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The adverse event following the immunization may be These anticipated reactions occur within a day or two of anticipated and not severe enough to cause discomfort immunization and are listed in Table 5 hoodia 400mg for sale rumi herbals pvt ltd. Another notable component of adverse events following Vaccination complications and their immunization is due to program errors that would result from errors and accidents in vaccine preparation hoodia 400 mg cheap herbs de provence uses, handling management or administration (Table 5 buy 400 mg hoodia grameen herbals. The most vaccination (3–6 weeks) which discharges buy hoodia 400 mg low price jovees herbals, ulcerates and heals by tiny scar (10–12 weeks). Emergency management of anaphylaxis: mumps • Place the patient in recumbent position and elevate the adverse reactions: Fever; rarely encephalopathy, seizures, feet. Repeat dose at 20 minutes intervals till adverse reactions: Arthralgia, lymphadenopathy, fever response. Discard the needle used for drawing and use a fresh needle for injection (one Local reactions: Redness, swelling and pain. The risk • Complete the vaccination schedule as per immunization of intussusception with rotavirus is not increased as with calendar. It is often difficult to prove definite cause-effect relationship between the act of vaccination and subsequent compli- Prevention and treatment of cation. The following guidelines as well as the list of contraindications for vaccinations will help in deciding Vaccine reaction vaccine administration (Table 5. It is mandatory for the person administering the vaccine to have sufficient knowledge regarding vaccines and Guidelines for safe Vaccination expected side effects and to inform parents thoroughly Always ensure safe injection practices for safe health by regarding such adverse effects, which may however occur using disposable syringes. It is also essential to be prepared and to always • Select proper vaccine and follow manufacturer’s have a ‘kit’ with lifesaving drugs and equipment at each instructions (dose/route/administration). Advice on managing the common reactions as well as • Inform the parents regarding vaccine benefits and their the instructions, to return to the clinic if there are more anticipated reactions. Immunization against infectious disease; the vaccine to advise the parent/patient at the time of 1996. For more serious problems, attention, hence there is tendency to dramatize and the patient should be advised to return or to seek medical personalize the event. More importantly, of panic and outrage about the events, which are unrelated they should be advised not to delay treatment of a to immunization (coincidental). The guiding principle coincidental illness falsely attributed as vaccine reaction. Key messages have to be prepared before media contact and channels and timeline for reporting they should include some of these facts: serious aefI cases • That benefit of immunization in preventing disease is When to Report? The routine Vaccines and autism vaccination program should continue while awaiting the Over the past decade there has been tremendous completion of the reporting and investigation. Consequently most chain, proper parent education and efficient resuscitation of the vaccine preparations available in the developed equipment are vital components essential to make immuni- nations are thiomersol free. Systematic review of evidence zation most cost-effective public health tool in child survival however has not supported any causal association between programs. Therefore in developing nations, where multi-dose vials significantly bring down vaccine costs and cold chain space requirement, the bibliography benefits of thiomersol far outweigh any possible risks. Manila: World Events that should be reported include all serious adverse Health Organization; 1999. New Delhi: Jaypee events that are unexpected in nature, severity, frequency or Brothers Medical Publishers Pvt. Mumbai: objective ‘to eliminate sickness and death caused by vaccine Indian Academy of Pediatrics; 2011. These developments Anecdotal evidence of vaccination does exist since the have helped identify numerous potential vaccine antigens eleventh century, but it was the landmark observation but complicated the issue of selecting the best. Pneumococcal adhesin antigen is being advancements in the field of immunology, structural looked upon as a potential candidate for a multi-serotype biology, systems biology and bioinformatics have led protection with a high herd effect. Glyco-conjugation to the development of newer, effective and highly safe of polysaccharide antigen has already revolutionized vaccines. The synthetic microbial antigens, expression protection against Hib, meningococcal and pneumococcal of protective antigens in live vectors and plants, antigen organisms and is being further exploited for group A and B sparing adjuvants that manipulate the desired immune Streptococcus and S. Subsequently, recombinant proteins of not only infectious diseases but also target the non- as effective immunizing agents have been enabled by gene infectious ailments like malignancy and degenerative insertion in yeast, E. The argument that have the advantage of simulating a natural infection and vaccines create wealth and prevent unnecessary deaths stimulating both humoral and cell-mediated immunity has to be percolated at all levels to ensure global health. The vectored approach has also the potential for therapeutic vaccines for cancer, e. Meningococcal clone selection with highest efficacy and lowest virulence, B protection which has eluded the researchers till now rapid and high productivity and re-assortment, i. The conventional alum adju- vant though safe had its limitations of reactogenicity, immune response. Both have had a different pace of development transgenic approaches and often vaccinology has lagged behind. The success of the euphoria of developing edible vaccines in the form vaccines till now has rested on high avidity, long lasting of locally available fruits or other plant parts for oral use, protective antibodies. However, there has been a renewed systemic immunity (many respiratory and enteric pathogens) interest in plant-made vaccines utilizing plants like tobacco has given the necessary fillip to development of vaccines which are not staple foods and using recombinant protein regulating these pathways for a higher efficacy. It is now an established fact that mucosal immunity is highly important for protection Vaccines in Pipeline against many pathogens. Recent developments in immunology, biotechnology, pharmacology, microbiology Though vaccines against 24 infectious diseases have been and biomedical engineering have opened new vistas in licensed, the future vaccine list is gradually expanding. The alternative routes of immunization chiefly the nasal and vaccine candidates are in varying stages of development. The nasal associated lymphoid tissue elicits a strong specific immune responses to prevent/treat disease and mucosal secretory IgA and systemic IgG response. Attempts are in progress to targeting new age Groups develop highly safe and immunogenic nasal vaccines by Conventionally vaccines have been primarily used for optimizing antigenic formulation and novel adjuvants and infants and children but the future needs demand universal mass administration by inhalational devices. The concerns of an aging stratum corneum without reaching the pain receptors in the population will merit a similar program for elderly, e. The breach in skin helps deliver antigen and/or the influenza, pneumococcal, cancer and degenerative diseases adjuvant to the abundant dendritic cells and Langerhans like Alzheimer disease. Electroporation, jet pregnant women against diseases like influenza, compounded propulsion and ultrasonic (sonophoresis) are other methods by various ethical issues merits consideration in future. Oral administration Protection against nosocomial infections and bioterrorism are of inactivated vaccines and rectal or vaginal administration areas where lot of new vaccines are being targeted. To simplify the immunization approach to guard against the remotest adverse event puts schedule, it is imperative that age appropriate combination the industry on the back foot. Translational studies can help vaccines are made available to simplify schedule, better identify the early predictors of success by assessment of early compliance and coverage with feasible costs and logistics. Recent advances in administration of vaccine targeting challenges for infectious diseases: Microneedles as painless delivery device for mass vaccination. A call to action for the new decade of and mortality, yet its introduction into public health is a vaccines. Intranasal drug delivery: How, availability, cost, its sustainability, safety and efficacy Why and What for? Trends affecting the future of vaccine development and delivery: the role of acceptable but it may erode the already meagre public demographics, regulatory science, the anti vaccine movement confidence in the vaccination program.
Prematurity is Older Infants associated with delay in the process of closure of the ductus generic hoodia 400mg mastercard herbals biz. For the preterm infant order hoodia 400mg online euphoric herbs, indomethacin or vertical discount 400mg hoodia fast delivery euphoric herbs, often from the undersurface of the aorta 400mg hoodia with mastercard herbals in india, while in the ibuprofen should ideally be the first line of treatment. The latter it connects the roof of the main pulmonary artery with younger the gestational age of the infant, the lesser is the the proximal descending thoracic aorta. In these circumstances, surgery should be blood will shunt from left to right into pulmonary artery considered. They the volume of shunted blood will increase pulmonary blood include coil occlusion and closure with occlusive devices. Majority of patients are asymptomatic in infancy • Coarctation of aorta and childhood. Features common in ventricular outflow obstruction Wide spitting of S2 is due to delayed closure of are concentric hypertrophy of the chamber proximal to pulmonary valve. The latter is seen in association with the Williams-Beuren characterized by narrowing of aorta typically located near syndrome. Constant systolic ejections click just after S1 is a consistent Depending on severity of obstruction, the femoral physical finding in bicommissural aortic valve. This is highly pulses are both weak and delayed (due to delayed upstroke sensitive and specific in children and often better heard of arterial pulse in lower extremity sites) or absent. In the common form of aortic dilatation with aneurysm formation, and berry pulmonary valve stenosis, the valve is thickened with fused aneurysms in cerebral vasculature are commonly seen. In older children, balloon dilatation is a less valve stenosis is the dysplastic valve (frequent in Noonan invasive option and in adolescents and adults, stenting of the coarctation segment can yield maximum reduction in ebstein’s anomaly gradient. Mild disease may resent for the first been a subject of intense study over several decades. Within this classic tetrad, there are numerous anatomical variations, most of which have an important 1. Clinical screening Palliation is possible in the very young through the Blalock- for congenital heart disease at birth: a prospective study in a Taussig shunt, balloon dilatation of the pulmonary vale or community hospital in Kerala. The earlier decline is related to the improved standards This is due to plastering and thickening of posterior leaflet, of living hygiene, health, literacy (particularly of females), thickening and retraction of anterior leaflet and lack of medical facilities, etc. Two major or one major and two minor can be prevented with specific antimicrobial treatment. It is important to emphasize that these the rheumatogenic strains share certain epitomes with guidelines are meant to help a physician in making a firm cardiac myocytes and sarcolemmenal membrane protein. In some areas, typical Aschoff nodules • Carditis • Arthralgia are formed with aggregation of multinucleated giant cells. These inflammatory changes are diffuse affecting heart, • Chorea • Previous rheumatic fever or large joints, brain and subcutaneous tissue. Inflammatory infiltrates are also frequently seen in myocardium with scanty injury and loss of Essential criteria myocardial fibers. Pericardial involvement results in fibrinous Evidence for recent streptococcal infection as indicated by: pericarditis, which may result in pericardial effusion which • Increased levels of antibodies against streptococci is serosanguinous. It usually resolves completely, never • Positive throat culture for Group A streptococcus causing constrictive pericarditis. Small pericardial effusion is • Recent scarlet fever common but cardiac tamponade rarely occurs. It is an early manifestation and occurs in 30–50% of cases Carditis in our country; there is no residual damage of the joints. The rheumatic carditis is a pancarditis involving pericardium, • subcutaneous nodules: Subcutaneous nodules appear myocardium and endocardium. Usually they disappear • Pericarditis:Pericarditis results in precordial pain, which in few days to few weeks rarely lasting even up to may be quite severe. Clinical pericarditis is seen in Persistence of nodules is associated with chronic carditis. It is friction rub there are no murmurs, it is unlikely to be due usually self limiting. It starts as a red spot with a pale center, (1) cardiac enlargement, (2) soft S1, (3) protodiastolic increasing in size to coalesce with adjacent lesions (S3) gallop, (4) congestive cardiac failure and (5) Carey to form serpigenous margin. Though specific but seen extremely rarely in India, pitched delayed diastolic mitral murmur heard during probably due to dark complexion. Many Indian authors take it as and tend to leave permanent scarring in most cases. The leukocyte count valve involvement results in early diastolic murmur of usually is between 10,000/cmm and 15,000/cmm. Aortic valve is involved in 20–25% of cases; it is an sedimentation rate is almost always elevated during isolated finding in only 5–8% of cases. Presence of Noncardiac Manifestations of Rheumatic Fever C-reactive protein, however, is not diagnostic since it • arthritis: Rheumatic arthritis is a fleeting polyarthritis becomes positive in many infections. The arthritis nondiagnostic criterion since it can occur in many 444 is typically migratory. The higher the level, more the likelihood of a recent • Patients sensitive to penicillin should be advised to take erythromycin streptococcal infection; lower level considered “normal” 20–40 mg/kg in two divided doses. Rising titers of antistreptolysin “O” is a strong • For patients having carditis with congestive cardiac failure, use of evidence of a recent streptococcal infection. With two antibodies tested, Management of chorea it rises to 90% and with three antibodies tested, it rises • Usually self limiting to 95%. With paired sera testing of single antibody, the • Complete physical and mental rest sensitivity is 80% rising to 99% if paired sera of two • In resistant cases, phenobarbitone, 3–5 gm/kg/day antibodies are tested. The desquamation of skin of palms and soles indicates that the patient has had scarlet fever within Prevention the previous 2 weeks. Primary because of low sensitivity although high specificity, it prevention requires identification of streptococcal sore was not found very useful. Drugs Dose Sore throat the total duration of aspirin or steroid therapy is generally treatment 12 weeks. With aspirin, the full doses are given for 10 weeks (duration) and then tapered off in next 2 weeks. The Penicillin V (oral) Children: 250 mg qid 10 d dose is 60 mg/day for patients weighing more than 20 kg. Adult: 500 mg tid 10 d This is continued for 3 weeks and then reduced to 50 mg/ Azithromycin (oral) 12. Following Cephalexin (oral) 15–20 mg/kg/dose bid 10 d this, the reduction in dose is by 5 mg/week. In patients Its success depends on the awareness of parents regarding increase in early diastolic filling. Less than ideal would be to mitral valve prolapse, cleft mitral valve, L-transposition with continue it till the age of 35 years.
Among the burden of vaccine preventable diseases the incubation period ranges from 10 to 12 days purchase 400mg hoodia with amex everyuth herbals skin care products. Occasionally they are hemorrhagic mostly seen on buccal mucosa opposite lower molars but may be seen all over the buccal mucosa buy 400mg hoodia with amex herbs contraindicated for pregnancy. It starts Measles is seen in early childhood in developing as faint erythematous maculopapular rash on upper countries cheap 400mg hoodia with mastercard quincy herbals. The disease usually occurs in infants below 3 lateral aspect of neck and typically behind the ears and increasingly involve face then spreading on to trunks and years of age best 400mg hoodia vaadi herbals pvt ltd. Infants are usually protected till the age of 4–6 then to legs and arms over next 3–4 days. By the time rash months due to immunity acquired transplacentally from appears on feet, it starts disappearing from face and fades mother. Temperature also suddenly age of 9 months but antibodies may persist up to 12 months normalizes once rash starts fading and child suddenly of age. The severity of disease is directly whereas the disease is severe in malnourished children. In severe Transmission occurs either by direct contact or droplet cases rash may become hemorrhagic. It is highly the browny desquamation and brownish discoloration contagious and secondary attack rate is approximately 90% characteristic of post-measles state which disappears in in susceptible household contacts. The antibody gradually wanes and complications the infant becomes susceptible to measles starting from Measles can affect various systems in the body resulting in 6 months of age. At this age, live attenuated measles • respiratory system: Post-measles bronchopneumonia vaccine offers good protection. Unconstituted vaccine empyema, mediastinal and subcutaneous emphysema remains viable for 2 years at 2–8°C, but once reconstituted and flaring of pulmonary tuberculosis. Postexposure Prophylaxis Prognosis • For a child, less than 6 months age (mother usually In developing countries measles has a devastating course with a mortality of 1–3% which may go up during epidemics immune in India), there is no need for prophylaxis as up to 5–15% and a high rate of complications. Management • For a child more than 12 months age, if unimmunized, Management is mainly supportive. A single dose of vitamin A 100,000 units orally for children, 6–12 months of age and 200,000 units orally for more than 1 year of age children reduces mortality. Antibiotics may bibliography be indicated if there is evidence of otitis media or bacterial 1. Epidemiology and Prevention of Vaccine-Preventable Prevention Diseases, 10th edition. Nelson Textbook of Pediatrics, 18th Measles can be effectively prevented by measles vaccine. Mumps is an acute viral infection which is characterized the submaxillary and sublingual glands are involved less by swelling of one or more of the salivary glands, most often and may be without parotid swelling. It generally occurs in children edema has been described due to lymphatic obstruction. The salivary glands, the pancreas, the Other than parotitis, orchitis is the second common testes or ovary, the brain, the breast, the liver, the joints and feature in adolescent and post-pubertal males but unco- the heart are the organs which are usually affected by the mmon in prepubescent males. Symptoms begin abruptly with etiology testicular swelling and tenderness and associated nausea, vomiting, and headache. Only one serotype of mumps develops in nearly half of the affected organs but sterility virus is known. Oophoritis in girls is much uncommon and may cause lower abdominal pain but does lead to sterility. Meningeal symptoms may develop anytime unimmunized population epidemics tend to occur every between a week and before several weeks after the 2–5 years, throughout the year but often with a peak in late parotitis. These findings revert the mumps virus is transmitted via saliva, through airborne to normal after about a week and sequels are uncommon. Occasionally meningitis or encephalitis may period of maximum communicability extends from 1 day to occur without manifest parotitis. Viremia occurs after Mumps pancreatitis may be present with pain abdomen 12–25 days and lasts for 3–5 days. During viremia the virus but diagnosis is difficult as serum amylase is elevated both spreads to multiple tissues. It then localizes in glandular in parotitis and pancreatitis but serum lipase is normal in and neural tissue. Infection with mumps virus to be followed parotitis, which is the most common has been implicated as a possible cause of juvenile onset of manifestation and occurs in 30–40% of infected persons. Earache, jaw tenderness There is no evidence of impairment of fertility in post- with chewing, and dry mouth are among the presenting pubertal girls with oophoritis. Sucking a myocarditis, deafness unilateral or bilateral (transient or sour stimulus produces significant worsening of the pain. The permanent), arthritis, optic neuritis, thyroiditis have been swelling is at the angle of the jaw, and obliterates the angle, reported. Arthralgia, arthritis and nephritis are other less common the vaccines should be protected from light. Immunization is indicated at about diagnosis 15 months of age in combination with measles and rubella vaccination and can be given at age of 12 months if child has Virus isolation not received measles vaccination at 9 months of age. Vaccine is not effective in that follow with a rise several weeks later, and may persist preventing mumps after exposure. Neutralizing and hemagglutination inhibiting antibodies appear during convalescence. Epidemiology and prevention of vaccine-preventable Management diseases, 10th edition. Skin rash is mostly discrete maculopapular in the mid-eighteenth century, hence it is also known as but quite variable in size and confluence. The virus In pregnant women, rubella virus can cross the placenta is transmitted by aerosol droplets from person to person and infect the developing embryo or the fetus resulting and transplacentally causing congenital rubella syndrome. The exact nature and Volunteer studies have shown that the virus remains in the extent of these malformations depend on the gestational nasopharynx from 7 days before to 14 days after the onset age of the affected fetus. It replicates in the mucosal cells of upper respiratory greatest with primary maternal infection. Congenital tract and spreads to the regional lymph nodes, especially defects occur in about 90% infants if maternal infection the posterior auricular and the suboccipital group. Small occurs before 11 weeks of pregnancy and about 10–20% number of infants with congenital rubella can continue to by the end of first trimester. Virus can be isolated from throat and urine from 1 week before the rubella virus is a cubical, medium-sized (70 nm) virus. The virus has function tests, hemolytic anemia, pleocytosis and very two transmembrane proteins, E1 and E2. Initial prodromal symptoms include malaise, headache, mild catarrhal symptoms and low- It is often confused with mild variety of scarlet fever or grade fever. General Fetal loss (spontaneous abortion and stillbirths) Antipyretics are used for symptomatic relief.
Patients with undiagnosed melasma can also have worsened hyperpigmentation a few weeks after treatment hoodia 400mg on line herbals on deck, and this occurs most often in the setting of repetitive laser treatments at short intervals (e purchase 400mg hoodia with amex mobu herbals x-tracting balm reviews. Hyperpigmentation usually resolves spontaneously over several months cheap hoodia 400 mg guaranteed herbals, although in rare instances may be permanent buy hoodia 400 mg online herbs good for hair. Pretreatment of dark skin types with hydroquinone for 1 month may also aid in preventing hyperpigmentation. Skin surrounding hypopigmented areas can be lightened with laser treatments in an attempt to blend the demarcation between background skin and hypopigmented areas. Prompt application of a wrapped ice pack to areas suspected of overtreatment at the time of treatment that are intensely erythematous and painful may reduce the area of injury. Blisters and crusting are managed with application of an occlusive ointment such as Aquaphor™ or bacitracin, and covered with a gauze dressing and tape. Patients are monitored over the next few weeks for formation of bullae, intense prolonged erythema, induration, and scarring. Tattoos and permanent makeup have concentrated ink pigments and treatment over these can result in full-thickness skin burns. Scarring is very rare but may occur with overly aggressive treatments, particularly in areas predisposed to scarring such as the sternum, or with treatments complicated by burns and infection. In addition, recent use of isotretinoin, previous radiation therapy in the treatment area, and a history of keloid formation are also risk factors for hypertrophic scarring. Interventions for persistent intense erythema to reduce the risk of scarring and management of scarring are discussed in the Scarring section, Chapter 6. Keratotic lesions such as seborrheic keratoses may lighten in color but do not flatten in response to nonablative lasers; they can be treated with resurfacing lasers and liquid nitrogen. It is advisable to fully discuss this risk if hair is present, especially if treating over men’s facial hair. Ocular injury can be avoided by wearing appropriate laser-safe eyewear at all times during treatment, directing the laser tip away from the eye and treating outside of the eye orbit. Women who are pregnant or nursing typically do not undergo elective procedures such as lasers for treatment of red vascular lesions. One possible complication in nursing women is inhibition of lactation due to pain associated with a prolonged painful laser treatment. Patients may not experience the same degree of reduction in unwanted pigmentation that lighter Fitzpatrick skin types can achieve due to these restrictions. Nonfacial areas have fewer pilosebaceous units, which serve as sites of re-epithelialization that facilitate healing. These areas have delayed healing relative to the face, with a greater risk of overtreatment and scarring, and should be treated conservatively. Aiming for subtle clinical endpoints of pigmented lesion darkening with minimal perilesional erythema is advisable initially. As procedural skill is gained, modify settings to achieve standard clinical endpoints and consider advancing to treatment of nonfacial areas. Current Developments Fractional resurfacing is one of the newest areas of laser medicine with many rejuvenation benefits including reduction of pigmentation. New applications for this technology, new wavelengths, and new device modifications are rapidly becoming available. Some of the latest techniques, for which there are limited clinical studies, involve combining fractional resurfacing with other laser technologies to achieve more comprehensive improvements for photoaged skin (see Introduction and Foundation Concepts, Combining Aesthetic Procedures section). Over-the-counter fractional nonablative devices are being developed with company claims of improving benign pigmented lesions in addition to treating other signs of photoaging such as wrinkles and skin texture. The ReAura (by Philips) is a nonablative fractional diode laser (1435 nm) that claims to improve photoaged skin. This laser penetrates 200 μm in depth, while in-office nonablative fractional lasers penetrate up to 1500 μm. Although modest improvements may be seen with home devices, their clinical effects are unlikely to be comparable to office-based technologies. Individual treatment prices range from $350– $500 for a single treatment to a large area such as the face or chest, and $150–$250 for a small area such as the hands or neck. Several treatments are typically required to achieve maximal benefits and a series of 3 or 5 treatments may be offered to patients. The most common vascular lesions associated with photoaging are telangiectasias, erythema, and cherry angiomas. In addition, certain skin conditions are also associated with or exacerbated by exposure to ultraviolet light such as poikiloderma of Civatte and rosacea. This chapter reviews laser principles as they relate to treatment of red vascular* lesions and conditions seen in photoaged skin and provides a step-by-step approach to treatment. Anatomy Telangiectasias are dilated vessels located in the superficial dermis, ranging in size from 0. Telangiectasias arising from dilated arterioles and venules have larger diameters, and those arising from capillaries may be discernible as fine lacy red vessels or erythema. Rosacea type I (erythematotelangiectatic rosacea) presents with telangiectasias and background erythema on the convexities of the face (i. They can result from skin trauma, sun exposure, and hyperestrogenic states related to pregnancy and liver disease but are usually idiopathic. Poikiloderma of Civatte is a mottled discoloration of the skin consisting of erythema, telangiectasias. Poikiloderma of Civatte is most common in women, and while chronic sun exposure is the chief etiologic factor, photosensitizing chemicals in perfumes and cosmetics may also be causative, as well as hormonal changes related to menopause. Laser Principles Laser treatment of red vascular lesions is based on the principle of selective photothermolysis, the conversion of laser energy to heat, which selectively destroys vascular lesions. To achieve removal of vascular lesions, laser energy is applied to the skin and absorbed by oxyhemoglobin, the target chromophore found in red blood. Oxyhemoglobin strongly absorbs light between 400 and 600 nm, and has absorption peaks at 418, 542 and 577 nm. Laser energy is converted to heat in red blood, causing vessel wall and perivascular damage, that results in vessel closure and reduced erythema. Laser Parameters for Treatment of Red Vascular Lesions By adjusting laser parameters of wavelength, fluence, pulse width and spot size, maximal efficacy and safety can be achieved with laser treatments of red vascular lesions (also see Introduction and Foundation Concepts, Laser Parameters section). High fluences are used when less target chromophore is present either due to sparse blood vessels or faintly colored vessels. Lower fluences are used when more target chromophore is present either due to dense blood vessels or intensely colored vessels. Very short pulse widths can result in abrupt heat transfer that can ruptures vessels, causing petechiae and purpura. Fast repetition rates allow for more rapid coverage of large treatment areas and can shorten treatment times. Slower repetition rates aid in precise placement of laser pulses and are useful for treatment of discrete lesions. Multipulse modes with long delays are safer for the epidermis as they allow thermal energy to dissipate and are preferred in darker skin types. Single pulse mode is more aggressive and is used for treatment when less target chromophore is present and in lighter skin types. Aggressive treatment parameters refer to the use of short wavelengths, short pulse widths, high fluences, and small spot sizes.
