makros : - black head-comedo

- dlm fol.pilo sebasea sumbat papel

- inf.skunder (+) stapilokokus
- pus supurasi
- parut (+)
Keratosis Seboroik

2
Keratosis
Seboroik

3
Skin tag

4
Hemangioma
6
INTERSTITIAL GROWTH
Interstitial
growth: mitotic
division of
existing
chondrocytes
and production
of matrix
ISOGENOUS
GROUP
REGENERATION & REPAIR
Despite the fact that cartilage is found in
relatively few sites in the adult body, its
functions are important for our well-being.
Cartilage in adults has very little
regenerative ability if damaged and is
subject to tear and wear with aging.
This is due to the dearth of cartilage cells,
minimal mitosis, absence of an integral blood
supply and overall low metabolic activity of the
tissue.
The clinical problems of damage or aging of the
tissue (osteoarthritis) are substantial.
With aging the cartilage matrix may develop
calcified deposits (calcified cartilage).
 The rational approach of NSAID usage
based on pharmacological values
NSAID Acid Sulfa COX-2 A-Cyt BK T 1/2 Distr + Prct Formula Cost
Celecoxib - + ++ + ? M ? ? PO >>
Diclofenac + - + +++ + S ++ + PO,INJ, <
SUP,TOP

Etodolac + - ++ ? + M ? ? PO >>
Ibuprofen + - - + ? S + + PO <
Indomethacin + - - ++ + S ++ + PO <
Ketoprofen + - - ? + S ++ ? PO,SUP <
Meloxicam + - + ? + L + ? PO,INJ,
SUP
>>

Naproxen + - - ? + M + ? PO >>
Nimesulide - + + +++ ? S + ? PO >>
Piroxicam + - - - + L ? ? PO,TOP <
Rofecoxib - + ++ - ? L ? - PO >>

Are they different?

T-1/2 and Duration of action
of NSAIDs
duration NSAID T-1/2 (hr)
short Diclofenac 1.1
Nimesulide 1.8 4.7
moderat Celecoxib 11
e
Naproxen 14
long Meloxicam 20
Piroxicam 57
 A = Enterohepatic circulation

Systemic effect

Liver

A
Kidney

Small
Intestine
Pancreas

A
PIROXICAM : long t1/2 (> 45 hr) enterohepatic cycle
Enterohepatic cycle and the incidence
of ADR of NSAIDs
NSAID Half-life EHC level Incidence ADR
Diclofenac 1-2 Low Small
Ibuprofen 1.5 3 Low Small
Nimesulide 1.5 ? Small
Celecoxib 11 ? Small
Naproxen 13 15 Intermediat Moderate
e
Nabumetone 22 Intermediat Moderate
e
Indomethaci 11 High High
n
Piroxicam > 45 High High
distribution into the synovial fluid
Route NSAID Reference
Systemi diclofenac Blagbrough et al,1992; Gallacchi &
c Marcolongo,1993
Davies & Anderson, 1997
ibuprofen Blagbrough dkk,1992
ketoprofen Barbanoj dkk, 2001; Audeval-Gerard
dkk, 2000
meloxicam Davies & Anderson, 1997
naproxen Blagbrough dkk,1992
Topical diclofenac Davies & Anderson, 1997
ketoprofen Audeval-Gerard dkk, 2000
meloxicam Davies & Skjodt, 1999
distribution into CSF
Physicochemic NSAID Reference
al
Lipophilic oxyphenbutazone Bannwarth B, et al., 1989
penetrate to , indomethacin,
CSF ketoprofen
 pharmacokinetic and clinical benefits
Half-life Useful for rescue
short
slow Brief duration of action
release
formulation

long Long duration of action

Increase side effects

NSAID Diclofenac Naproxen Piroxicam

Dose (mg/d) 100 750 20
Half-life (hr) 1.5 14 50
24 hr fecal blood 0.53 +/- 0.21 2.76 +/- 2.22 1.16 +/- 0.62
loss (mL)

Scharf, et al. Aust N Z J Med 28(4):436-9,1998

Incidence rates of major events possibly
prevented or caused by COX inhibitors, as
assessed in observational studies among
non-users
Incidence rate
Event
per 1,000 patient
years
Heart failure 24
Myocardial infarction 14
Upper GI
bleeding/perforation 0.6 1.7
Colorectal cancer 0.4 0.7
Acute renal failure 0.002 0.08
RADIOLOGIC FINDINGS?
GRADE 1 - 4?
 Treatment

Teriparati
de
(Forteo)

Denosum
ab
(Prolia)

21
Necrotizing Fasciitis
Necrotizing Fasciitis
Synovial Sarcoma
 FAT
LIPOMA
LIPOSARCOMA

NORMAL FAT LIPOMA, LIPOSARCOMA,

encapsulate often