiate to (regulatorhelper and suppressor and effector-cytotoxic)

2 types of acquired immunity (active and passive) 1. ACTIVE ACQURIED IMMUNITY: 2types (Natural and Artificial) 1. Natural Active Immunity - acquire the disease naturally or contracted from other person who has the disease *vaccine used to stimulate the dev of antibodies and thus yield active immunity against a specific disease 2. Artificial Active Immunity - through vaccination of a modified infecting agents or modified toxins - required immunizations are the following: REQUIRED IMMUNIZATIONS: I. VACCINES 1. BCG (Bacille Calmette-Guerin) Intradermal - a strain of tubercle bacillus that has lost the power to cause TB (weakened/attenuated) but retains its antigenic activity 2. DPT (Diphtheria Pertussis (or whooping cough) Tetanus) IM - prepared from their toxoids and other antigens - toxoids: a preparation of the poisonous material (toxin) that is produced by dangerous infective organisms -3doses: at 2,3,4th month old - diphtheria and tetanus require booster 3. Hepa B Vaccine IM - derived from either human plasma of carriers of Hepatitis B (hepatitis B v. inactivated) or from cloning in yeast cells (hepatitis B v. (recombinant)) 1st dose: 1month old 2nd dose: 1month after 3rd dose: 6 months after 4. MMR (Mumps measles rubella) IM - a combination of live attenuated vaccine which is recommended to be given bet. 12-15 mo. Old - specific C/I *Neomycin antibiotic mostly affecting skin and eyes ^ specific contraindication immunosuppression and allergy to neomycin and anaphylactic reaction to eggs ^in form of ointment inner to outer canthus to avoid cross contamination 5. OPV (Oral Polio Vaccine) - polio vaccine inactivated (IPV) Salk v.; a suspension of formalin-inactivated polio viruses used for immunization against poliomyelitis - polio vaccine live oral (OPV) Sabin v.; a preparation of a combination of the 3 types of live attenuated polioviruses used as an active immunizing agent against poliomyelitis ^drops depends on doctors order 6. Influenza Vaccine through IM - it is a trivalent, usually containing two influenza A virus strains and one influenza B virus strain 7. Chicken Pox or Varicella Vaccine 5

Immunologic and Inflammatory - Meriel Espanilla

- VARICELLA ZOSTER (virus) causes chicken pox and herpes zoster - Herpes Zoster aka SHINGLES is a localized rash caused by recurrent varicella, vesicles are restricted to areas supplied by single associated nerve groups. ^Eg.C5 C6 - shoulder to deltoid to hands 8. Cholera Vaccine - acute infection of small intestine by the bacterium VIBRIO CHOLERAE - a preparation of killed vibrio cholerae which is effective for only 6-9months ^contracted from food and water (feces); rice watery stool 9. Small Pox or Variola - spread by direct contact, contact with linens/clothing, droplets from person to person - attenuated/weakened vaccines are used II. TOXOIDS (lived or killed) a. tetanus toxoid IM b. diphtheria 2. PASSIVE ACQUIRED IMMUNITY - is temporary immunity transmitted from a source outside the body that has developed immunity through previous disease or immunization - ^ATS: Antitetanus serum ^live attenuated vaccines against TB, rabies, small pox ^dead organism cholera and typhoid, ^either - diphtheria and tetanus 2 Types of Passive Immunity a. Natural Passive Immunity o From mother in utero or colostrum thru best feeding which will last for about a year b. Artificial Passive Immunity o Immune globulin or antiserum obtained from blood plasma of people with acquired immunity e.g. ATS (Anti Tetanus Serum) Diphtheria Anti Toxin (DAT) IV. 5 General Immune Response - The question here is What happens when a foreign cell or foreign object enters the body? 1. Phagocytic (Engulf, Ingest, Destroy) Immune Response o The first line of defense o Involves the WBCs (Granulocytes and macrophages or monocytes more phagocytic action) 2. Humoral o Sometimes called ANTIBODY RESPONSE o Begins with the b-Lymphocytes (responsible for producing antibodies) which can transform themselves into plasma cells that manufacture antibodies, these antibodies are highly specific proteins that are transported in the blood stream and attempt to disable invaders e.g. o Main function : B-lymphocytes stored in lymph nodes are subdivided into thousands of clones, each responsive to a single group of antigens, when message is carried t lymph node, specific clones of the B-lymphocytes are stimulated to enlarge, divide, proliferate and differentiate into plasma cells capable of producing specific antibodies to the antigen 6

Immunologic and Inflammatory - Meriel Espanilla

Types of Antibodies 1. IgG (75% of total immunoglobulin) o Appears in serum and tissues (interstitial fluid) 2 Compartments a. ICF (Intracellular fluid) approximately 2/3 of body fluid b. ECF (Extracellular Fluid) fluid outside the cells ECF Compartments: i. Intravascular Space approximately 3 liters of the average 6 liters of blood volume is made up of plasma remaining 3 liters is made up of erythrocytes, leukocytes and thrombocytes inside the blood vessels ii. Interstitial Space Total about 11-12 liters in adult e.g. lymph Outside the cells and the blood vessels iii. Transcellular Space Smallest division and contains approximately 1 liter of fluid e.g. CSF, pericardial, synovial, intraocular and pleural fluids, sweat and digestive secretions FYI - Approximately 60% of adults weight, consist of fluid (water and electrolytes) - Obese people have less fluid than thin people because fat cells contain little water o assumes a major role in blood borne and tissues infections o activate the complement system o enhances phagocytosis o crosses placenta (only Ig to do this) 2. IgA (15% of total immunoglobulin) o Appears in body fluids (blood, saliva, tears, breast milk, and pulmonary, gastrointestinal, prostatic and vaginal secretions) o Prevents absorption of antigen from food o Respi, GIT and genital protection o Found in colostrum 3. IgM (10% of total immunoglobulin) o Appears as the 1st immunoglobulin produced in response to bacterial and viral infection o Activates the complement system o Found in the intravascular space 4. IgD (0.2%) o Appears in small amounts in serum o Possibly B lymphocytes differentiation 5. IgE (.004%) o Appears in serum o Combats parasitic infection o Allergic and some hypersensitivity reaction 3. CELLULAR IMMUNE RESPONSE - Involves T-lymphocytes - T-cells migrate from lymph nodes into the general circulatory system and ultimately to the tissues, where they retail until they either come in contact with their respective antigens or die 7

Immunologic and Inflammatory - Meriel Espanilla

Differences in Cellular and Humoral Immune Responses: Humoral Responses (B Cells) o Bacterial and phagocytosis and lysis o Anaphylaxis o Allergic hay fever and asthma o Immune complex disease o Bacterial and some viral infection Cellular Responses (T Cells) o Transplant rejection o Delayed hypersensitivity (tuberculin reaction) o Graft vs. Host disease o Tumor surveillance or destruction o Intracellular infection (inside the cells) o Viral, fungal and parasitic infection 4. Complement - Are circulating plasma CHON are made in the liver and activated when an antibody connects with its antigen - Creates a rapid sequence of events with rapid action causing a hole in the plasma membrane of the antigen, releasing water and ions to enter and cause cystolysis - Produced by liver - Only produced if there is antigen 5. Interferon - A CHON compound, believed to prevent viruses from multiplying in the body - Have antiviral and anti tumor properties - Produced by T and B lymphocytes and macrophages in response to antigen - Only produced if there is antigen - FYI o Some interferons are already used to treat immune related D/O (e.g. MS Multiple Sclerosis) and Chronic Inflammatory condition (e.g. Chronic Hep) o Also undergoes extensive testing to evaluate their effectiveness in treating tumors and AIDS V. FACTORS THAT AFFECT YOU IS: 1. Age Inc in Age Immune Response (IR) Dec 2. Nutritional Status (NS) poor NS (Underwent and Overweight) = IR Dec 3. Lifestyle physical and emotional stress, more stressful = IR Dec 4. Environmental exposure more environmental hazard = IR Dec 5. Medication more medication take IR Dec 6. Immunization complete schedule of immunization Inc IR 7. NSG Implication (How to keep the IS Healthy?) ways are discussed in SL

Immunologic and Inflammatory - Meriel Espanilla

Inflammation - Is a defensive reaction intended to neutralize, control or eliminate the offending agent and to prepare the site for repair. - Infection is one of the agents that can trigger an inflammatory response A. Vascular Response Inflammation Process Cell Injury Release of Kinins, HistamineProstaglandin Local vasodilation Hyperemia (Inc of blood flow in an area of injury) Capillary permeability Fluid Exudate Clinical Manifestation: 5 Cardinal Signs of Inflammation or Local manifestation 1. Redness 2. Pain 3. Swelling 4. Warmth 5. Loss of function Rubor (Redness) due to the Inc in size of the small BV or dilation in the are, which therefore contain more blood Calor (Heat/Warmth) b/c of the distended BV, which allow an Increased flow of blood Swelling due to the leakage from small BV of clear CHON-containing fluid, which accumulates between the cells, edematous because of albumin released in blood causes fluids to be drawn to the are Dolor (Pain) thought to be due to the release of chemicals (e.g. Prostaglandin) from damages cells and pressure to the nerve endings Funcio Laesa (Loss of Function) is most likely related to the pain and swelling but the exact mechanism is not completely know Momentary local vasoconstriction

B. Cellular Response D7-what will happen to the cells or, what are their functions during inflammatory response Cell Injury (Neutrophils and Monocytes are first at site) Margination (movement of neutrophils and monocytes at the inner surface of capillaries) and Diapedesis (amoeboid fashion to the site of injury) of WBC Chemotaxis (mechanism for ensuring accumulation of neutrophils and monocytes at site of injury) GUIDE toward Directional migration of WBC Migration of WBC to site of Injury 9

Immunologic and Inflammatory - Meriel Espanilla

1 to arrive, 24-48h Life Span, dead neutrophils, cell debris, dead bacteria = pus Inc in WBC esp Neut Semented Mature Neut Bands Immature Neut
st

Neutrophil

***Monocytes (Macrophage) Macrophages Phagocytosis Cellular Exudate

***Lymphocytes

Inc Band Neutrophils known as shift to the left; commonly found in px with acute bacterial infections ***Monocytes/Macrophages arrive in 3-7 days after inflammation long life span, can stay in tissues for weeks and can multiply; upon entering tissue spaces (from blood) monocytes transform to macrophages; important in cleaning the area, (engulf, ingest, destroy) *** Lymphocytes arrive later and the role is related to humoral and cell mediated immunity

Concept II Alteration in any IS: puts impact on the bodys ability to defend itself against the harmful and substances Immunologic D/O: 1. Immunopathology - Study of diseases resulting in dysfunctions within the immune systems 2. Immunocompetence - Exist when the bodys immune system can identify and inactivate, or destroy foreign substances - When the IS overacts, hypersensitivity D/O such as allergies and autoimmune diseases may occur A. Hypersensitivity Reaction - When IR overreacts against foreign antigens or fails to maintain self-tolerance this will result in tissue damage and it is termed HYPERSENSITIVITY REACTION - Classification of Hypersensitivity reaction may be done according to a. Source of allergen foreign object could be: Exogenous outside the body (dander, pollen) Homologous same species (serum) Autogenous within the body (graft vs. host rxn) b. Time sequence immediate or delayed reaction e.g. Food c. The basic immunologic mechanism causing the injury Types of Hypersensitivity Reaction Type 1: IgE Mediated Reaction E.g. Anaphylactic reaction occur only in susceptible persons who are highly sensitized to specific allergens IgE antibodies produced have a characteristic property of attaching to mast cells and basophils, prostaglandins, histamine and leukotrienes (cell mediators) A genetic predisposition to the development of allergic diseases exists. The capacity to become sensitized to an allergen appear to be the inherited trait, rather than specific allergic D/D E.g. a father with asthma may have a son who has allergic rhinitis Pollens, food, drugs, dust (Exogenous) Clinical Manifestations of Anaphylactic Reaction o Local Manifestation: cutaneous response termed wheal and flare reaction e.g. mosquito bit o Reactions occur in minutes or hours, not dangerous 10

Immunologic and Inflammatory - Meriel Espanilla

Wheal and flare reaction serves a diagnostic purpose as a means of demonstrating allergic reactions Common Allergic Reactions (Type 1) 1. Anaphylaxis Can occur when mediators are released systematically (e.g. after injection of a drug, after an insect sting) Reaction occurs within minutes and can be life threatening because of bronchial constriction Initial Sx: edema and itching at the side of the exposure to the allergen Shock can occur rapidly manifested by. 1. Rapid weak pulse 2. Hypotension compounded by bronchial edema and angioedema 3. Dilated pupils 4. Dyspnea Possibly cyanosis Death if Emergency Treatment is not initiated *D3 allergens causing Anaphylactic Shock 2. Atopic Reactions 5 Types a. Allergic Rhinitis or Hay Fever Most common type 1 hypersensitivity reaction May occur year round (perennial allergic rhinitis) or seasonal (seasonal allergic rhinitis) Primary cause are: o Perennial A R: dust, mold and animal dander o Seasonal A R: pollens from trees, weeds and grasses Target area affected: conjunctiva of the eyes mucosa of the upper respiratory tract Sx: nasal discharges, sneezing, lacrimation, mucosal swelling with airway obstruction, pruritus around the eyes, nose, throat and mouth b. Asthma Patients frequently have a history of atopic D/O (e.g. infantile eczema, allergic rhinitis, food intolerance0 Inflammatory mediators produce bronchial smooth muscle constriction, excessive secretion of viscoid mucus, edema of the mucous membranes of the bronchi and decreased lung compliance S/Sx: dyspnea, wheezing coughing, tightness in chest and thick sputum c. Atopic Dermatitis Chronic, inherited skin D/O characterized by exacerbation and remission Increase IgE levels and (+) skin tests but feature is not just wheal and flare TypeI, skin lesions are more generalized resulting in interstitial edema with vesicle formation d. Urticaria Characterized by transient wheals (pink, raised, edematous, pruritus areas) that vary in size and shape and may occur throughout the body Histamine causes localized vasodilation (Erythema), transudation of fluid (wheal) and flaring and responsible for the pruritus associated with the lesion e. Angioedema Similar to urticaria but involves deeper layers of the skin and the mucosa Principal areas of involvement: eyelids, lips, tongue, larynx, hands, feet, GIT and genitalia

11

Immunologic and Inflammatory - Meriel Espanilla

Swelling usually begins in the face, and then progresses to the airways and other parts of the body (if involves GIT it may cause acute abdominal pain) The swelling may occur suddenly or over several hours and usually last for 24 hours

Type II: Cytotoxic and Cytolytic Reactions Involves the binding of IgG or IgM to an antigen on the cell surface Antigen-antibody complexes activate the complement system Target cell: erythrocytes, platelets and leukocytes Antigens involved: ABO blood group, Rh factor and drugs Pathophysiologic Disorders Includes a. Hemolytic Transfusion Reactions - Occurs when a recipient receives ABO incompatible blood from a donor Type A A or O, Type O only O - Review of Rh factor/incompatibility o Rh (+) has D antigen, no anti-D antigen (almost all of us) are (+) o Rh (0) with transfusion or childbirth, may be exposed to Rh (+0 which result in formation of antibody (anti-D) which acts against Rh antigens and become sensitized to Rh (+) blood and a 2nd exposure to Rh (+) will cause severe hemolytic reaction o Coombs test test to evaluate Rh status - If the recipient is transfused with incompatible blood, antibodies coat foreign blood causing agglutination (clumping). The clumping of cells blocks small BV in the body, uses existing clotting factors and depletes (To empty of a principal substances) them leading to bleeding

b. Goodpasture syndrome (discussed more on Urologic and Renal Problems) - A D/O involving the lungs and kidney - B/c of the complement activation due to antigen-antibody binding together it causes cytolysis leading to pulmonary hemorrhage and glomerulonephritis Type III: Immune Complex Reactions Tissue damage in immune complex reactions occurs secondary to antigen-antibody complexes Soluble antigens combine with IgG and IgM to from complexes that are too small to be effectively removed by phagocytosis, therefore it will be deposited usually in kidneys, skin, joints, BV and lungs, wherein there is inflammation and destruction of the involved tissues Deposition of substances in some parts of the body Severe Type III reactions are associated with - Auto immune d/o: SLE, acute glomerulonephritis and RA Type IV: Delayed Hypersensitivity Reactions Also termed a CELL MEDIATED IMMUNE RESPONSE It takes 24-48 hours for a response to occur Clinical Examples a. Contact dermatitis o Antigenic substances are metal compounds (e.g. nickel or mercury), rubber compounds, catechols present in poison ivy, poison oak and cosmetics and some dyes. o Erythematous and edematous and are covered with papules, vesicles and bullae and very pruritic o Atopic is: Contact Dermatitis localized and restricted to area exposed to the allergens Atopic Dermatitis usually widespread 12

Immunologic and Inflammatory - Meriel Espanilla

b. Hypersensitivity reactions to bacterial, fungal and viral infection c. Transplant rejections II. Collaborative Care - The cardinal principle in therapeutic management (Mx) Anaphylaxis is SPEED in: 1. Recognition of S/Sx of an anaphylactic reaction 2. Maintenance of a patent airways 3. Prevention of spread of the allergen by using a tourniquet (venom or sting) 4. Administration of drugs (Epi) 5. Treatment of shock A. Drug Therapy o Used for symptomatic relief of chronic allergic d/o 1. Antihistamine - Are the best drug for treatment of allergic rhinitis and urticaria - Act by competing with histamine for H1 receptor sites and thus blocking the effect of histamine - Effect to tx Edema and pruritus - E.g. Benadryl (Diphenhydramine) (IM or PO 50mg) 2. Sympathomimetic/Decongestant - The major drug is Epinephrine (Adrenalin), (can be given through ET) which is the drug of choice to treat an anaphylactic reaction - The action of epinephrine lasts only a few minutes and for the treatment of anaphylaxis, drug must be given parenterally (usually SQ) - Causes vasoconstriction of the peripheral BV and relaxes the bronchial smooth muscle - Action of Epi only last a few minute; interval is 15 minutes 10 5 minutes 3. Corticosteroid - Nasal corticosteroid sprays are effective for allergic rhinitis, with severe manifestations that person becomes incapacitated, a brief course of oral corticosteroid use 4. Antipruritic Drugs - Topically applied are most effective when skin is not broken - Common OTC drugs are: calamine lotion, coal tar solutions and camphor 5. Mast Cell Stabilizing Drugs - Inhibits the release of histamine, leukotrienes - Available as an inhalant nebulizer solution or a nasal spray - Low incidence of side effects compared to corticosteroids - Used in the Mx of Asthma and allergic rhinitis 6. Leukotrienes Receptor Antagonists - Leukotrienes one of the mediators of allergic inflammatory process - Can be taken orally, used in allergic rhinitis and asthma B. Immunotherapy Is the recommended therapy for control of allergic Sx when the allergen cannot be avoided and drug therapy is not effective Involves administration of small titers of an allergen extract in increasing strengths until hyposensitivity to the specific allergen is achieved, desensitization Unfortunately not all allergy related condition respond to immunotherapy Food allergies cannot be safely treated with this therapy and eczema may worsen with immunotherapy Absolutely indicated For px with anaphylactic reaction to insect venom 13

Immunologic and Inflammatory - Meriel Espanilla

B. Immunodeficiency - Immunodeficiency d/o involves an impairment of 1 or more immune mechanism which include: 1. Phagocytosis WBC 2. Humoral Response B Lymphocytes 3. Cell-mediated response T Lymphocytes 4. Complement 5. Interferon 2 Types of Immunodeficiency D/O (Primary 1 and Secondary 2) 1. Primary - If immune cells are improperly developed or absent - Rare type and often serious disorders D/O Basic Categories of Primary Immunodeficiency a. Phagocytosis b. B-cell deficiency c. T-cell deficiency d. Combined B and T deficiency 2. Secondary - if the deficiency is caused by illness or treatment - more common and less severe - drug-induced immunosuppressions is the most common, because immunosuppressive therapy is prescribed for patients to treat autoimmune D/O and to prevent transplant rejection - E.g. AIDS, autoimmune disease, chemo, corticosteroid therapy i. Acquired Immunodeficiency Syndrome (AIDS) A. Characteristics: o A serious illness terminal disease o It destroys the bodys natural defense resulting to many infections o It is an investigational problem (still under the domain of research) B. Causing Agent: Virus o HIV Human Immunodeficiency Virus o In 1985 AIDS was determined to be an advanced stage of chronic HIV o Is a fragile virus and can only be transmitted under specific conditions that allow contact with infected body fluids including: 1. Blood 2. Semen 3. Vaginal secretions 4. Breast milk o HIV cant be transmitted through hugging, dry kissing shaking hands, sharing eating utensils, using toilet seats, or attending school or working with an HIV infected person o It is not transmitted through tears, saliva, urine, emesis, sputum, feces or sweat ii. ARV AIDS Related Virus o Retrovirus this virus carries its material in the RNA rather the DNA C. How , Who and Source of Transmission How Who 1. Sexual Contact Hetero Homo Bi

Source Prostatic and Vagina Secretions Blood and products blood Transmission occurs when there is a break 14

2. Needle Use

Paramedics patients IV drug abusers

Immunologic and Inflammatory - Meriel Espanilla

in the skin and mm 3. Placental transfer Infected child mother to Blood and blood products breast milk

D. S and Sx: Syndrome 1. Lymph Adenopathy Associated Syndrome (L A A Sx) a. Swollen lymph nodes due to infections b. Body malaise, weakness c. On/off fever d. Easy fatigability 2. GIT Sx a. Loss of appetite N/V b. LBM c. Cold sores (Oral Thrush) e.g. Oral Candidiasis white cheesy oral lesions d. Marked by obvious weight loss 3. Respiratory Sx a. Mycobacterium Avium-Intracellulare (common to AIDS, resistant to conventional Antibiotics and Anti-tuberculosis) b. Mycobacterium Tuberculosis - The respiratory Sx are the following: 1. Dry persistent cough 2. Difficulty in lying down 3. Orthopnea 4. Chest tightness 5. Frequent nasal discharges 4. Hematologic Sx a. Pale looking b. Dizziness Anemia c. Faintness Problems of blood clotting Bleeding problems: Sx are: 1. Bleeding gums 2. Bleeding nose (epistaxis) 3. GI bleeding (+) blood in stool (occult blood) 4. Hemoptysis coughing up of blood 5. Hematuria 5. Neurologic Sx a. Dementia (loss of memory) progressive confusion b. Poor coordination and cooperation c. Paresthesias (abnormal tingling sensation described as pins and needles) partial damage to peripheral nerves 6. Opportunistic diseases are present Infections that happen because of the px exposure It is associated with rare infections and malignancies (causes by protozoa that are manifested by sx of pneumonia) a. PCP (Pneumocystic Carinii Pneumonia) o Sx of pneumonia 15

Immunologic and Inflammatory - Meriel Espanilla

b. Kaposi Sarcoma o Starts with a bluish black spot on the skin, when traumatized can turn edematous, hemorrhagic and necrotic (gangrene) E. Diagnostic Tests to Confirm HIV 1. ELISA (Enzyme Linked Immunosorbent Assay) now, it is termed as EIA Enzyme Immunoassay o Swab test o (+) results must be validated usually with Western Blot test o Determines presence of antibodies that are directed specifically to HIV in the blood or saliva 2. Western Blot o Is used to confirm seropositivity when the EIA is (+) o Not necessarily done if ELISA is (-) Interpretation of (+) Test Results: o Antibodies to HIV are present in the blood (the px has been infected with the virus and the body has produced antibodies) o HIV is active in the body, and the patient can transmit the virus to others o Despite HIV infection, the px does not necessarily have AIDS will later develop AIDS if IS decreased. The patient is not immune to AIDS (the antibodies do not indicate immunity) Interpretation of (-) Test Results: o Antibodies to HIV are not present in the blood at this time, which can mean that the patient has not been infected with HIV or, if infected, the body has not yet produced antibodies (which takes from 3 weeks to 6 months or longer) o 3 weeks after or 6 months after = test o The px should continue taking precautions. The test result does not mean the px is not infected, it just mean that the body may not have produced antibodies yet. How long will HIV be in the body before you turn AIDs (+)? - Incubation period is 3-5 years 3. Responsibilities of an HIV person: a. Keep your immune system healthy (Healthy Lifestyle) b. Not to infect anyone with the virus c. Involve other in the family to disseminate education on AIDS and HIV F. Management is geared towards: 1. Treating the opportunistic infection and malignancies 2. Mx for AIDS is purely SUPPORTIVE CARE: because of the debilitating effects like a. Malnutrition b. Skin breakdown c. Immobility d. Extreme weakness e. Social stigma 3. Drug Therapy as ANTIRETROVIRAL Agents i. Zidovudine (ZDV, AZT , Retrovir) ii. interferon Considerations in Doing HIV Testing o DOH has designated, a licensed and trained medical technicians to detect presence of antibodies against HIV 16

Immunologic and Inflammatory - Meriel Espanilla

o o

Consent to be signed = saying that, the result is considered of utmost confidentiality = result is forwarded to DOH; Px undergoes CONTACT TRACING They only do it to population at risk - commonly are the seamen G. Nursing Management This is the HIV infection/AIDS Prevention and Control Program 1. Roles of the nurse - Direct care provider - Health Educator - Counselor - Trainer 2. Competencies expected of you as a nurse Knowledge (cognitive domain) a. Education factual giving of information b. Universal blood and body fluid protection all health workers should: i. Used an appropriate barriers when in contact with blood and body fluids E.g. gloves, gown and foot protector ii. Handwashing iii. Precautions to prevent injury caused by needles, scalpel, sharp instruments iv. Implementation of universal blood and body precautions in any health care setting

Skills Use simple and direct language E.g. 1. You can call the client PWA not AIDS victim 2. Use the word population at risk, not homosexual, prostitute etc. 3. Use the word contact tracing, dont use the word partners, friends and groups 4. Use the word commercial sex worker instead of prostitute, GRO, Pink card holder Attitude Non-judgmental, acceptance, respect for the person, compassion

Autoimmune Phenomena Autoimmunity - Is an immune response against the self. The immune system no longer differentiates self from nonself - Theories of Causation (factors in the development of autoimmunity) - The inheritance of susceptibility genes, which may contribute to the failure of self tolerant (Genetic Susceptibility) - Initiation of Autoreactivity E.g. Viral infection MS, DM (Type 1) Streptococcal infection Rheumatic fever and Rheumatic Heart Dse Drugs Methydopa (Aldomet) Hemolytic Anemia Procainamide (Pronestyl) Lupus-like syndrome Hormones: during pregnancy, autoimmune diseases gets better, following delivery there will be exacerbation 17

Immunologic and Inflammatory - Meriel Espanilla

Examples of Autoimmune Diseases: Systemic Diseases - SLE - RA - Progressive systemic sclerosis (Scleroderma) - Mixed connective disease Organ Specific Disease (Blood) - Autoimmune hemolytic anemia - Immune thrombocytopenic purpura CNS - MS, GBS (Guillain Barre Syndrome Muscle - MG (Myasthenia Gravis) Heart - Rheumatic fever Endocrine System - Addisons disease - Thyroiditis - Hyperthyroidism - Type 1 DM Gastrointestinal System - Pernicious anemia - Ulcerative colitis Kidney - Goodpasture syndrome - Glomerulonephritis Liver - Primary biliary cirrhosis Eye - Uveitis Systemic Lupus Erythematosus o Is a multi system inflammatory disease of autoimmune origin o Typically affects the: skin, joints and serous membranes (pleura, pericardium), renal, hematologic and neurologic system o Alternating periods of Exacerbations and remissions characteristic, unpredictable S/Sx o Mostly affects women in their child bearing years o No SLE for pregnant women
Pathophysiologic Changes Genes, hormones (pregnancy), environmental (sun), infectious agents, drugs Autoantibodies against the constituents of cell nucleus (DNA) self Product of immune complexes (autoantibodies against DNA will form this immune complexes) will circulate in the blood stream Which will be in the basement membranes of capillaries in the: kidney, heart, skin, brain and joints Complement is activated and inflammation occurs all throughout the organs affected SLE

Clinical Manifestations 18

Immunologic and Inflammatory - Meriel Espanilla

A. Dermatologic Manifestations 1. Classic Butterfly rash o Over the cheeks and the bridge of the nose occurs in 50% of px o Due to cutaneous skin vascular lesions o Develop in sun exposed area esp in face 2. Alopecia o transient defuse or patchy hair loss o Hair may grow during remission B. Musculoskeletal Problems 1. Polyarthralgia o Multiple pain in the joints o Occurs in 90% of px - arthritis o With morning stiffness is often the 1st complaint o Arthritis is usually non erosive, but may cause deformities such as: a. Swan neck deformity extension of MCP and DIP, flexion of PIP b. Ulnar deviation c. Subluxation with hyperlaxity of joints C. Cardiopulmonary Problems 1. Pericarditis (With or Without Pleural Effusion) Ominous sign of SLE fore warning S/Sx a. Tachypnea b. Pleurisy (characteristic rub during auscultation) c. Dysrhythmia (irregular/abnormal) heart rhythm D. Renal Problems o Lupus Nephritis occurs 40-85% with SLE o Px may have Proteinuria which may progress to Glomerulonephritis, seen in U/A E. Nervous System Problems CNS 1. Generalized or focal seizures 2. Cognitive dysfunction disordered thought processes, disorientation, memory deficits and psychiatric Sx (E.g. severe depression and psychosis) 3. Headache (sever during exacerbation) F. Hematologic Problems o Anemia, mild leukopenia, and thrombocytopenia o Antiphospholipid antibody syndrome which causes hypercoagulability which may cause excessive bleeding or blood clot development G. Infection o Infection is a major cause of death especially because of Pneumonia o Defects in ability to phagocytize bacteria o Deficiency in the antibody Collaborative Care Medicines 1. NSAIDS for mild disease arthritis, watch out for GI effects (bleeding) 2. Steroid-sparing drugs (E.g. Methotrexate) if cant take corticosteroids 3. Antimalarials (E.g. hydroxychloroquine) for fatigue and skin/joint problems 4. Corticosteroids for exacerbations and severe disease Polyarthritis 5. Immunosuppressive drugs (E.g. Cyclophosphamide and Azathioprine) lupus nephritis Nursing Management During exacerbations: 19

Immunologic and Inflammatory - Meriel Espanilla

1. Accurately record the severity of Sx and document the response to therapy 2. Assess the following: fever pattern, joint inflammation, limitation of motion, location and degree o discomfort, fatigability; Goniometer measures degree of movement 3. Monitor weight, IO (if corticosteroid are prescribed) 4. 24 hours, urine collection for CHON and Creatinine clearance 5. Observe for signs of bleeding (pallor, skin, bruising, petechiae, tarry stools) Pregnant with SLE May cause spontaneous abortion, stillbirth and intrauterine growth retardation due to deposits of immune complexes in the placenta and inflammatory responses in the placental blood vessels Exacerbation is common during post partum NLS (Neonatal Lupus Erythematosus) rare, will have characteristic skin rash, 30% of cases. Criteria for Diagnosis of SLE 1. Malar rash (aka CBR) 2. Discoid rash patches 3. Photosensitivity 4. Oral ulcers 5. Arthritis (non erosive) involves 2 or more joints, characterized by tenderness, swelling, and effusion 6. Serositis it could be pleuritis or pericarditis 7. Renal Disorder persistent proteinuria or cellular cast in urine 8. Neurologic Disorder seizures or psychosis 9. Hematologic Disorder hemolytic anemia, leucopenia, lymphopenia, or thrombocytopenia 10. Immunologic Disorder antinuclear to antibody ***classified as having SLE if 4 or more of the criteria are present simultaneously during any interval of observation

Immunosuppression - IS with suppressed response immunosuppression caused by medicines, radiation and diseases A. Immunosuppressive Agents/Therapy Goal: goal is to adequately suppress response to prevent rejection of the transplanted organ while maintaining sufficient immunity to prevent overwhelming infection. 1. Corticosteroids (PO, IV) suppress inflammatory response, E.g. Prednisone 2. Calcineurin Inhibitors (PO, IV) - Most effective immunosuppressant available, prevent a cell-meditated attack against the transplanted organ, but potentially nephrotoxic. E.g. Cyclosporine 3. Cytotoxic drugs (PO, IV) o Suppressive effects both T and B lymphocytes o Major limitation is GI toxicities: N/V, diarrhea, E.g. Mycophenolate mofetil 4. Monoclonal Antibodies o Cloned from mouse o Used to prevent acute rejection episodes o S/E: fever, headache, myalgia, GI disturbances B. Radiation Therapy It is the emission and distribution of energy though space or a material medium CA cells are more likely to be permanently damaged by cumulative doses of radiation because they are less capable of repairing sublethal DNA damage than healthy cells Local treatment modality for CA 20

Immunologic and Inflammatory - Meriel Espanilla

Myelosuppression (bone marrow suppression) one of the most common effects of radiation which may cause infection, hemorrhage, and overwhelming fatigue, but the affected aria will just be the area exposed to radiation whereas chemotherapy affects throughout the body.

2 Types of Radiation 1. Teletherapy o External beam radiation o Most common form of radiation treatment delivery 2. Brachytherapy o Internal radiation o Consist of implantation of insertion of radioactive materials directly into the tumor

Concept III Functions of the Skin 1. First line of defense against infection 2. Protects underlying tissues and organs from injury 3. Receives stimuli from external environment; detects touch, pressure, pain and temperature stimuli and relays that information to the nervous system 4. Maintains normal body temperature 5. Excretes salts, water, and organic wastes (perspiration) 6. Protects the body from excessive water loss 7. Synthesizes Vit. D3 which converts to calcitriol for normal Ca metabolism 8. Stores nutrients Layers of the Skin o Epidermis o Dermis o Hypodermis (SQ insulin) o pH of 4.2 5.6 halts the growth of bacteria o normal acidity of the skin and perspiration protects against bacterial overgrowth A. Specific health Protection and Maintenance o Skin reflects both physical and Psychologic well-being and this includes: Avoidance of: 1. Environmental Hazards a. Sun Exposure - UV rays of the sun cause degenerative changes in the dermis resulting in premature aging (E.g. loss of skin elasticity, thinning, wrinkling, drying of the skin) - Everyone should use a sunscreen with a minimum SPF of 15 daily (Sun Protection Factor) b. Irritants and Allergens 2 Type of Contact Dermatitis - Irritant Contact Dermatitis produced by direct chemical injury to the skin - Allergic Contact Dermatitis is an antigen-specific, Type IV delayed hypersensitivity response - Nurse should counsel patients to avoid known irritants (Ammonia, harsh detergents) c. Radiation - Can cause serious S/E: Erythema, dry and moist desquamation, edema and hypo/hyper pigmentation 2. Rest and Sleep 21

Immunologic and Inflammatory - Meriel Espanilla

Sleep is restorative, rest reduces the threshold of itching and potential skin damage from the resultant scratching 3. Exercise - Inc circulation and dilates blood vessels - Causes healthy glow and psychological effects 4. Hygiene - Are influenced by the skin type, lifestyle and culture of the patient 5. Nutrition Vitamin A essential for maintenance of normal cell structure necessary for normal wound healing; lacks causes dryness of the conjunctiva Vitamin B Complex deficiencies of Niacin (B3) and Pyridoxine (B6) manifest as dermatological Sx: Erythema, bullae and seborrhea-like lesions Def: Niacin Pelagra scaly dermatitis, diarrhea, depression Vitamin C (Ascorbic Acid) essential for connective tissue formation and normal wound healing Causes scurvy: Bleeding Gums, Purpura (skin rash resulting from bleeding of capillaries) Vitamin K essential for sensitizing blood clotting factors Protein for normal wound healing Unsaturated fatty acids necessary to maintain the function and integrity of cellular and subcellular membrane in tissue metabolism 6. Self treatment - Nurse must increase patients awareness of the dangers of self diagnosis and treatment - Follow instruction of OTC meds B. Dermatologic Disorders 1. Malignant Conditions of the Skin (40% of new CA Dx) ABCDE Rule (Examination of skin lesion): Asymmetry Border Irregularity Color change/variation Diameter Evolving or changing in some way Common Skin CA i. Basal Cell Carcinoma - Is a locally invasive malignancy arising from epidermal basal cells - Not deadly; 90% cure rate - Most effective treatment for CA is laser surgery blood less Clinical Manifestations: a. Nodular and ulcerative small, slowly enlarging papule; borders semi-translucnet or pearly with overlying telangiectasia (localized collection of distended blood capillaries) b. Superficial erythematous, sharply defined, barely elevated multinodular plaques with varying scaling and crusting 22

Immunologic and Inflammatory - Meriel Espanilla

ii.

Treatment and Prognosis: Tx (applicable for other skin CA) a. Excisional surgery b. Chemosurgery c. Electrosurgery d. Cryosurgery Squamous Cell Carcinoma - Deadly, less common than BCC but very aggressive; potential to metastasize; invasive - Malignant neoplasm of keratinizing epidermal cells which frequently occurs on sunexposed skin - Pipe, cigar and cigarette smoking contribute to the formation of SCC to the mouth and the lips Clinical Manifestation Superficial thin, scaly, erythematous plaque without invasion into the dermis Early manifestation: firm nodules with indistinct borders

Late manifestation: covering of lesion with scale or horn from keratinization Malignant Melanoma - Is a tumor arising in melanocytes which are the cells producing melanin - Metastasize to any organ including the brain and the heart - Most deadly skin CA Clinical Manifestation: i. Irregular color, surface and border ii. Flat or elevated iii. Eroded or ulcerated Back and Chest common sites for men Legs and Back common sites of women C. Bacterial Infections a. Staphylococcus aureus Major types of bacteria resp for primary and secondary skin infection b. Group A Beta-Hemolytic iii. Common Bacterial Infections: 1. Impetigo caused by Group A Beta Hemolytic streptococci, staphylococci o Associated with poor hygiene and low socioeconomic status o May cause Glomerulonephritis (Descending Infection) Clinical Manifestation a. Vesiculopustular lesions that develop thick, honey colored crust surrounded by Erythema b. Pruritic c. Most common of face as primary infection Treatment and Prognosis a. Systemic antibiotics IVF b. Oral penicillin, Erythema c. Local treatment warm saline or aluminum acetate soaks followed by soap and water removal of crusts, topical antibiotic (Bactroban) 2. Folliculitis o Caused by staphylococci o Present in areas subjected to friction, moisture and rubbing o Inc incidence in px with DM 23

Immunologic and Inflammatory - Meriel Espanilla

Clinical Manifestation a. Small pustule at hair follicle opening with minimal Erythema b. Most common on scalp, beard, extremities in men; areas of friction and rubbing of extremities Treatment and Prognosis a. Antistaphylococcal soap (Dial) b. Water cleansing topical antibiotics (Bactroban) c. Warm compresses of water 3. Furuncle o Deep infection with staphylococci around hair follicle often associated with severe acne or seborrheic dermatitis Clinical Manifestation a. Tender erythematous area around hair follicle b. Draining puss c. Most common on face, back of the neck, axillae, breast, buttocks, perineum, thighs d. Painful Treatment and Prognosis a. Incision and drainage, packing may be required b. Antibiotics c. Frequent application or warm, moist compresses 4. Carbuncle o Multiple interconnecting furuncles Clinical Manifestation a. Many pustules b. Common at the nape of the neck 5. Cellulitis o Inflammation of the subcutaneous caused by S. aureus and Streptococci Clinical Manifestation o Hot, tender, erythematous and edematous o Chills o Malaise o Fever Treatment and Prognosis i. Moist heat (circulation) ii. Immobilization and elevation iii. Systemic antibiotic therapy iv. Progression to gangrene if untreated D. Viral Infections Types of Viral Infection: 1. Herpes Simplex Virus (HSV) Type 1 and 2 o Oral or genital infections o Contagious o Exacerbated by sunlight, stress, menses and systemic infections o Transmission is through respi droplets, saliva, cervical secretions o Route may be oral or genital Clinical Manifestations 1st Episode a. Symptoms 3-7 days or more after contact b. Painful local reaction c. Systemic symptoms (e.g. Fever and malaise) 24

Immunologic and Inflammatory - Meriel Espanilla

Recurrent a. Small b. Recurrence in similar spot 2. Plantar Warts o Caused by HPV (Human Papillomavirus) Clinical Manifestation o Wart on bottom surface of foot-growing inward because of pressure of walking or standing Treatment and Prognosis o Liquid nitrogen like a spray after dried, it can be taken out E. Fungal Infections 1. Candidiasis o Caused by Candida albicans (or moniliasis) o Found in moist areas: groin area, oral mucosa (oral thrush white cheesy substance in the mouth) o Due to the depression of cell mediated immunity that allows yeast to become pathogenic Clinical Manifestation o Mount oral thrush (white cheesy substance/flakes) resembles milk curds o Vagina Vaginitis red, edematous, painful, vaginal wall vaginal discharges, very pruritic, pain in urination, pain during intercourse o Skin diffuse popular erythematous rash Treatment a. Nystatin (vaginal suppository/oral lozenges) b. Abstinence or use of condom c. Myscostatin powder for skin lesions F. Infestation and Insect Bite 1. Pediculosis o Parasites suck blood and leaves egg on skin and hair o Nits eggs of lice 3 Types a. Head Lice Pediculus humanus var capitis b. Body Lice Pediculus humanus var corporis c. Public Lice Phthirius pubis var; Transmitted through sex Clinical Manifestation a. Minute, red, inflammatory b. Pruritus Treatment Pyrethrins 2. Scabies o Caused by Sarcoptes scabiel o Mites penetrates stratum corneum, deposits eggs -> allergic reaction from presence of eggs, fees, mite parts o Through direct contact o Rarely seen in dark skinned people Clinical Manifestation a. Severe itching especially at night, usually not on face b. Burrows interdigital webs, flexor surface of wrists, genital, anterior axillary folds Treatment a. 5% Permethrin topical lotion, 1 overnight application with 2 nd application 1 week later, may yield 95% eradications; Possible residual pruritus up to 4 weeks after treatment b. Antibiotics if 2ndary infection is present 25

Immunologic and Inflammatory - Meriel Espanilla

G. Benign Conditions of the Skin 1. Acne Vulgaris o Inflammatory D/O of sebaceous glands common in teenager o This can occur before menses o With the use of corticosteroids and androgen Clinical Manifestation a. Non-inflammatory lesions including open comedones (black heads) and closed comedones (white heads) b. Inflammaotry lesion including papules and pustules c. Most common on face, neck and upper back d. Chubby inner arm and inner thigh Treatment a. Mechanical removal of multiple lesions with comedo extractor b. Topical Benzoyl peroxide c. Systemic antibiotics d. Often improvement with sun exposure e. Used of Isotretenoin (Accutane) for severe acne, but it is C/I in pregnant and with liver diseases

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