Glucotrol XL

By Q. Angir. National Technological University.

Try to identify your parasites before killing them so you can be on the lookout for them in the future purchase 10mg glucotrol xl with amex. Get slides or dead cul- tures of various pathogens and search in your white blood cells generic glucotrol xl 10 mg on line. Her urinalysis stated “hazy” (hazy with bacteria or crystals) instead of clear urine. It also listed white blood cells, red blood cells, and a few bacteria present in her urine. She was also full of beryl- lium (usually from “coal oil”) contained in the hurricane lamps she kept in every room. She had numerous parasites, including Strongyloides and hookworms spread through her body tissues. She was thrilled to learn how to get her health back and started with the dental problem. It all started with fever and chills that she thought was the flu but after they went away, she was left with a tremor. Joint Pain or Arthritis Two main kinds of arthritis are recognized clinically, os- teoarthritis and rheumatoid arthritis. In rheumatoid arthritis the bacteria come from larger parasites—wormlets ac- tually living in these joints. The worms are the common little roundworms whose eggs hatch into microscopic wormlets that travel. Their life cycle normally directs them to travel to the lungs but in some people they travel through the entire body, including brain, muscles and joints. My suspicion is that there are toxins, like mercury, thallium, cadmium, lead, as well as solvents, distributed through the body, lowering immunity and allowing the tiny larvae to reside there. Once the pathway (routing) to these organs has been established, it continues to be used by other parasites as well. Soon a variety of parasites, their bacteria and viruses, and pollutants are all headed toward these organs. Osteo or Common Arthritis When joints are painful it is a simple matter to kill the bac- teria with an electronic zapper. The most common source for Staphs and Streps are small abscesses in the jaw bone, under and beside old extractions, root canals and mercury fillings. You may get immediate pain relief just from a dental cleanup, and again disappointment may follow. Staphs and Streps are such ubiquitous bacteria, they may come not only from jaw bone infections but from gallstones, kidney stones and other parasites. If any toxin is overlooked, especially asbestos and fiberglass, it is sure to find your joints and permit bacteria to return and cause pain. Make sure to correct your body acid levels after doing pH measure- ments of the urine (page 57). This calcium came from some other bone, such as the base of your spine or the wrist. Calcium was taken out of your bones for the simple purpose of neutralizing the ex- cess phosphate in your diet. Reduce phosphate consumption (meats, soda pop, grains) by half, eating fish, milk, vegetables and fruit instead. If you are al- lergic to milk, do several liver cleanses, switch brands of milk, use milk digestant, and use it in cooking and baking. Cheese and cottage cheese are not substitutes for milk (the calcium stayed in the whey). Dairy products must be boiled before consuming and should be no less than 2% butter fat. If you are not used to dairy products, start slowly and work up gradually to the 3 cups a day needed. Her blood test showed a high phosphate and alkaline phosphatase level showing she was dissolving her bones. After changing her diet to include milk, extra oyster shell calcium (one a day), magnesium oxide and vitamin B6, and reducing her meat and grain consumption her phosphate level went down to normal (below 4). She did the kidney cleanse and liver cleanse as well as parasite program but still had pain. It was traced to a drugstore variety multivitamin tablet she had taken daily for years. When she stopped these and added prescription vitamin D (50,000 units) for three weeks to help her bones heal she got relief. Four months later, after killing parasites, her hand pain and gums were much better. She had the dryer vent taped up tighter and this got rid of her as- bestos problem. She started on kidney herbs and in one month saw that her enlarged knuckles were beginning to go down.

T wave inversion over the right precordial leads is seen when patients are in sinus rhythm proven 10mg glucotrol xl. It results in left ventricular hypertrophy purchase 10mg glucotrol xl amex, involving the interventricular septum. Hypertrophy may be present in infants, but typically develops during childhood and adolescence. The underlying pathophysiology is decreased cardiac output secondary to left ventricular outflow tract obstruction and arrhythmias. Medical therapy with beta-adrenoceptor antagonists (beta-blockers), or verapamil is the first treat- ment option in all symptomatic patients. The absence of non sustained ventricular tachycardia during Holter monitoring has a high nega- tive predictive value in adults but this has not been proven in children or adoles- cents. Patients should be restricted from vigorous exercise since most cases of sudden death occurs shortly after exertion. Aortic Stenosis Aortic Valvar Stenosis is due to decreased valvar size resulting from thickening of the valve leaflets. If severe enough it will result in obstruction of left ventricular outflow and decreased cardiac output. The pathophysiology of aortic stenosis results in obstruction of left ventricular outflow and compensatory increase ventricular wall size. The subendocardium and the papillary muscles are hence most susceptible to ischemia. At rest the compensa- tory coronary artery vasodilation is near maximal, hence with exertion there is very little coronary reserve. Exercise creates an inbalance in oxygen supply and demand which results in ischemia and infarction. The clinical features of severe aortic valve stenosis are easy fatiguability, syn- cope with exertion and sometimes angina type symptoms. On examination there is a an ejection systolic murmur heard best at the aortic region (upper right sternal edge). The management of severe aortic valve stenosis includes exercise restriction and subsequent balloon valvuloplasty. Aortic valve replacement is required in patients who develop recurrent stenosis after valvuloplasty or who have significant regurgi- tation after valvuloplasty. Coronary Artery Anomalies Congenital anomalies of the coronary artery may result in syncope and sudden cardiac death in the adolescents. The origin of the left coronary artery from the right main coronary artery is the most common coronary anomaly. When the anomalous branch passes between the aorta and the right ventricular infundibulum the associa- tion with sudden death is increased. Bell-Cheddar and Ra-id Abdulla Patients present with recurrent syncopal attacks or chest pain with exercise or exertion. Summary In summary; syncope may be an indicator or precursor of sudden death, and a good history, physical examination and evaluation are important for the patient. The history is by far the most important clue to identify the patient with syncope who is at risk for sudden death. Any patient presenting with syncope should have a careful cardiac and neurological examination. Judicious use of laboratory testing and cardiac monitoring may assist the physician in making the diagnosis. Most common cause of syncope is neurocardiogenic cause; however the most malignant life threatening causes of syn- cope are of cardiac origin. Patients are often times misdiagnosed with seizures as seen in our case 3 scenario. Effective treatment modalities are available and with prompt diagnosis appropriate treatment has proven to be life-saving. Case Scenarios Case 1 18-year-old female presents to the clinic with a 3-year history of recurrent syncopal and pre-syncopal episodes. Syncope in her is often times triggered by anxiety, long standing and is more frequent around the times of her menses. She often times gets nauseated, with profuse sweating, blurred vision and light headedness prior to fainting. Possibility of Orthostatic intolerance was also entertained – based on blood pressure change with position at the time of her clinic visit Treatment: Adequate daily oral hydration was recommended. Awareness of her trig- gers and prodrome was lauded in this patient and it was recommended that should these symptoms recur; that she assumes the recumbent position as much as is possible. Physical examination: Heart rate was 92/min-irregular, Respiratory rate was 14/min.

Prominent bleeding points are identified Method and ligated or cauterised and the proce- Surgery is generally done under general dure repeated on the other side cheap 10 mg glucotrol xl. Postoperative Care The dissection method is the procedure of Normal unaided respiration should be choice for tonsillectomy cheap 10mg glucotrol xl overnight delivery. Guillotine tonsillec- established before the patient leaves the tomy is not favoured at present. The patient is placed in method is more quick in expert hands but it is tonsil position. This position allows free respi- not suitable for the cases with excessive ration and permits any blood and secretions, fibrosis and does not provide an effective which may collect, to run out of the nose and control for bleeding. The dissection method allows complete A strict watch should be kept on the pulse removal of the tonsillar tissue under direct and respiration of the patient. Cold drinks and The following are the steps of the operation: soft diet are prescribed for the initial few days. Antiseptic a Davis Boyle’s mouth gag is used to open mouth washes help to keep the mouth clean. It could be primary (during operation), reactionary (within the first 24 hours), or secondary (between fifth to tenth postoperative day) haemorrhage. Excessive bleeding at the time of operation usually arises because of trauma to an aberrant vessel or paratonsillar vein. Reactionary haemorrhage usually arises as a result of slipping of a ligature or because of the postoperative rise in blood pressure. Sometimes, the tonsillar aetiology and pathogenesis of peritonsillar pillars may need to be stitched over a pack to abscess. A antiseptic mouth washes are given in addition review of peritonsillar abscess has been under- to bed rest. A mixed bacterial flora of Peritonsillar abscess is a complication of acute streptococci, staphylococci and pneumococci or chronic tonsillitis. Alternatively, the intersection of an ima- ginary line drawn from the base of the uvula and another imaginary line drawn along the anterior faucial pillar is the site of drainage. The tip of a guarded sharp scalpel can be used to make an incision and the abscess drained by sinus forceps. Anaesthesia is not Clinical Features needed as the pain is already intense and a The condition usually affects adolescents and sharp stab for the drainage does not add to it. The patient complains of Besides drainage, heavy doses of antibiotics, unilateral throat pain after a few days of sore usually coamoxiclox or clindamycin are throat. The pain gradually becomes severe and prescribed in addition to antiseptic mouth may radiate to the ear. There is a unilateral swelling of the palate and pillars on the side Abscess tonsillectomy (Quinsy tonsillectomy) This of the abscess. The tonsil is displaced down- procedure of draining the peritonsillar abscess wards and medially. The oedematous uvula by removing the tonsil has been advocated by is pushed towards the opposite side with its some surgeons. It is done on the assumption tip usually pointing to the side of the that since the tonsil forms the medial wall of 290 Textbook of Ear, Nose and Throat Diseases the abscess, therefore, tonsillectomy would because of extension of this abscess to the give drainage to the abscess as well as save parapharyngeal space. Extension of the inflammatory process However, this procedure is not favoured as from the peritonsillar space can lead to the abscess may rupture during anaesthesia laryngeal oedema with resultant asphyxia. Systemic infection with the development of Besides as the tissues are acutely inflamed, septicaemia and multiple abscesses may there occurs severe bleeding and chances of occur. Peritonsillitis Complications of Peritonsillar Abscess It is a stage in the development of peritonsillar The abscess may rupture spontaneously and abscess before the pus formation. Spread of features are those of severe tonsillitis with infection to the parapharyngeal space can trismus. Heavy doses of antibiotics cure the even a carotid artery rupture can occur condition and prevent abscess formation. As the child grows, the size of the nasopharyngeal tonsils diminishes and they disappear by puberty. Clinical Features Hypertrophied nasopharyngeal tonsils may produce symptoms because of their size. The other important symptoms with a typical appearance called “adenoid include headache possibly due to infected facies” (Fig. There is a dull look, pin- material in the nasopharynx and nocturnal ched nostrils, open mouth, narrow maxillary cough because of postnasal discharge. Complications of Adenoids Throat examination reveals postnasal discharge and in a cooperative child, poste- These include recurrent attacks of otitis media, rior rhinoscopy shows enlarged mass of secretory otitis media, maxillary sinusitis and 292 Textbook of Ear, Nose and Throat Diseases Fig. The operation is performed under general anaesthesia and oral intubation is preferred. Besides, such The adenoid curette is held in the right hand and passed behind the soft palate to the patients are likely to encounter speech posterior end of the nasal septum. Chronic infection may lead to the against the roof of the nasopharynx to engage the adenoid mass.

But if the kidneys are doing a poor job of this safe 10mg glucotrol xl, levels in the body and blood stream rise purchase glucotrol xl 10 mg with mastercard. Hippuric acid is made in large amounts (about 1 gram/day) by the liver because it is a detoxification product. It makes no sense to con- sume benzoic acid, the common preservative, since this is what the body detoxifies into hippuric acid. If you cannot find your pulse just below your inner ankle your circulation is poor. Some people do not have pain although these acids and other deposits are present making their joints knobby and unbending. Toe deposits are made of the same crystals as kidney stones, which is why the Kidney Cleanse works for toe pain. But because these deposits are far away from the kidney, it takes longer than merely cleaning up kidneys. This will at the same time remove kidney crystals so that these are no longer a source of bacteria. Get teeth cavitations cleaned (cavitations are bone infec- tions in the jaw where a tooth was pulled; it never healed; see Dental Cleanup page 409). The effect lasts for days afterward showing it is not the dental anes- thetic that is responsible. This, too, can give immediate pain relief in the toes showing you they are a source for bacteria. Ordinary pH paper, as for fish tanks, is almost as accurate and will serve as well. Taking a calcium and magne- sium supplement at bedtime, drinking milk at bedtime, using baking soda at bedtime are all remedies to be tried. Balance Your pH Most persons with painful deposits anywhere in their feet have a morning urine pH of 4. The urine gets quite alkaline right after a meal; this is called the alkaline tide. During these periods, lasting about an hour, you have an opportunity to dissolve some of your foot deposits. But if you allow your pH to drop too low in the night you put the deposits back again. Taking more calcium at one time is not advised be- cause it cannot be dissolved and absorbed anyway and might constipate you. One cup of sterilized milk or buttermilk, drunk hot or cold, plus 1 magnesium oxide tablet, 300 mg. Mix two parts baking soda and one part potassium bicarbonate (see Sources) in a jar. Label it sodium potassium bicarbonate alkalizer (this potion is also very useful in allergic reactions of all kinds). Keep watching your pH, since it will gradually normalize and you will require less and less. If you are using plain baking soda, instead of the mixture, watch your pH each morning, also, so you can cut back when the pH goes higher than 6. Persons with a limit on their daily sodium intake must care- fully count the grams of baking soda consumed in this way. The sodium/potassium mixture would only give you half as much sodium (½ gram per tsp. You have done five things to pull the rug out from under the bacteria living in and around the deposits in your toes. Now when you kill bacteria with your zapper, you can expect the pain to go away and stay away. Deposits and bacteria here are even more painful because this is the location of nerve centers. If the build-up is large, you may prefer some surgical help or a cortisone shot rather than wait several years for solid relief. Foot Pain This kind of pain does not involve as much deposits as toe pain and is therefore easier to clear up. When circulation is very poor, the heart pulse cannot be felt in your feet (take your pulse just below your inner ankle). The adrenals are located on top of the kidneys and together they regulate how much salt and water stays in your body. Because they are situated so close together, they share their parasites and pollution. When the kidneys form kidney crystals the flow through the kidney tubes is hindered, and less water and salt can leave the body.

These patients frequently require prolonged antibiotic therapy and often surgical intervention for debridement and replacement of the prosthetic valve cheap 10mg glucotrol xl free shipping. These postoperative infections are thought to be caused by organ- isms inoculated at time of surgery buy glucotrol xl 10 mg. The presentation is usually in the first 2–3 months after surgery, but can occur several months after. She devel- ops evidence of pulmonary embolism which requires surgical therapy with replace- ment of the pulmonary valve. Chapter 30 Myocarditis Rami Kharouf and Laura Torchen Key Facts • Most cases of myocarditis are thought to be secondary to viral infection; however, in many instances, documentation of viral infection is lacking. Echocardiography cannot differentiate acute myocarditis from dilated cardiomyopathy. Definition Myocarditis is characterized by an inflammatory infiltrate of the myocardium with necrosis/degeneration of the myocytes. It is estimated that 50–80% of pediatric patients with acute presentation of dilated cardiomyopathy have myocarditis as the underlying cause. Coxsackievirus type B and parvovirus B19 are common viral agents implicated in myocarditis. Besides viruses, myocarditis can be caused by a myriad of other infectious agents like bacteria, rickettsiae, protozoa, and others. In South America, Chagas disease caused by Trypanosoma cruzi is the commonest cause. Toxicity to medications such as antimicrobials and chemotherapeutic medications such as anthracyclines has been implicated in the cause of myocarditis. Hypersensitivity reactions to certain medications represent a particular type of cardiomyopathy. Pathology The gold standard for diagnosing myocarditis has been the pathological findings on endomyocardial biopsy. The cellular infiltrate is usually lymphocytic, but can also include eosinophils and plasma cells. There is usually variable and patchy myocyte degeneration and necrosis, which sometimes makes biopsy diagnosis difficult. Recently, immunohistochemical staining of biopsies has allowed the identifica- tion of viral genomes in the affected cardiac tissues. Other more advanced staining has allowed for the characterization of different immune mediated reactions of the involved myocytes to the causative agents. In all stages, direct damage to myocytes and inflammatory reaction leads to loss of myocytes and fibrous tissue formation, thus diminishing the contractility of the myocardium. The onset is usually heralded by a viral prodrome consisting of fever, upper respiratory and gastrointestinal symptoms, thought to coincide with the viremic stage of the disease. Infants usually present with nonspecific symptoms of lethargy, poor feeding, irritability, respiratory distress, or even sudden collapse and cardio- genic shock. Older children and adolescents are more likely to have chest pain, easy fatigue and general malaise, exercise intolerance and abdominal pain, or even arrhythmias and syncope. On physical examination, infants might have pallor and appear dusky in addition to the findings of congestive heart failure signs. Respiratory distress is the next most common finding, fol- lowed by hepatomegaly and abnormal heart sounds or a heart murmur of mitral regurgitation. Jugular venous distension is more likely in older children, as this is an unreliable sign in the younger age group. Chest X-Ray Chest X-ray may show the presence of cardiomegaly and increased pulmo- nary vascular markings or frank pulmonary edema in almost half of patients (Fig. Arrhythmias such as ventricular or supraventricular tachycardia or atrio- ventricular block can also be seen. Echocardiography The typical findings include the presence of a dilated left ventricle with decreased systolic function in most patients (Chap. Echocardiography may also reveal the presence of mitral valve regurgitation and pericardial effusion. Pulmonary vasculature is prominent due to congested pulmonary venous circulation secon- dary to poor ventricular function due to myocarditis Laboratory Investigations The gold standard for the diagnosis of myocarditis historically has been endomyo- cardial biopsy. However, this is not routinely done due to the low sensitivity of the procedure (3–63%) and the often patchy involvement of the myocardium. Elevation of the cardiac enzymes especially involving cardiac troponins is posi- tive in about 1/3 of patients. Cardiac Catheterization This is not routinely performed in the workup of patients with myocarditis.

In severe cases cheap glucotrol xl 10mg fast delivery, vesicular lesions appear on various parts of the body cheap 10 mg glucotrol xl amex, especially the hands; these dermatophytids do not contain the fungus but are an allergic reaction to fungus products. Presumptive diagnosis is verified by microscopic examination of potas- sium hydroxide-or calcofluor white-treated scrapings from lesions that reveal septate branching filaments. Note that bacteria, including Gram- negative organisms and coryneforms, as well as Candida and Scytalidium species, may produce similar lesions. They are also common in industrial workers, schoolchildren, athletes and military personnel who share shower or bathing facilities. Period of communicability—As long as lesions are present and viable spores persist on contaminated materials. Educate the public to maintain strict personal hygiene; take special care in drying between toes after bathing; regularly use a dusting powder or cream containing an effective antifungal on the feet and partic- ularly between the toes. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics in some countries; no individual case report, Class 4 (see Reporting). Oral terbinafine, or itraconazole may be indicated in severe, extensive or protracted disease; griseofulvin, although less active, is an alternative. Epidemic measures: Thoroughly clean and wash floors of showers and similar sources of infection; disinfect with a fungi- cidal agent such as cresol. Identification—A chronic fungal disease involving one or more nails of the hands or feet. The nail gradually becomes detached from the nail bed, thickens, and becomes discolored and brittle, an accumulation of soft keratinous material forms beneath the nail or the nail becomes chalky and disintegrates. Diagnosis is made by microscopic examination of potassium hydroxide preparations of the nail and of detritus beneath the nail for hyaline fungal elements. Mode of transmission—Presumably through extension from skin infections acquired by direct contact with skin or nail lesions of infected people, or from indirect contact (contaminated floors and shower stalls) with a low rate of transmission, even to close family associates. Preventive measures: Cleanliness and use of a fungicidal agent such as cresol for disinfecting floors in common use; frequent hosing and rapid draining of shower rooms. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Official report not ordinarily justifiable, Class 5 (see Reporting). Epidemic measures, Disaster implications and International measures: Not applicable. It is a symptom of infection by many different bacterial, viral and parasitic enteric agents. The specific diarrheal diseases—cholera, shigellosis, salmonellosis, Escherichia coli infections, yersiniosis, giardiasis, Campylobacter enteritis, cryptosporidiosis and viral gastroenteropa- thy—are each described in detail under individual listings elsewhere in this book. Diarrhea can also occur in association with other infectious diseases such as malaria and measles, as well as chemical agents. Change in the enteric flora induced by antibiotics may produce acute diarrhea by overgrowth and toxin production by Clostridium difficile. Approximately 70%–80% of the vast number of sporadic diarrheal episodes in people visiting treatment facilities in less industrialized countries could be diagnosed etiologically if the complete battery of newer laboratory tests were available and utilized. From a practical clinical standpoint, diarrheal illnesses can be divided into 3 clinical presentations: 1) Acute watery diarrhea (including cholera), lasting several hours or days; the main danger is dehydration; weight loss occurs if feeding is not continued. The details pertaining to the individual diseases are presented in separate chapters. Each has a different pathogenesis, possesses distinct virulence properties, and comprises a separate set of O:H serotypes. Transmission is usually through contaminated food, water or hands; an outbreak in 2003 in Ohio was attributed to respiratory transmission via contaminated sawdust. The diarrhea may range from mild and nonbloody to stools that are virtually all blood. Lack of fever in most patients can help to differentiate this infection from that due to other enteric pathogens. The other most common serogroups in the United States are O26, O111, O103, O45, and O121. Occurrence—These infections are an important problem in North America, Europe, Japan, the southern cone of South America and southern Africa. Mode of transmission—Mainly through ingestion of food contam- inated with ruminant feces. Direct person-to-person transmission occurs in families, child care centers and custodial institutions. Waterborne transmission occurs both from contaminated drinking water and from recreational waters. Period of communicability—The duration of excretion of the pathogen is typically 1 week or less in adults but 3 weeks in one-third of children. Little is known about differences in susceptibility and immunity, but infections occur in persons of all ages. Preventive measures: The potential severity of this disease and the importance of infection in vulnerable groups such as chil- dren and the elderly calls for early involvement of local health authorities to identify the source and apply appropriate preven- tive measures. Measures likely to reduce the incidence of illness include the following: 1) Manage slaughterhouse operations to minimize contamina- tion of meat by animal intestinal contents. Decrease the contamination with animal feces of foods consumed with no or minimal cooking 4) Wash fruits and vegetables carefully, particularly if eaten raw.

Zinc induced copper deficiency: a report of three cases initially recognized on bone marrow examination buy 10 mg glucotrol xl with amex. The effects of minoxidil cheap glucotrol xl 10mg visa, 1% pyrithione zinc and a combination of both on hair density: a randomized controlled trial. Finasteride treatment may not prevent telogen effluvium after minoxidil withdrawal. The effects of minoxidil, 1 zinc pyrithrione an a combination on both on hair density: a randomized controlled trial. Pimecrolimus cream 1% vs hydrocortisone acetate cream, 1%, in the treatment of facial seborrheic dermatitis: a randomized, investigator-blind, clinical trial. Reversal of Androgenetic alopecia by topical ketoconazole: relevance of anti-androgenic activity. Contact dermatitis to propylene glycol and dodecyl gallate mimicking seborrheic dermatitis. Dandruff- associated smouldering alopecia: a chronobiological assessment over 5 years. Oral terbinafine in the treatment of multi-site seborrheic dermatitis: a multicenter, double-blind placebo-controlled study. Fluconazole and its place in the treatment of seborrheic dermatitis—new therapeutic possibilities. Stress inhibits hair growth in mice by induction of premature catagen development and deleterious perifollicular inflammatory events via neuropeptides substance P- dependent pathways. Burden of hair loss: stress and the underestimated psychosocial impact of telogen effluvium and Androgenetic alopecia J Invest Dermatol 2004; 123(3):455–457. The importance of dual 5 alpha reductase inhibition in the treatment of male pattern hair loss: Results of a randomized placebo-controlled study of dutasteride versus finasteride. Effects of minoxidil 2% vs cyproterone acetate treatment on female Androgenetic alopecia: a controlled, 12 month randomized trial. Topical liposome targeting of dyes, melanins, genes, proteins selectively to hair follicles (Review). In vitro permeation and in vivo depositon studies using hamster flank and ear models. Our challenge is to harness the knowledge we have gained in hair biology to improve our understanding of these incredibly devastating diseases that leave patients with permanent hair loss. Fortunately, prog- ress is occurring, including efforts to clarify clinical and histologic classification of the diseases, and to identify major areas of interest in research. This classification was based on the predominant histologic inflammatory infiltrate (Table 1) (1). It was hoped that the classifi- cation would serve to clarify and unify the often vague or divergent terminology and diagnostic categories found in the literature and to facilitate collaborative trials to determine pathogenic fac- tors and effective therapeutic options (1). The sebotrophic mechanism puts forth the notion that the desquamation of the inner root sheath is dependent on the normal function of the sebum and that the absence of the normal gland leads to obstructed outflow of the hair shaft. Although the sebaceous gland plays a central role, the problem could be proximal or distal to this gland, leaving room for the possibility that environment, toxins, infection, etc. Furthermore, biopsies of clinically unaffected scalp in patients with lichen planopilaris have shown early sebaceous gland atrophy (2). This is where the slow-cycling hair follicle stem cells that are capa- ble of initiating follicular renewal at the end of the resting phase of the hair cycle are located. Studies suggest that the hair follicle stem cells and not the epidermal stem cells are injured in these disorders, however, whether these cells are a primary target or destroyed as an innocent bystander is a question that remains to be resolved (3). In normal anagen hair, macrophages are virtually absent from the hair follicle epithelium. It has been proposed that deletion of hair follicles may be caused by a macrophage-driven attack on epithelial hair follicle stem cells in the bulge of the outer root sheath under pathologic circumstances (15). Alternatively, the underlying pathophysiol- ogy may be similar to that seen with the lymphocytic scarring alopecias, however, bacteria may provide an ongoing nidus for inflammation thus perpetuating the destruction of hair follicles. Peroxisomes are single, membrane-bound, ubiquitous, subcellular organ- elles catalyzing a number of indispensable functions in the cell, including lipid metabolism and Cicatricial Alopecia 139 the decomposition of harmful hydrogen peroxide. A thorough history should be completed to evaluate for autoimmune disease, systemic illness, infections, neoplasms, associated inflammatory skin disease, and radiation treatment or burns. Signs of scalp inflammation including erythema, scaling, pustules, scalp bogginess; compound follicles and wiry hairs are also commonly seen. Women are more commonly affected than men with an age of onset typically between 20 and 40 years; it is uncommon in children (25,26). Typical scalp lesions are round or “discoid” in appearance; follicular plugging and adherent scale may be present (Fig.