4 questions | Applied Sciences homework help

1. Stafford RS and others. The potential of pill splitting to achieve cost savings. American Journal of Managed Care 8:706–712, 2002.

Chapter Eighteen Skin Care and image enhanCement For every beauty dilemma, there’s a product that’s claimed to solve it. But many don’t, and lots of us have been suckered into buying stuff that doesn’t work. ShopSmart magazine1 To think that a moisturizer with herbs, vitamins, botanicals, or some other skin care ingredient can feed the skin, is like thinking that you can put a bologna sandwich on your face and have lunch. paula Begoun2 For things that are clearly image-threatening or stigmatizing, fix them—cleft palate, buck teeth, severe acne, big stick-out ears. If your nose is really badly deformed, fine. Other than that, the more maturity, the better. . . . If you want to give your kid something when they graduate from high school, give them a book, not breasts. arthur Caplan, ph.D.3 Man can be cured of every folly but vanity. Jean-JaCqueS rouSSeau (1712–1778) © medical economics, 1996 “Who’s been into my Rogaine?” Part Five Other Products and Services380 A mericans spend many billions of dollars a year for pills, powders, creams, potions, and proce- dures that they hope will make them look better. The American Academy of Dermatology states that the average American adult uses at least seven skin-care products a day.4 Drugstore News5 has reported that in 2010 Americans spent $36.5 billion for cosmetics and toiletries. The American Society of Plastic Surgeons6 states that 13.1 million cosmetic and 5.3 reconstructive plastic surgery procedures were performed in 2010. Consumer Reports7 estimated that nearly 30 million Americans would visit a tanning salon in 2005. This chapter discusses cosmetics, soaps and hand cleansers, moisturizers, hair products, sun protection, insect repel- lents, cosmetic surgery, tattooing, body piercing, and several other types of products and services related to personal appearance and skin care. CoSmetiC regulation The federal Food, Drug, and Cosmetic Act defines cosmetics as “articles (other than soap) intended to be applied to the human body for cleansing, beautifying, promoting attractiveness, or altering the appearance without affecting the body’s structure or functions.” The FDA has classified cosmetics into 13 categories: skin-care products (creams, lotions, powders, and sprays); fragrances; eye makeup; other makeup (lipstick, foundation, and blush); manicure products; hair color- ing preparations; deodorants; shaving products; baby products (shampoos, lotions, and powders); bath oils and bubble baths; mouthwashes; sunscreens; and shampoos, permanent waves, and other hair products.8 Cosmetic product labels must list all ingredients that compose more than 1% of a product (by weight), in the order of predominance, with the ingredient pres- ent in the largest amount first. This enables individuals with allergies and sensitivities to avoid problematic ingredients and can help people compare differently priced products. The International Cosmetic Ingredient Dictionary, which is available at many public libraries, provides definitions, trade names, and other information about more than widely used 5000 ingredients. Cosmetics marketed with claims that they can affect structure or function must meet the labeling standards for drugs in addition to those of cosmetics. Such prod- ucts include dandruff shampoos, fluoride toothpastes to prevent dental decay, and sunscreen and sun-blocking cosmetics. Dual-classification products must be proven safe and effective for their therapeutic claims before marketing. Color additives also require FDA approval. Under the FDA’s good manufacturing practice guidelines, even cosmetic products that are not regu- lated as drugs should be tested for safety and subject to quality control during manufacture. FDA review of the tests is not necessary, but safety warnings are required if problems become apparent. The products that require warnings include products in pressurized containers (potentially dangerous to children), detergent bubble bath products (may irritate the skin or urinary tract), genital deodorant sprays (may cause irritation or al- lergic reaction), hair-dye products that contain coal-tar dyes (can irritate skin), chemical depilatories and hair straighteners (alkaline ingredients can cause burns),

• Many ingredients in cosmetic products are included for marketing purposes and serve no useful purpose. Price is not a reliable measure of quality.
• Antiperspirants and deodorants have been oversold. Bathing is by far the most important body-odor control measure.
• By masking tiny lines, some moisturizing agents may help the skin look and feel better for a few hours.
• Some products and procedures can reduce fine wrinkles and age spots, but no cosmetic product can prevent or eliminate wrinkles, repair sun-damaged skin, or retard or reverse the aging process of the skin.
• The main causes of premature skin aging are (a) excessive ultraviolet light exposure and (b) cigarette smoking.
• Effective over-the-counter and prescription products are available to treat acne.
• People contemplating cosmetic surgery should think carefully about why they want it, thoroughly investigate the credentials of a prospective surgeon, and gather realistic information about the limitations and possible adverse ef- fects of the procedure.

keep theSe pointS in mind aS You StudY thiS Chapter Key Concepts Chapter Eighteen Skin Care and Image Enhancement 381 shampoos and conditioners (can irritate eyes), and nail builders (can irritate skin).9 SoapS and CleanSerS Soaps are traditionally made of natural ingredients: fatty acids from animal fat or vegetable oils, alkalis, scents, and coloring materials. Solid soaps are made from so- dium alkalis, such as lye, whereas liquid soaps are based on potassium alkalis. Most bar soaps are inexpensive, but some marketed for their scent or other aesthetic feature are priced quite high. Low-priced bar soaps usually cost less than low-priced liquid soaps. Detergents, which are commonly used for washing dishes and laundry, are not soaps; they are made from synthetic, often petroleum- based, chemicals. A small percentage of people react adversely to alka- line soap. A soap’s pH indicates the extent of its acidity or alkalinity. A pH of 7 is neutral, a higher number means the product is alkaline, and a lower number means it is acidic. High-alkaline soaps can cause the skin to become rough, red, and dry. People with dry skin may find that a superfatted soap (containing additional fats or oils such as moisturizing cream, lanolin, or cocoa butter) will leave the skin feeling more comfortable. However, a moisturizing lotion used after bathing is likely to be more effective. In 2001 Consumer Reports10 evaluated 30 soap and body wash products and concluded that the vitamin and botanical ingredients listed on their label were unlikely to have any effect. The editors advised finding a scent you like and shopping for price. Soaps remove visible dirt and debris from the skin but do not necessarily kill bacteria. Deodorant soaps include an antibacterial agent. Perspiration has no odor; body odor is caused by bacteria that thrive on perspira- tion. However, all soaps provide some protection from unwanted odors by washing off bacteria along with dirt, bacterial products, grease, and skin debris. Hand sanitizers, which can supplement or serve as an alternative to handwashing, are available in liquid, foam, or gel form. They contain an alcohol that quickly kills most bacteria and fungi and some viruses. The FDA regulates antimicrobial hand soaps and sanitizers as over-the-counter drugs. It states that adding triclosan to soaps and body washes has not been proven to provide any benefit over washing with regular soap and water.11 Hand sanitizers can reduce the transmission of many diseases but are not completely effective. The FDA12 has ordered several manufacturers to stop claiming that their sanitizers protect against swine flu or MRSA (one of the so-called “flesh-eating bacteria” that is resistant to many antibiotics). moiSturizerS Moisturizing lotions, creams, and gels can help the skin feel smoother by increasing the amount of water retained in the outermost layer of the skin. The skin constantly renews itself through multiplication of cells beneath the surface. Dead cells are gradually pushed toward the surface, where they lose their moisture and eventually slough off. If the skin loses moisture too quickly, its outer layer dries out and may even crack. Glands within the skin produce oil that retards evaporation of the skin’s water. If the glands become less active (as usually hap- pens when people age) or too much oil is removed by washing, the skin will become too dry. Moisturizers contain ingredients that can penetrate the outer layer of the skin but not the living cells un- derneath. Emollient ingredients block moisture from leaving the skin by coating it with a thin layer of a slip- pery substance. The most common ones are petrolatum, lanolin, mineral oil, propylene glycol, and dimethicone. Humectant ingredients slow down the rate of water loss by attracting water from the skin and surrounding air. The most commonly used humectants are glycerine, propylene glycol, and phospholipids. Most moisturizers contain both types of ingredients, but products intended for dry skin have more oil, whereas products for oily skin contain only humectants. The best time to apply a moisturizer is after washing, while the skin is still damp, so that the moisturizer traps some of the water. In 2011 Consumer Reports13 tested 14 body lotions that cost from 14¢ to $1.15 per ounce. Its tests showed that some low-cost products worked better than expen- sive ones, but Cetaphil and Eucerin were most effective. In a previous report14 the editors concluded that people with oily skin or who live in a humid climate may only need regular cleaning and sunscreen use to keep their face looking its best, whereas people with dry skin may benefit from a moisturizer. They recommended the fol- lowing test for determining your skin type: A few hours after washing with a nonmoisturizing soap hold pieces of eyeglass lens-cleaning paper for 10 seconds against your forehead, nose, chin, and a cheek. If the paper from all areas is oily, your skin is oily. If the paper from all areas is dry, your skin is dry. For normal skin, the paper held to the cheek will be less oily than the paper held to the forehead, nose, and chin. Part Five Other Products and Services382 QueStionable ClaimS A certain amount of wrinkling is inevitable as people get older. Both cigarette smoking15 and excess sun exposure can cause facial wrinkling to become apparent in middle age. When both occur, the effects are multiplied.16 Many cosmetic manufacturers suggest that their moisturizers and other products can help people look more youthful. Moisturizers may help the skin look and feel better for a few hours. By preventing water loss from the skin, they can fill in fine lines to make the skin look smoother. Alpha hydroxy acids (AHA) can facilitate removal of dead skin cells, making the skin smoother and enabling the moisturizer to work more effectively.17 Although some evidence suggests that AHA may facili- tate skin repair, the FDA has received reports of adverse reactions such as severe redness, swelling (especially in the area of the eyes), burning, blistering, bleeding, rash, itching, and skin discoloration. Because they have been available only since 1992, their long-term effects are unknown. An industry-sponsored study found that people who use AHA products have greater sensitivity to sun, which may mean that they increase the risk of photoaging and skin cancer.18 Paula Begoun,2 author of Don’t Go to the Cosmet- ics Counter Without Me, advises her readers to be wary of phrases like “appears to,” “leaves the skin looking smoother,” “changes the appearance of,” “lessens the signs of,” “reduces the chances of,” “reduces the tem- porary signs of aging,” and “reverses the visible damage of aging.” She states that because they refer to the skin’s appearance, rather than its structure, they are cosmetic claims and do not have to be truthful. Her book discusses the ingredients in more than 10,000 cosmetic products and states what she and people who responded to her surveys have concluded about the products. Table 18-1 comments on several questionable cosmetic ingredients. Nicholas Perricone, M.D., who wrote The Perricone Prescription and several other books, has developed elaborate antiaging programs that include dietary strate- gies, exercise, skin products, dietary supplements, and 8 to 10 glasses of spring water per day. The total cost of the products is about $5000 per year. Perricone claims that “inflammation” is the underlying cause of aging and Substance Aloe vera Amniotic fluid Bovine albumin Cerebrosides and ceramides Collagen and elastin Liposomes Nayad Vitamin E Other vitamins QueStionable CoSmetiC ingredientS Table 18–1 Sources: Modified from data in Consumer Reports19 and FDA Consumer.20 Description Plant with anti-irritant properties Fluid that surrounds the developing fetus (from cow or ox) to protect it from injury Protein from cow milk or cow blood Phospholipids similar to compounds formed in the skin that help the skin retain its moisture Proteins under the top layer of skin; tend to deteriorate with age or sun damage Microscopic capsules made from phospho- lipids and other fatty substances, some of which occur naturally in the skin Trade name of a yeast extract Fat-soluble vitamin that can preserve the fatty components in cosmetic creams and lotions Vitamins included in various cosmetic formulations Comment Most skin lotions listing aloe vera as an ingredient do not contain enough (5% to 10%) to work as an anti- irritant; those that do are expensive Does not promote tissue growth or remove wrinkles Federal court ordered manufacturer to stop claiming it can give a “face lift without surgery” The claim that they “help fortify and replenish the skin’s moisture barrier” is merely a fancy description of what all emollient ingredients in moisturizers do Skin proteins cannot be “replenished” by a cosmetic product Does not “work beneath the skin’s surface” or carry useful ingredients to underlying skin layers because moisturizers do not penetrate living cells Use claimed to result in “smoothing of lines and wrinkles.” FDA has no data to substantiate or refute this claim Prevents products from discoloration and rancidity, but has no proven value for skin preservation or “rejuve- nation” Vitamins applied to the skin do not nourish the skin Chapter Eighteen Skin Care and Image Enhancement 383

that his program will counter that. Hall and Barrett21 have concluded:

Although some of his advice is standard, most of his recom- mendations are based on speculation and fanciful interpreta- tion of selected medical literature. He makes lots of money by convincing patients and consumers, but he hasn’t succeeded in convincing critical thinkers, doctors, scientists, or anyone who wants to see hard evidence. Perricone’s “prescription” isn’t science; it’s creative salesmanship. Despite Perricone’s dubious claims, his books have made best seller lists and the Public Broadcasting System (PBS) has featured him during fundraising campaigns. The American Academy of Dermatology22 has warned that many “antiaging” products referred to as cosmeceuticals contain ingredients that have been stud- ied individually but not in combination. Many products are sold with false claims that rub- bing them on the skin will eliminate “cellulite.” This subject is discussed in Chapter 12. ShopSmart magazine1 recommends avoiding eye- lash growers, under-eye circle erasers, hair smoothers (may contain formaldehyde), lip plumpers, and scar eliminators. Enforcement Actions It is illegal to claim that a cosmetic product can prevent or eliminate wrinkles, repair sun-damaged skin, or retard or reverse the aging process of the skin. Specific statements to that effect would be drug claims because they would indicate that the product is intended to affect a bodily function or the body’s structure. However, if true, it is legal to make a cosmetic claim that a moisturizing prod- uct can temporarily reduce the appearance of wrinkles. The FDA, which has jurisdiction over labeling claims, has warned about 25 manufacturers to stop mak- ing antiaging (drug) claims for their skin care products. Most have complied, but other many other companies still make them. The FDA’s most significant recent ac- tion related to skin claims was a letter ordering Basic Research LLC of Salt Lake City, Utah, to stop claiming that StriVectin would reduce stretch marks, fine lines, wrinkles, and crow’s feet.23 The Federal Trade Commission, which has jurisdic- tion over advertising claims, could attack the deceptions that are common in cosmetic advertising, but it has not done so. WrinkleS and age SpotS In 1996 the FDA approved the marketing of Renova, an over-the-counter (OTC) tretinoin product capable of slightly reducing fine wrinkles and age spots. The prod- uct is similar to the prescription acne remedy Retin-A but has an oilier formulation. Renova is labeled as “an adjunctive agent for use in the mitigation (palliation) of fine wrinkles, mottled hyperpigmentation, and tactile roughness of facial skin in patients who do not achieve such palliation using comprehensive skin care and sun avoidance programs alone.” The label must also state: “Renova does not eliminate wrinkles, repair sun dam- aged skin, reverse photoaging, or restore more youthful or younger skin.” The FDA’s action was based on evidence from two clinical trials in which patients treated with Renova for 24 weeks were compared with patients who used an emollient cream. Although about 65% of the Renova group showed some improvement of wrinkling and mot- tling, Consumer Reports on Health24 noted: (a) 40% to 50% of the people who used the emollient cream reported similar improvement; (b) nearly all users experienced redness, dryness, itching, and peeling of the skin; and (c) the benefit will disappear if use of the drug is stopped. OTC tretinoin, marketed as Renova, costs about $190 for a tube that should last 4 to 6 months. No study has determined how safe it is to use Renova for longer than 48 weeks. In 2010, Consumer Reports25 tested nine anti-wrinkle serums that were claimed to reduce the appearance of wrinkles. After 6 weeks of use, the effectiveness of the best products was limited and varied from subject to sub- ject. Every serum produced a visual change in wrinkle length or depth for at least one person and did nothing for some of the others. √ Consumer Tip Healthy Perspectives on Makeup • The information you get at the cosmetics counter is rarely accurate when it comes to skin care. • There are no antiaging products available besides sunscreens. • No one needs more than a daytime moisturizer that contains a sunscreen and a nightime moisturizer without a sunscreen.

• Spending more money doesn’t mean you will look more beautiful. Knowing how to apply makeup is the key to looking good.
• All the makeup and skin care products in the world can’t cover up an unhealthy lifestyle.
• Find ways to feel good about yourself that don’t come from your appearance.

Paula Begoun2 Part Five Other Products and Services384 Several laser devices are FDA-approved to treat wrinkles or resurface the skin. The FDA cautions that skin abrasion, whether achieved by lasers, chemicals, or abrasive materials, means removing one or more layers of skin, which can be painful and could cause redness, swelling, or scarring, depending on how each person heals.26 Fade CreamS Skin bleaches (fade creams) are used to lighten skin discoloration (hyperpigmentation) caused by freckles, flat moles, and age spots. However, they make the skin especially sensitive to the sun. An FDA expert panel reported that the only safe and effective ingredient for OTC use is hydroquinone in concentrations from 1.56% to 2%. Nonprescription products containing 2% hydro- quinone include Esoterica, Porcelana, and Artra. More concentrated products are available by prescription. Hydroquinone does not actually bleach the skin but inhibits the cells that produce melanin. Since these cells are deep within the skin, lightening products work slowly, if at all. Results may not be apparent for 3 months. Users (including those who do not sunbathe) should apply a sunscreen because fade creams increase sensitivity to the sun. Consumer Reports27 has offered these additional comments:

• When fade creams work, they work only against freckles and age spots.
• They will not cause blemishes to completely disappear. • Apply them only to the pigmented areas and not the sur-

rounding skin. • If no results are obtained after 3 months, consider profes- sional treatment. • Protect hands and face from excessive exposure to the sun to prevent pigment production. • Foundation creams can cover skin blemishes and serve as an alternative to fade creams. antiperSpirantS and deodorantS Sweating is a natural body function that helps regulate body temperature and helps protect the skin against dry- ness. Normal skin secretions do not have an objection- able odor. However, when skin bacteria interact with sweat, the result may be unpleasant. There are two types of sweat glands: eccrine and apo- crine. Eccrine glands, the main source of perspiration, are located near all skin surfaces except the margins of the lips and certain parts of the sex organs. They secrete watery or water-soluble substances. The apocrine glands are located in the armpits, around the nipples, on the abdomen, and in the genital area. They do not function in body temperature regulation but respond to hormonal stimulation. After puberty they produce a milky secre- tion that emits a strong odor when metabolized by local bacteria. Heat and emotional stress can trigger activity of both types of glands. Antiperspirants reduce secretions from the eccrine glands by astringent action, which contracts the skin to prevent the flow of perspiration. Deodorants either reduce the number of odor-causing bacteria in the un- derarm area or cover up the odor. Combination products are also available. Antiperspirants are regulated as OTC drugs because they affect a bodily function. Deodorants are regulated as cosmetics. More powerful antiperspirant drugs are available by prescription. However, no product can stop sweating completely. The University of California at Berkeley Wellness Letter28 stated: (a) bathing is by far the best way to control body odor; (b) antiperspirants and deodorants have been oversold; (c) many people use more of them than they need; (d) people who use these products daily should try using them two or three times a week to see whether this works just as well; (e) sticks, roll-ons, and creams tend to provide more protection than aerosols; and (f) inhaling aerosol mist may pose a safety hazard. Some ingredients in antiperspirants and deodorants can cause allergic reactions. People who are unable to tolerate these products may be helped by washing more frequently or by using an antibacterial soap. Hyperhidrosis is an abnormal condition in which people sweat excessively even when the temperature is cool or when they are at rest. Several types of medical treatment are available, but some cases are difficult to control. aCne Care Acne is a skin condition characterized by whiteheads, blackheads, pimples, and sometimes cysts, all of which result from the clogging of sebaceous glands. About 80% of teenagers are afflicted, and it remains a problem for many people into their 20s and sometimes beyond. At puberty the sebaceous glands increase in size and activity and secrete more sebum (a mixture of fats and waxes), which normally exits from the pores and lubricates the skin and hair. Figure 18-1 shows the anatomic relationship be- tween a hair follicle and its nearby sebaceous glands, which secrete sebum into the follicle. In acne, ducts from these glands become plugged with comedos com- posed of sebum and dead cells. If bacteria invade, the Chapter Eighteen Skin Care and Image Enhancement 385 surrounding skin can become inflamed, and pimples or pustules may form. Most people with acne have a mild (noninflammatory) form and get occasional whiteheads or blackheads. Severe (inflammatory) acne involves a constant outbreak covering the face and sometimes also the neck, back, chest, and groin. Pimples and pus-filled cysts occur and can result in pitting and scarring of the skin. Heredity is often an important factor in acne. In adult women, cosmetics (especially greasy, heavy creams) may be the cause. In some, acne can be triggered by hor- mone fluctuations. Jobs that involve exposure to grease or oil may also be a factor. There is little evidence that acne is related to diet. However, if self-experimentation suggests that a specific food aggravates acne, avoiding the food may be reasonable. Acne cannot be prevented or cured, but it can be controlled and minimized. Only about 10% of cases need medical supervision. Most cases respond to self- treatment with nonprescription products, although physician-directed treatment might produce quicker and better results. The first step is to keep the skin as free of oil as possible by washing twice a day, shampooing as needed, keeping oily hair off the face, and avoiding cosmetic products that contain oil or grease. If this is insufficient, the next step should be treat- ment with a topical product containing benzoyl peroxide. Benzoyl peroxide produces irritation that speeds up the turnover of cells lining the follicle. This increases the sloughing of these cells and promotes resolution of the comedos. Benzoyl peroxide often stings and burns the skin and sometimes causes redness and scaling. Self- treatment can be done with an OTC product, but a medi- cal consultation would be more prudent. A doctor can determine which type of product would be best, provide instructions about comedo removal, and advise whether anything else is needed. The 2.5%, 5%, and 10% benzoyl peroxide solutions are equally effective, but the lowest concentration is the least irritating.29 Benzoyl peroxide is the key ingredient in Proactiv, which is widely advertised through TV infomercials that feature Justin Bieber, Jessica Simpson, and other celebrities (see Personal Glimpse box). If treatment with benzoyl peroxide is not effective, a doctor may prescribe a topical retinoid such as treti- noin (Retin-A), which is stronger but more irritating to the skin. An antibiotic may also be prescribed. Because tretinoin increases susceptibility to sunburn, prolonged exposure to the sun should be avoided, and an effective sunscreen should be used. Accutane (isotretinoin), a prescription drug taken orally, can be prescribed for severe acne that does not respond to other forms of therapy. Treatment takes Skin surface Hair follicle Hair root Hair shaft Figure 18-1. Cross-section of skin. When the openings of sebaceous glands are blocked by sebum, cells and sebum accumulate to form plugs (comedos). photograph from fDa ConSumer Sebaceous gland Personal Glimpse Proactiv Hype Gone are the days when getting rid of acne meant a trip to the drugstore for Stridex or Clearasil. Now the product the kids clamor for is Proactiv. . . . So what’s in this blockbuster drug? After all, the basic “Proactiv System” will cost you $19.95 (though it’s “a $72 value”). The short answer is not much. Make a few clicks around Proactiv’s Web site and you’ll find out the active compound is benzoyl peroxide. That’s the same stuff in Stridex, Clearasil and just about every nonprescription acne medica- tion available in drugstore aisles across America. A tube of the same compound costs $5.25 at my local pharmacy. . . . Perhaps the three-step “Proactiv System” helps make it easier for teens. But the real key to Proactiv’s success is celebrity. Endorsements have helped make it the acne product to buy. . . . My biggest problem is something else, though: How hard they work to equate confidence with beauty and nothing else. Every celebrity testifies that having pimples was the source of all their insecurities. . . . They all claim that Proactiv gave them the confidence they needed to be their best. As a physician who sees plenty of teens with real confidence problems and the consequences they engender—eating disorders, depression, anxiety, drug use—I’d like to see a com- pany with this much influence pull a few gears back on that message. Rahul Parikh, M.D.30 Part Five Other Products and Services386 several months and is expensive. Women who are preg- nant or might become pregnant should not use Accutane because it can cause severe birth defects. Accutane can also cause severe depression and psychosis. In 2005, the FDA initiated a risk management program (iPLEDGE) intended to prevent women who are pregnant or might become pregnant from taking Accutane. To obtain the drug, patients must complete an informed consent form and undergo counseling about the risks and requirements for safe use. Women who are capable of getting pregnant must also have a negative pregnancy test and agree to use two separate forms of effective birth control at the same time one month before taking Accutane, while taking it, and for one month after taking it.31 Ultraviolet light from sunlight or a sunlamp can be effective for some people with acne but will aggravate the condition of others. However, it is no longer recom- mended, because it increases the risk of skin cancer. Dermatologists and plastic surgeons can improve the appearance of people with severe acne scars. The procedures they use include dermabrasion (facial plan- ing), chemical peels, cryosurgery, and injections of filling material. head hair and SCalp Care The hair shaft, which is the visible part of the hair, is a complex, nonliving structure made of protein. The shaft is produced by the bulb-shaped hair root, at the bottom end of the shaft, deep in the scalp (see Figure 18-1). The shaft and root are encased together in a cellular structure called the follicle, which supplies nourishment and support. The healthy scalp of a young adult normally has about 100,000 hairs and loses 50 to 100 each day. In most people, the loss is not significant because the re- placement rate is about the same as the rate of loss. As people age, however, the rate of loss increases, and a permanent thinning may be inevitable. Hair can be split or otherwise damaged by rough handling or excessive use of bleach, hair dye, or certain other hair-care products. Shampoos and Conditioners Some oiliness and flaking of the scalp are normal. Se- baceous glands located just beneath the skin secrete an oil that lubricates the hair follicle and the scalp, keeping the hair glossy and the scalp comfortable. Washing the hair once or twice weekly is usually sufficient to control oiliness and dandruff, but people with an oily scalp may have to wash daily. Soaps remove the oil and leave a residue of mineral salts on the hair shafts that can make the hair look dull. So it is better to use a shampoo that enables some of the natural oil to remain or that contains lanolin as a replacement. That way the hair remains shiny and manageable. The main function of shampoo is to clean the hair by removing dirt, dead skin scales, and excess sebum. Shampoos generally contain (a) water, (b) a synthetic detergent, (c) a sudsing agent that makes rinsing easier, (d) antistatic and detangling agents, (e) a moisturizing agent, (f) a thickener to give the shampoo a pleasing consistency, and (g) a fragrance. Many shampoos contain a conditioner such as collagen, protein, amino acids, or panthenol. Conditioners are intended to counteract the depletion of natural hair oils, but most are washed away. People who want maximum benefit from a conditioner should apply a separate product after shampooing. Dry shampoos are useful for people who are ill or incapaci- tated and unable to wash their hair. These are left on the hair for a specified time and then are brushed or combed out. Begoun33 states that shampoos are 50% to 90% wa- ter, and exotic ingredients such as awapuhi and burdock root have no effect on the hair. She also notes that people can tell immediately after use if their hair feels clean, soft, defrizzed, and easy to style, and whether or not it stays put. Most people who wash their hair frequently do not need a medicated shampoo. Personal Glimpse FTC Zaps “Acne Cure” Software32 In 2011, marketers of two mobile phone applications signed consent agreements under which they must re- frain from making baseless claims that their products could successfully treat acne by generating colored lights. In both cases, users were advised to hold the display screen next to the problematic skin area for a few minutes daily while the application was activated. Software developer Koby Brown and dermatolo- gist Gregory W. Pearson, M.D., doing business as Dermapps sold about 11,600 copies of “AcneApp” through the iTunes store for $1.99. Their settlement included payment of $14,294 to the FTC. Software developer Andrew N. Finkel sold about 3300 copies of “Acne Pwner” through Google’s Android Market- place for $.99. His settlement included payment of $1700. These were the first cases brought by the FTC against health claims in the mobile application marketplace. Chapter Eighteen Skin Care and Image Enhancement 387 Consumer Reports34 adds that the “workhorse” in- gredients in shampoos are (a) detergents (or surfactants), such as ammonium lauryl sulfate, which clean the hair; (b) cationic polymers that can attach to the hair shaft to add smoothness and volume; and (c) silicones, such as dimethicone, that can coat the hair, making it feel soft, pliable, and easy to comb. The magazine has also noted that other ingredients such as herbs, vitamins, proteins, AHA, and moisturizers do nothing to improve the condi- tion of the hair. Its tests have found that expensive brands performed no better than inexpensive brands. Hair-care products sold at barber shops and hair sa- lons tend to be more expensive than those sold through retail outlets such as drugstores and supermarkets, but there is no reason to believe they are better. Dandruff The surface layer (epithelium) of the scalp renews itself once a month. Dead scalp cells are constantly being pushed from the skin’s deepest layer to its surface, where they gradually die. Usually this process is not apparent. Dandruff occurs when the dead cells are shed in clumps or flakes. It is a problem with the scalp, not the hair. Nearly everyone has dandruff to some extent. Dandruff is usually treatable with an OTC product and causes no general health problem or permanent damage. But care should be taken not to confuse simple dandruff with other conditions that cause flaking of the scalp, such as seborrheic dermatitis or psoriasis. Five ingredients are approved for use in shampoos, rinses, or products consumers apply to the scalp: salicylic acid, pyrithione zinc, sulfur, selenium sulfide, and coal tar. However, in many cases, washing the hair more often will provide adequate dandruff control.35 Seborrheic dermatitis is characterized by redness, inflammation, itching, and flaking of the skin. It most commonly affects the scalp and face but can also occur on the ears, chest, and other parts of the body. Hormones, heredity, diet, emotions, medications, cosmetics, and climate can be factors in seborrhea, but often the cause is an infection with a yeast (fungus) called Pityrosporum ovale. Mild cases are treatable with OTC products, but severe cases should be treated by a physician. Some cases respond well to treatment with a shampoo containing ketoconazole, which kills the fungus. Psoriasis is an inflammatory skin disease in which cells reproduce about 10 times faster than normal, but the rate of shedding is unchanged.36 Live cells then ac- cumulate and form thick patches covered with flaking skin. The scales can occur in many areas of the body, most commonly the knees, elbows, back, and buttocks. Although coal tar and salicylic acid preparations are approved for OTC use against psoriasis, more effective drugs are available by prescription. Because coal tar can make skin overly sensitive to sunlight, people using a coal-tar product should be cautious about exposing their skin to sunlight. Hair Removal and Reduction Excess hair (hirsutism) results from an overabundance of androgens (male hormones) produced in the adrenal glands and ovaries. Many women of reproductive age have at least a few long, coarse facial hairs. Except for electrolysis, all methods of hair removal are temporary. The reappearance time depends on the location of the hair and how much of the hair is removed. Shaving is the fastest method but results in the quickest regrowth. Tweezing is also quick and, because it removes a portion of the hair below the skin, tends to have a longer-lasting effect than shaving. Small amounts of hair can be removed with a pumice stone or other abrasive. However, this can irritate the skin. Waxing, which is similar in effect to tweezing, is done by applying melted wax to a hairy area. When the wax cools, it can be stripped off in the direction of hair growth, carrying hairs with it. Waxing can irritate the skin and can cause infection of the hair follicles. Depilatory creams and lotions contain a chemical agent (most commonly thioglycolate) that breaks down the protein in the hair, turning it into a soft mass that is easily wiped off the skin. The root of the hair is left intact. The products are applied to the skin and removed after 5 to 15 minutes. Since the chemicals can irritate or burn the skin, depilatories should not be used without testing them. The test is carried out by applying the product to a small area of skin and inspecting the area 24 hours later. Laser devices generate intense heat that injures the follicle to stop or delay growth. Stable reduction in hair growth is possible but may require multiple treatments. Dark hair responds best. Treating a small area may take only a few minutes, but large areas can take several hours. Sun exposure should be minimized for at least a week afterward because the treated skin will be very sensitive to ultraviolet radiation. The risks include loss of skin pigment, blisters, and scarring. Two devices are FDA-approved for home use on areas of the body other than the face. People contemplating the use of a home laser device should discuss the pros and cons with a dermatologist.37 Electrolysis is performed by inserting a fine needle into the hair follicle and delivering an electric current to destroy the hair root. Its safety and effectiveness depend Part Five Other Products and Services388 on the expertise of the operator. The competence of non- medical electrolysis operators varies widely. Thirty-two states license electrologists. Two professional organiza- tions offer certification based on a written examination. Electrolysis devices are also available for self-treatment. Electrolysis can be tedious, time-consuming, ex- pensive, and uncomfortable, depending on the areas involved and the amount of hair to be removed. In addi- tion, excessive exposure to electric current can damage the skin and cause scarring or infection. A fresh needle should be used for each patient to prevent the spread of hepatitis or HIV. People considering electrolysis should consult a dermatologist to determine whether it is advis- able and to obtain the name of a suitable practitioner. Growths that contain hair, such as moles, should be diagnosed and evaluated by a physician. Severe cases of hirsutism should be medically inves- tigated because there may be an underlying disease

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