Note: Some of the above are my own, others have been adapted from colleagues' handouts and yet others are links to portions of other pages.  Check the URL to see where they reside.  Some dermatologic sites of interest can be found on the Cosumer Health Information  page.

ACNE and ACCUTANE (RoACCUTANE)
 This is a handout I've used for years.  It could be better.  I recommend you check AcneNet is addition.  Also, please feel free to ask me any questions you may still have after reading this page.

There a a number of kinds of Acne, but the most frequent type is called Acne Vulgaris (from the Latin: Vulgar = common). The disease usually begins at or around puberty. Most causes are seen in the middle and late teenage years, however, particularly in women, one may see acne into the twenties and thirties.

Acne is a disease of the sebaceous glands. After puberty, glands produce fat which are acted on the normal bacteria of the skin. Fats then become irritating to the skin and cause acne lesions.

The common acne lesions are:
1. Comedones - opened and closed
2. Papules - red bumps
3. Pustules
4. Cysts
 

Acne Myths:

Diet: In most cases, your diet probably plays a very small role in causing acne. If you feel that some food makes your acne worse, it is best to avoid them; but by and large soda, chips, chocolates and other "forbidden foods" do not cause acne. Occasionally a patient who eats large amounts of iodides (seaweed, kelp, vitamins with iodine) will get acne.

Sun: While a suntan may cover the acne lesions, the sun probably has no curative role in acne.

Treatment:

There are many ways to treat acne. Basically they can be divided into topical and Systematic (oral). Some cases don't even need therapy.

Topical Therapy:

1. Cleansing: The surface fat and bacteria do not cause acne. Only those fats and bacteria in hair follicles provoke acne lesions. Therefore, simple washing is not helpful in acne. Excessive washing may make the condition worse. However, washing may remove excessive surface oil and improve appearance somewhat.

2. Benzoyl Peroxide (BP): This is a potent antibacterial agent. By killing the number of bacteria on the skin, it decreases the number of acne lesions found. For the first few weeks of use, it causes some redness, scaling, and itching. Therefore, usually the weak 2.5 or 5% preparation before the stronger 10%. BP comedones as a wash or a gel.

3. Retinoic Acid: (Vitamin A Acid (Retin A, Differin, Azelex). Topical vitamin A preparations function primarily as irritants, peeling agents and are particularly useful when there are many white heads (closed comedones). These may exaggerate the effects of the sun. For this reason, they are best applied in the evening. Fair-skinned patients should be careful about prolonged sun exposure.

4. Topical antibiotics: Erythromycin and Clindamycin are the most widely used. These are quite effective, but it is doubtful that they will replace systematic antibiotics in moderate to severe acne. These too may cause redness, scaling, and itching for a short time.

Systematic Therapy:
 
Antibiotics:

Tetracyclines and Erythromycin are the most common antibiotics used. If a patient is taking tetracycline, it is not absorbed in the presence of food, and must be taken on an empty stomach. Iron pills taken with the tetracycline will interfere with the absorption also. The tetracycline derivatives - doxycycline and minocycline are less dependent on an empty stomach and easier to take.

Tetracyclines result in a yeast vaginitis in around 10% of the women who take them. This is not serious and can be handled with creams and is not a reason to stop the drug. (Remember, 90% of the users do not develop this.) Tetracycline is usually prescribed before Erythromycin, because more studies have been done with it; but both are equally safe. Warning: Tetracycline should not be taken after the third month of pregnancy or by children under 12, as it will stain growing teeth. Erythromycin is similarly to be avoided during pregnancy. Tetracyclines may also interfere with the efficacy of the birth control pill.

Isotretinoin (Accutane)

Accutane was introduced for acne around 1982. It is a vitamin A derivative and is the most effective anti-acne agent we have. Originally used for only the most severe cases, it is being used now for milder cases which have failed other therapies. A five - six month course of Accutane will completely clear almost every patient. Fifty percent are cured - their acne does not come back - while the acne recurs in another 50%. Of these, most have milder acne that can be managed more simply. Around 20% of patients go on to receive a second course of Accutane. Accutane can raise the fats in the blood and causes birth defects in woman who are pregnant when they take it, therefore close monitoring is important - and all sexually active women who take Accutane must be using oral contraceptives or two alternative methods. Pregnancy testing is done monthy on these patients. Sexually active patients who are categorically against abortion should not take this drug.
 

Hormones:

Birth control pills (BCP) can help women with acne. In my experience these are not as effective as oral antibiotics - but some women do quite well with these. Orhto TriCyclen and Demulen are two pills which are recognized to be of value. Some BCP can actually make acne worse - so this should be discussed with a patients dermatologist of gynecologist.

Antiandrogens are quite effective for acne in women with resistant disease. The most commonly used is cyproterone acetate. However, this is not available in the United States. For more information on these agents, you can check PubMed.

Other treatments:

Acne cysts respond to weak concentrations of steroids injected into them. The improvement is rapid and the procedure is not very painful.
 

Acne surgery refers to the removal of acne lesions. It is most commonly applied to comedones, and may prevent their evolution into more inflammatory lesions (the papules, pustules, and cysts).
 

Course under Treatment:

With therapy, results are seen within 2-3 month. The response is not usually more rapid and it is unwise to change therapy radically before 2 months on a given treatment. Those patients that do not respond to tetracycline may respond to erythromycin (as well as Bactrim, Septra, amoxicillin or other antibiotics). About 60% of patients will do well with either of these two agents (or other antibiotics) and good topical care. In their early twenties, most patients will spontaneously improve, however, some patients will continue to develop lesions into their thirties or beyond and still need treatment. Acne scarring frequently improves with time, but certain patients may have significant scarring which requires definitive treatment. In the past, this was dermabrasion - but now laser techniques are used.

After you read this, if you have any questions, please do not hesitate to bring them to my attention.

For further information on acne click on AcneNet
 

Actinic Keratoses (Solar Keratoses, AK)

AKs are rough scaly spots which appear on the sun-damaged skin. Especially common in fair-skinned persons, they result from repeated sun exposure. Photo-damaged skin is dry and wrinkled and may form persistently scaly spots, actinic (solar) keratoses, even though the crust or scale is picked off.

The standard treatment of a AKs calls for removal of the defective skin cells. New skin then forms from deeper cells which have escaped sun damage. However, there is no evidence that treatment of most AKs is of any value. Removal of all AKs is quick and easy and very lucrative for a practicing physician.

While textbooks of dermatology state that around 10% of AKs progress to skin cancer (squamous cell carcinoma, SCC) if left untreated, this number was derived from no study and crept into the literature without any factual basis. The only study on the malignant transformation of AKs was performed in Australia by Professor Robin Marks, a research dermatologist.

This is an abstract of Robin Marks' study:
Br J Dermatol 1986 Dec;115(6):649-655
Spontaneous remission of solar keratoses: the case for conservative
management.
Marks R, Foley P, Goodman G, Hage BH, Selwood TS

One thousand and forty people aged 40 years and over, 616 (59.2%) of
whom had solar keratoses, were followed for 12 months. Two hundred and
twenty-four people (36.4%) had a spontaneous remission of at least one
of their solar keratoses. A total of 485 lesions (25.9%) underwent
spontaneous remission out of the 1873 lesions that were present at the
first examination of these 224 people. There was no significant
difference between the number of lesions present at the initial
examination in those who had a spontaneous remission compared with those
who did not. There was a 21.8% increase in the total number of solar
keratoses in the 1040 people studied in the 12-month period, due to new
lesions forming at the same time as remissions were occurring. The
incidence rate of squamous cell carcinoma occurring in the people with
solar keratoses was 0.24% for each solar keratosis present at the
original examination. With a substantial proportion of solar keratoses
remitting spontaneously, plus the low rate of malignant transformation
and the low potential for metastasis to occur from squamous cell
carcinoma arising in a solar keratosis, the rationale of treating all
solar keratoses appears questionable.

DJE: Comment: Robin Marks could not get his study published in the United States or Australia. The reason was that dermatologists derive a significant proportion of their income from these usually banal lesions. The image of the dermatologist running from room to room with a spray bottle of liquid nitrogen is all too familiar to elderly patients.

There are lesions which look like AKs which need treatment. These are the hypertrophic AKs which can be indistinguishable from early squamous cell carcinomas. An experienced dermatologist will be able to tell the banal from the worrisome in most cases. However, it will be a long time before the average practitioner will give up income for the pursuit of truth - so it is caveat emptor.

My mother recently saw a dermatologist in her area. She's a light complected Caucasian in her early 80s - thus fair game for the cryospray gun. Her dermatologist received around $200 from Medicare and AARP for less than 5 minutes work. You be the judge.

For the orthodox story on AKs go to http://www.dermnet.org.nz/
 
 
 

HOW TO EXAMINE YOUR SKIN
Don't Be Shy!
(This was adapted from the website of  Dr. Norman Goldstein of Honolulu.  Dr. goldstein is one of the foremost proponents of skin self-examination and the dermatologist who coined the phrase "Practice Safe Sun."

Careful examination of your skin every month will improve your chances of finding early warning signs of skin cancer. This is especially important if:

You have fair skin and sunburn easily.

You have had several blistering sunburns.

You have had a lot of moles on your body.

You have a family history of skin cancer.

Examine your skin in a well-lighted room using a full length mirror and a smaller hand mirror. Undress completely and examine every inch of your skin, including hard to see places. You may want to have someone else help you.

1. Examine your entire face including lips and eyelids. Inspect your scalp, neck, and tops of your ears.

2. Examine the front and back of your body. Raise your arms and look at your sides. Check the skin under your breasts.

3. Check all sides of your arms and hands, including between your fingers and fingernails.

4. Examine the back and front of your legs. Use the hand mirror to scan your buttocks and genitals.

5. Sit down to check your ankles and feet, including the soles and between your toes.

Contact your health care provides right away if you notice any changes in your skin such as a new mole or change in an existing mole.

The A-B-C-D's

Malignant melanoma is a deadly form of skin cancer. However, when it is found early, treatment can be very successful. Monthly self-examination is the best way to become familiar with the moles, freckles, and spots on your skin. A change in a mole or spot may be the first sign of skin cancer.

Malignant melanomas do not usually look like normal moles. A handy way to remember the features of melanoma is to think of A-B-C-D.

A - Asymmetry. One side of the mole doesn't match the other side. Normal moles are round or oval.

B - Border irregularity. The edges of the mole are uneven, scalloped, or notched. The edge can look blurred. Normal moles have smooth, even borders.

C - Color. The mole may have different shades of brown or black, and possibly spots of red or blue. Normal moles are usually a single shade of brown.

D - Diameter. Any mole or growth larger than 6 millimeters (about the size of a pencil eraser or 1/4") is a matter of concern. Normal moles are usually smaller.

Keep in mind that change in a preexisting lestion is the most important finding.  This means observable growth over a period of weeks to months.  Bening lesions can grow slowly over years, but malignant lesions usually change over weeks to months.  Change over a few days most often is associated with inflammation or infection.

If in doubt, please contact your dermatologist.

) 1997 Pacific Monograph
 

Herpes Zoster (Shingles)

Herpes zoster, or shingles, is a common skin disease characterized by a painful, one-sided band like blistering eruption. It may occur at any age.
The disease represents activation of the chicken pock virus which remains in the body after that infection. It is estimated that by age 85 at least half of the population will have had one attack of Herpes zoster. Second attacks, although uncommon, may occur.
Patients with shingles are infectious to people who have not had chicken pox. One may contract chicken pox from a person with shingles. Patients with advanced cancer may also be at risk and should be isolated from patients with Herpes zoster.
The first symptom of Herpes zoster is pain or an abnormal sensation in the area which will later develop the rash. This may last for two to three days before the rash occurs, and may be mistaken for a number of medical or surgical problems: such as, pleurisy, heart attack, ulcer disease, appendicitis, disc problems, and others. The rash, when it occurs, is distinctive. It is band-like and does not cross the mid-line of the body, being entirely on the right or left side. It is made up of blisters which vary in size from patient to patient, some being quite small and clear, others being large and occasionally blood-filled. The rash spreads for 1-4 days, dries, and crusts for 7-10 days, and heals over 2-3 weeks. It tends to be more severe in older patients.

Treatment:
The uncomplicated case requires no special treatment. Pain medications (aspirin, acetaminophen, or codeine) are sometimes necessary. Cool compresses and calamine lotion may speed up drying of the blister, and the application of olive oil to the crusts may loosen them. Recently, it had been shown that acyclovir and related antiviral agents may shorten the duration of zoster. This is particularly true is the drug is started within three days of the onset of the rash. It is important to keep in mind that acyclovir does not prevent post herpetic neuralgia and that for thousands of years people have recovered from herpes zoster without any therapy.

Complications:
1. Pain may last for months to years after an attack. This is rare in patients less than age 50, but more common in patients over 60.
2. Dissemination: 2 to 10% of patients with H. zoster may have many blisters outside of the original band covering wide-spread areas of the body. This is usually not serious.
3. Secondary infection may occasionally occur in zoster lesions. This is by no means the rule, but one must look for it.
4. When shingles occur on the forehead and especially the nose, the possibility of eye involvement exists. Your doctor will know when to refer you to an eye specialist, as involvement of the eye with H. zoster requires prompt treatment.
5. There are a number of other rare complications which may occur. Most of these are related to the muscles and nerves. Consult your doctor if anything unusual occurs with or shortly after your zoster.
6. Zoster may be more severe in HIV positive patients. Special attention should be given to zoster patients at risk for HIV infection.
 

MOLES
Beauty marks or Nevi

We all have "moles." The average person has 15, but many people have 40 or 50 moles. The medical term is nevus (plural: nevi), the common term is "mole." "Beauty mark" is probably the best term, if you have one or two, and they are not too big and not on the tip of your nose!

THE NATURAL HISTORY OF A "MOLE"
A small number of moles are present on the skin at birth (congenital nevi) . They are skin-colored, tan or brown.  But, most moles are acquired and develop from age four or five to around age 40.  As you get older, your moles may get larger and frequently darker, especially in sunlight-exposed areas. Puberty and pregnancy can also make moles darker. Any "mole" that develops after age 40 should be biopsied.

The vast majority of moles are benign, and never become cancerous. Most require no treatment. If your mole is large, unsightly, or irritated by clothing or shoes, it may be advisable to have it removed.  Around 20% of Caucasians have dysplastic nevi. These are moles with atypical appearances.  Please see the handout on these.

If your mole bleeds,itches, becomes painful or suddenly changes in size, shape or color, it should be examined.

Frequently, examination of the mole will be sufficient to determine the nature of the mole. If there is any question of a cancerous change, a biopsy will be taken. A microscopic examination of the tissue is the best way to be certain if cancer is present. If cancer is found, additional treatment may be required, either surgery, x-ray, anticancer creams, etc. If this is the case, you will be contacted to return to the office for more treatment.

REMOVAL OF A MOLE
Most moles can be removed by surgery.  Occasionally they can be shaved off.   Large moles are best removed by a plastic surgeon.

If you have any doubts about your mole, it is best to have it checked.
 
 

RETIN-A GUIDELINES
START LOW AND GO SLOW

Retin-A has been a mainstay for acne therapy for 25 years. It is safe and effective and no dermatologist could practice without it. Yet, it can be irritating if one does not use it properly. Generally, one should use the strongest preparation tolerated, but it must be worked up to slowly.

Retin-A comes in the following strengths:
Cream: 0.025, 0.05, 0.1
Gel: 0.01, 0.025
Solution: (rarely used)

The gel is more potent than the cream in spite of being a lower concentration. The 0.025% cream was marketed not for acne - but for older patients who are using Retin-A for wrinkles and aging changes. Now, there is Renova for this group of patients.

Here are some guidelines which may help you.

1) Use a non-soap cleanser, like Cetaphil Cleansing Lotion, twice a day. If you do this, you need not wait 20 minutes after washing to apply Retin-A.

2) Here is how to start:

Retin-A .01 .025 .05 .1 cream gel (see your prescription) apply a pea-size drop to the entire face every other night for two weeks, then every night for eight weeks. Occasionally, you can advance to morning and evenings.  After around two months the strength can usually be increased.

If redness or dryness develops after increasing the strength (which are rare) drop back to the preceding dosage until it resolves, then increase the dose again. The 0.025 and 0.05% creams are generally too weak to work all that well for long term treatment.

Please be patient. This takes a while to work - but it is very effective.
 
 

SCABIES: THE ITCH

Scabies is caused by Sarcoptes scabei variant hominis, the itch mite. Mites are tiny animals related to spiders. The female mite is the troublemaker. She burrows into the skin, lays eggs and deposits feces there. The characteristic itching takes weeks to months to develop and is based on allergic mechanism.
The diagnosis of scabies depends on the following characteristics:
1. Small burrows located on the hands, elbows, wrists, breasts of women, genitalia of men, or other areas. The head and neck are spared, except in infants.
2. In about 1/3 to 1/2 of the cases, the mite, eggs, and/or feces can be demonstrated.
3. The itching is most pronounced at night.
4. Other family members (and household contacts) frequently itch, too.
TREATMENT:
Much has been written in the recent years about the best and safest treatment for scabies, and there is no general agreement. Most authorities, however, favor the use of 1% benzene hexachloride (Kwell).
Kwell is applied over the entire skin from the neck down, especially between the fingers and toes. It is important to reach all areas, except the face, with especially careful attention to the sites of greatest involvement. The medicine should be left on for 12-24 hours and washed off.
Two applicants of Kwell are all that is necessary. It is a toxic and irritating and should not be reapplied.
Until recently, children under two were treated with other agents. These agents are not as effective and useful for scabies, and have not proven to be any safer than Kwell.
Both 5% permetherin cream (Elimite) and Lindane (Kwell) Lotion are effective. It is rubbed into the skin from the scalp to the feet and left on overnight. A second treatment should be done in one week. No matter whether you use Kwell or Elimite, it is of the utmost importance that all other household members and close contacts be treated.
In the past year, ivermectin, has been approved for use.  this is an oral agent which is probably more effective than the topicals; but also easier to use.  Ivermectin (Stromectol) is not approved at this time for young children.
Ordinary laundering or dry cleaning of clothing, bed linens, and blankets is all that is required. Some patients, because of their scratching developed impetigo, and this will have to be treated with antibiotics. After treatment, it is uncommon for itching to last for 2-4 weeks.
Re-infestation: This is suspected in patients who persist in itching for more than two-four weeks after treatment. If evidence of active scabies is found, then re-treatement may be advisable. The patient should be questioned closely about the possible source for re-infestation.
 
 

TINEA VERSICOLOR

Tinea versicolor (TV), a superficial yeast infection of the skin, is caused by Pityrosporon orbiculare, a normal scalp organism. Obesity, pregnancy, and a warm, moist environment may predispose a person to this infection.
The disease may show up as white, tan, or brown spots on the skin. The back, chest, and upper arms are most frequently involved, but other areas may be affected. Frequently, it is first noticed after the skin is tanned, because the color difference is then obvious. The yeast may interfere with the normal tanning process and therefore, the skin may look pale in the affected areas. Usually there are no symptoms or only mild itching.
Untreated, TV may persist for many years. Thorough scrubbing of the skin followed by a mild fungicide will usually control the infection, but the skin may not return to its normal color for a number of months. Sun exposure will eventually retan the affected skin. In addition, most patients who have tinea versicolor will experience relapses.

Treatment Directions
There are various therapies for TV, and no one of them is perfect for all patients.
1. Selenium sulfide suspension (Selsun, not Selsun Blue) has been the standard therapy for years. It should be massaged into the skin from the neck down covering all areas, allowed to dry, and remain on for 10-15 minutes, after which is washed off in a shower. Some people clear after as little as two weeks of treatment. After the first two weeks, Selsun may be reapplied weekly or every other week in a similar fashion. (Now see "C" below.)
2. Imidazole creams and lotions (Miconazole, Clotrimazole, Econazole, and Ketoconazole, and others) are effective when reasonably small area are involved. They should be rubbed in once or twice daily to the affected areas for three to four weeks.
3. In patients with very intense disease, oral Ketoconazole is quite effective in eradicating the infection. This is not for every patient, because of possible serious, but very infrequent, side effects. An informed patient may decide to use this drug after appropriate blood tests are done. Recurrences are the rule, however.

Your therapy will be:

A._________________________
B._________________________
C. Use Selsun, a shampoo with zinc pyrethion or Nizoral Shampoo for your hair. These chemicals control the growth of Pityrosporon yeasts on the scalp.
 

URTICARIA (HIVES)

Urticaria is a common skin problem. 15 to 20% of people will have at least one episode of hives during a lifetime. Most of these will be of the short-lived variety (acute urticaria). Less commonly, an attack of urticaria may last for more than six to eight weeks. This is called chronic urticaria. In the acute type, a cause can usually be found; however, in chronic cases, the origin is usually not detectable.
The typical hive is a light red bump or swelling on the skin. Hives may vary from less than half an inch to many inches in diameter. As a rule, an individual hive lasts for less than 24-48 hours and then disappears. New lesions continue to develop for days, weeks, and less commonly, months.
There are a great number of causes for hives. Drugs, foods, inhalants, insect bites, creams, certain infections, emotional stress, and local injury to the skin (from such diverse causes as physical trauma, heat, cold, and sunlight) may all trigger an attack.
Laboratory tests are usually not necessary for the short-lived case. Occasionally, blood studies, urinalysis, x-rays, and allergy testing may be helpful in uncovering the cause of hives. Unfortunately, even extensive studies often fail to determine the cause in most cases of chronic (long duration) urticaria. But these studies will help to rule out the probability of a serious underlying disease.
The ideal treatment is the identification and removal of the causative agent. When this is not possible, non-specific measures should be taken. Alcohol, aspirin, heat, emotional stress, and excessive exertions should all be avoided if possible. Drug therapy affords considerable relief in most cases and antihistamines, and occasionally combinations of these are required to control an attack; however, most causes will respond to hydroxizine (Atarax). Most antihistamines cause drowsiness, especially in the first few days of use. Therefore, driving, drinking, and working around potentially dangerous machinery should be limited when first taking these agents. In the past two years, two antihistamines, Seldane and Hismanyl, which do not cause drowsiness have been approved for use.
 

WARTS AND ALL

Warts are benign growths on the skin which are the result of a specific viral infection. Although they may occur at any age, they are most common in the 10-20 year-old age group. It is estimated that 10% of teenagers have warts. Almost everyone will get one or more warts in their lifetime. As with other infections, warts may be transmitted from one individual to another. They may also be contracted from inanimate objects (for example, the cements around a swimming pool).

Warts may occur on any location of the skin. In different locations, they have different appearances. This accounts for the many confusing names given to warts. For instance, the plantar warts are merely warts found on the soles (plantar area) of the feet.

"The strangest thing about warts is that they tend to go away. Fully grown, nothing in the body has so much the look of toughness or permanence as the wart, and yet, inexplicably and often very abruptly, they come to the end of their lives and disappear." *Warts resolve because the body's immune response destroys them as it does with other infections. Thereafter, an immunity to the wart virus develops. Because warts vanish without treatment in most cases, the routine treatment of every wart is unnecessary and undesirable.

In general, the therapy of warts is nonspecific, destructive, and often painful. For these reasons, it is often wise to proceed slowly and with gentle methods at first, especially in children. Some of the methods we use are the destructive chemicals (Duofilm, Canthardin, and for genital warts, Podophyllin). Liquid nitrogen, an electric needle, and Zonas tape occlusion. Some people believe suggestion or hypnosis may cure warts. No matter what treatment, 1 in 3 treated warts will recur. However, in most cases, after a few treatment sessions, the patient will be free of warts.

*From : "On Warts : Lewis Thomas, The Medusa and the Snail
 
 

WET DRESSINGS

Wet dressings are used for acutely inflamed skin conditions. These rashes have varying degrees of redness, swelling, blistering, oozing, crusting, infection, and itching. The dressings cool and dry the skin. In addition, they cleanse the skin of exudates, crusts, and debris and help to maintain drainage of infected areas. Various medications may be added to the solution, but water is the most important ingredient.
The most common types of wet dressings I use are Domeboro powder packets or tablets (aluminum acetate) and normal saline, which can be mixed up by dissolving one teaspoon of slat in a pint of water. Directions for the Domeboro is to dissolve a packet or tablet in a pint or quart of water.

Method:

1. The dressing need not be sterile. Gauze, Kerelix, soft linen (such as old sheeting, pillowcases, handkerchiefs, or shirts) are acceptable. If cloth is used, it may be washed and reused.
2. Moisten the dressings by immersing them in the solution and gently ring them out. They should be sopping wet, not dripping. The solution should be warm and tepid. Cover with a soft towel or a cloth that will allow evaporation.
3. Apply or wrap skin loosely. Multiple layers (6-8) should be applied to prevent rapid drying or cooling.
4. The dressings should be removed, remoistened, and reapplied every 10-15 minutes for 1/2 to 2 hours three times a day.
5. After the dressing is removed, a lotion or cream may be applied to the skin as directed.

For some skin infections and abscesses (boils) the technique for wet dressings is modified somewhat. Follow steps 1-3, but then cover the warm dressings with plastic or Saran wrap. This helps to localize and heal the infection.
 

Reason used:___________________________________
Type solution:___________________________________
Use:____times a day for _________minutes for ________days.
____Cover ________Do not cover the dressing with plastic or Saran Wrap.