There are diseases that are little called terrible. They gradually suck their human life and make existence just unbearable. It is important to remember that modern medicine is going forward very quickly, and the fact that it was previously considered impossible, today is amenable to treatment. Even if you come across something frightening, do not lose hope, but proceed to action. The first point of any plan to combat the enemy is more about it.
Today we will get acquainted with Stevens-Johnson's syndrome, its features, symptoms, methods of infection and treatment.
What it is?
Stevens-Johnson Syndrome - This is a severe disease that violates the work of the whole organism due to the systemic allergic reactions of a slow-type type. The syndrome has another name - malignant exudative erythema. Externally, the disease looks like damage to the skin with ulcers of different sizes, by swelling mucous membranes. Also, this syndrome is accompanied by the defeat of the shells of some internal organs.
The difference between Stevens-Johnson's syndrome from Layella's syndrome is that the first is more like a sharp respiratory disease, when, as a second disease, the process begins with abundant rash throughout the body.
How does it occur?
Scientists and doctors agree that there are only 4 main reasons due to which such syndrome can develop.
- Strong allergic reaction to drugs. In this case, Stevens-Johnson syndrome comes in the form of an acute reaction with complications. Among the drugs that often cause syndrome are called antibiotics (more than half of cases), anti-inflammatory, sulfanylomides, additional vitaminizing drugs, vaccines. There are cases when the syndrome began to develop after the use of heroin.
- Infections. The reason for the symptoms of Stevens-Johnson syndrome can be the already hazardous infections, such as HIV, flu, hepatitis of different types and others. Also, provocateurs of the disease repeatedly were bacteria, fungi, microplasms, streptococci and other infections.
- Malignant tumors are oncological diseases. In some types of cancer, the body is not able to cope with them and begin the processes of rejection, an allergic reaction.
- The disease may occur by itself. In medicine, this is called an idiopathic case. Unfortunately, such cases happen quite often, almost 50%. Recently, doctors believe that a tendency to this disease can be congenital, and transmitted genetically.
Symptomatics of the disease
Symptoms of Stevens-Johnson syndrome are diverse. The disease is striking both men and women, not bypassing and children. The predominant time of development of the disease is a period between 20 and 40 years. It is characteristic that more men are susceptible to this disease.
The first symptom is the appearance of the infection of the upper respiratory tract. The next guest is a strong temperature that is accompanied by severe fever, as well as the weakening of the body, pain in different parts of the body, cough, pain of the throat - all the symptoms of the cold. At this stage, a terrible diagnosis can be confused with a typical cold or influenza. It is possible to understand that this diagnosis can be erroneous only when the rapid and widespread skin lesion begins. If the lesions first resemble small pink stains, then on the soft sections of the kokhi turn into bubbles with different shades: from grayish to red. The same applies to the mucous membranes that are covered by blisters. If you physically get rid of these ulcers (combing, tear off), then there will be a bloody mixture in their place, which will flow constantly. All the heel on the skin is cushed. A strong blow takes the eyes: they are subjected to an infectious disease (for example, conjunctivitis), as a result of which complication can begin up to loss.
All this happens with a person in a matter of hours, in a rare case - throughout one day. Body changes are amazing and visible to the naked eye. The lesions on the skin can be replaced by cracks and large dry ds.
Another place for which the syndrome beats - the genitals and the area around them. The very first step is urethritis (inflammation of the urinary channels), difficult to urinate and inflammation of the genitals.
If a person has acquired such a disease in age, more than 40 years old, then the forecasts of doctors can be disappointing.
Symptoms can start suddenly and manifest several weeks, mostly two or three. Other accompanying syndromes are pneumonia, stomach weakness, kidney problems and so on.
Possible consequences
Among all cases of the disease, such consequences were observed:
- Female outcome - up to 10-15%
- Blindness, partial loss of vision
- Deformation of internal organs, including a narrowing reduction in the size of the urinary tract
Proper diagnosis
Since the disease progresses very quickly, then it is necessary to diagnose it immediately. For this, the doctor needs to find out several key moments associated with the patient's life and health:
- What patient has allergic reactions and on which substances, products, media.
- What caused allergies? Possible options?
- The doctor must necessarily find out all the symptoms of the disease and medicines that the patient recently used.
- How the patient tried to overcome his ailment.
It is also necessary to inspect skin damage, their character, appearance, areas where most ulcers and so on. Special attention - mucous membranes, inspection of the oral cavity and eye. To diagnose, it is important to measure the body temperature and make blood test. The results of the last analysis will show what the main problem may cause the reaction. Blood analysis should be taken regularly to monitor changes in its structure. The same is characteristic and for the analysis of urine.
First of all, an allergist and dermatologist are engaged in such health problems with the patient. But if the problem has spread greatly to other organs (urinary channels, genitals, eyes, etc.), then often resort to the help of such specialists as a urologist, dermatologist and others.
Fast assistance in hospitalization
The main thing is that you can help the patient with such syndrome - to force it to drink a lot of water. Doctors who diagnose the disease will first of all will also replenish the reserves of the lost fluid using the introduction of special solutions and mixtures. Sometimes specialized drugs are used, hormones.
Treatment of syndrome
The effect of receiving glucocorticosteroids.
The main principle of treating this syndrome is to remove allergen from the body, if there is such. For this, complete cleaning is performed at different levels. Another direction is to protect the patient from possible infections that can penetrate through numerous open wounds.
Also, treatment includes such items:
- Mandatory diet against allergies;
- Clean injection and injection into the blood of solutions;
- Application of glucocorticosteroids;
- Restoration of the skin after an ulcer with special ointments, creams and other drugs;
- Restoration of injured bodies;
- Treatment of symptoms of the disease.
For a diet, a dally strict diet, which consists only of products, which are almost never allergens are used. The basis of such food:
- Boiled meat (beef);
- Lean soups on the croups and vegetables (can be added repeated broth);
- Simple dairy products (kefir, cottage cheese);
- Apples and abruses;
- Cucumbers, greens;
- Inherent faint bread;
- Rice, buckwheat, oatmeal;
- Compote.
What is contraindicated with such a system of nutrition: citruses, alcohol, many berries (strawberry, currant); Seasonings and sauces, poultry meat, chocolate and other sweets, nuts, fish, and so on.
It is necessary to consume food in a certain amount, it is desirable that the overall calorie content does not exceed 2800 kcal, but not less than 2400 kcal for an adult. During inpatient treatment, you should still continue to drink a lot, that is, to replenish the lost moisture. Recommended amount of water - 2-3 liters.
Following actions
Reception of drugs should be carried out only with the prescription of the doctor. Even if a certain drug had a tremendous impact, it is not necessary to continue to accept it if there is no appropriate instructions from the doctor. If the hospital has established the cause of the syndrome, then he is issued a special document in which all allergens are recorded, including medical drugs. After inpatient treatment, it is necessary to regularly visit the immunologist, an allergist and a dermatologist. These specialists will help with further rehabilitation, and also contribute to the disease not repeated.
Stevens-Johnson syndrome is a very heavy skin disease, a malignant type of exudative erythema, in which strong redness appears on the skin. At the same time, large blisters appear on the mucous membranes and the skin. The inflammation of the mucous membrane prevents the mouth to close, eat, drink. Strong pain provokes enhanced saliva, breathing difficulty.
Inflammation, the appearance of bubbles on the mucous membrane system makes it difficult to natural departure. Urination and sexual acts become very painful.
Most often, Stevens-Jones syndrome occurs as a response allergic reaction to the reception of antibiotics or drugs intended for the treatment of bacterial infections. Representatives of medicine are inclined to the fact that the tendency to the disease is inherited.
The reason for exacerbation may be, scientists, several factors.
Most often, Stevens-Jones syndrome occurs as a response allergic reaction to the reception of antibiotics or drugs intended for the treatment of bacterial infections. The reaction can cause funds from epilepsy, sulfonamides, non-steroidal painkillers. Many drugs, especially synthetic origin, also affect the appearance of symptoms characterizing the Sivenson Johnson syndrome.
Infectious diseases (flu, AIDS, herpes, hepatitis) also can provoke a malignant form of exudative erythema. Fungi, mycoplasma, bacteria that have in the body can provoke an allergic reaction
Finally, the symptoms are very often registered with oncological diseases.
More often than Stevens Johnson syndrome manifests itself in men from twenty to forty years, although the disease was registered in women, children until six months.
Since the disease refers to instant type allergies, it develops very quickly. It begins with strong indisposition, the appearance of unbearable pain in the joints, muscles, a sharp increase in temperature.
A few hours later (less often - days), the skin is covered with silver films, deep cracks, blood clots.
At this time, bubbles appear on lips and eyes. If the initially allergic reaction in the eyes is reduced to their strong redness, then ulcers may appear, purulent bubbles. The cornea is inflamed, the rear departments of the eye.
Stevens-Johnson syndrome can hit the genital organs, causing cystitis or urethritis.
To make a diagnosis, a general blood test is necessary. Usually in the presence of the disease, it shows a very high level of leukocytes, the rapid settlement of red blood cells.
In addition to the overall analysis, it is necessary to take into account all the drugs, substances, food that the patient took.
The treatment of syndrome usually provides for intravenous transfusion of blood plasma, drugs that purify the body from accumulated toxins, the introduction of hormones. To prevent the development of infection in ulcers, a complex of antifungal and antibacterial drugs is prescribed, solutions of antiseptics.
It is very important to comply with a tough diet appointed by a doctor, drink plenty of liquid.
It is statistically established that with a timely handling of a specialist, the treatment ends quite successfully, although it takes a lot of time. Therapy usually lasts 3-4 months.
If the sick did not begin to receive drug treatment in the first days of the disease, then Stevens-Johnson syndrome can lead to a fatal outcome. 10% of the diseased dying due to late treatment.
Sometimes after treatment, especially if the disease passed in severe form, scars or stains can remain on the skin. The emergence of complications in the form of colitis, respiratory failure, violation of the functioning of the urogenital system, blindness is not excluded.
This disease absolutely excludes self-treatment, since it is potentially fatal.
For the first time, the pathological condition was described in detail in 1922, immediately after which the syndrome began to be called in honor of the authors who recorded her symptoms. Later the disease received the second name - "malignant exudative erythema".
Along with Layella syndrome, a bubble, a bullous version of the system red lupus (SLE), allergic contact dermatitis and Haley-Heili disease, modern dermatology refers to Stevens-Johnson syndrome to bullous dermatitis. Diseases combines the community of clinical manifestations - education on the skin and mucous patient bubbles.
The Stevens-Johnson syndrome often represents the danger to the patient's life - with this form of toxic epidermal necrolis, the motion of epidermis cells is accompanied by separation from the dermis. The bullous damage to the mucous and skin of allergic nature is usually developed against the background of the patient's severe condition. The disease affects the oral cavity, the eyes and organs of the urogenital system.
Causes of Stevens-Johnson's Syndrome
The development of the disease is due to an allergic reaction of an immediate type. To date, there are three main groups of factors capable of provoking:
- infectious agents;
- medications;
- malignant diseases.
In other cases, the causes of the syndrome remained unexplained.
In children, Stevens-Johnson syndrome develops against the background of viral diseases, including:
- simple herpes;
- viral hepatitis;
- flu;
- adenoviral infection;
- chickenpox;
- measles;
- parotitis.
According to experts, the risk of developing the syndrome rises with gonorly, yersiniosis, mycoplasmosis, salmonellosis, tuberculosis and tularemia, as well as fungal infesses, including histopathy and trico.
Adult patients are more likely to face Stevens-Johnson syndrome due to the reception of some drugs or against the background of malignant processes. In the case of medicines, the fatal role can play:
- allopurinol;
- carbamazepine;
- lusotein;
- modatinyl;
- neusaren;
- sulfonamide antibiotics.
A number of researchers consider non-steroidal anti-inflammatory agents and regulators of the central nervous system to the risk group.
Among the oncological diseases, at which the Stevens-Johnson syndrome is most often diagnosed, carbonated and lymphoma prevail.
In cases where it is not possible to establish a specific etiological factor, we usually go about the ideopotic syndrome of Stevens-Johnson.
Diagnostics
Stevens-Johnson syndrome can be diagnosed based on the results of a thorough examination of the patient, immunological research and coagulogram, as well as skin biopsy. The reasons for the appearance of characteristic symptoms that can be detected at the initial stage with a thorough dermatological examination, it is often possible to find out as a result of a patient's survey.
With histological examination, it is usually revealed:
- necrosis of epidermis cells;
- perivascular infiltration lymphocytes;
- subepidermal formation of bubbles.
In a clinical analysis of blood, with Stevens-Johnson syndrome, various non-specific signs of the inflammatory process are observed, on the coagulogram you can see disorders of coagulation. Biochemical blood test may detect reduced protein content.
The most informative in the diagnosis of this disease is the immunological examination of the blood, as a result of which the growth of the level of T-lymphocytes and specific antibodies can be revealed.
When diagnosing is found, it is important to exclude other diseases that are manifested in the formation of bubbles, in particular:
- contact dermatitis (allergic and simple);
- aktinic dermatitis;
- herpetyiform Durring dermatitis;
- bubble tape (including true, vulgar and other forms);
- layella syndrome and others.
If this disease is suspected, such research may be additionally conducted as:
- lung radiography;
- Ultrasound urinary bubble and kidneys;
- biochemical urine analysis.
In addition, consultations of other specialists may also be required.
Symptoms
The disease is characterized by sharp start. Patients celebrate a rapid rise of symptoms:
- malaise and general weakness;
- sharp rise temperature that can reach 40 °;
- headache;
- tachycardia;
- painful sensations in the muscles and joints.
Patients can complain about sore throat, cough, vomiting and chair disorders.
A few hours after the first signs of the disease (maximum per day), bubbles of quite large sizes begin to form on the oral mucous cavity. After their autopsy, extensive defects are observed, which are covered with a white-gray or yellowish tint films, as well as blood baked. In addition, the pathological process applies to lips. As a result, patients lose the opportunity not only normally, but also drink water.
Eyes are initially affected by the type of allergic conjunctivitis. However, complications in the form of secondary infection often occur quite often, after which purulent inflammation develops. When diagnosing Stevens-Johnson's syndrome, it is important to consider typical education in conjunctiva and cornea. In addition to small erosive-ulcers, are also likely:
- lesion of the iris;
- blufarite;
- iridocyclitis;
- keratitis.
Approximately half of the patients, pathological processes also apply to the mucous membrane of the organs of the urogenital system. Most often, when developing Stevens-Johnson's syndrome, can be identified:
- vaginitis;
- vulvit;
- balanopostitis;
- urethritis.
In connection with the scarring of erosion and ulcers, the mucous membranes often observed the formation of stricture of urethra.
The lesion of the skin is expressed in the appearance of multiple rounded towering elements visually reminiscent of blisters (bulls) up to 5 cm, the buggle.
With Stevens-Johnson syndrome, the characteristic feature of bubbles is the appearance of serous or bloody bubbles in their center. After opening the Bull, bright red defects arise, which are quickly covered with crusts. The most common places of rash is the torso and the crotch area.
The period in which new rashes may appear, it lasts about 2-3 weeks. The duration of the healing of ulcers is usually about one and a half months.
Treatment
Patients who are diagnosed with this disease receive therapy with the following methods:
- extracorporeal hemocorrection;
- glucocorticoids;
- antibacterial drugs;
- infusion treatment.
In the treatment of Stevens-Johnson syndrome, high doses of glucocorticoid hormones are prescribed. Given the damage to the mucous membrane of the oral cavity in most patients, the drugs are entered most often in the form of injections.
The dosage of drugs begin to gradually reduce only after the seducing severity decreases and the general condition of the patient is improved.
In order to purify the blood from immune complexes formed during Stevens-Johnson syndrome, the following types of extracorporeal hemocorrection are used:
- hemosorption;
- immunosorption;
- cascade plasma filtering;
- membrane plasmapheresis.
In addition, plasma transfusion and protein solutions is shown. An important role in therapy is to ensure the body of patients with sufficient fluid volume and support of normal rate of daily diurea.
Antibacterial drugs of local and systemic effects are prescribed to prevent and treat a secondary infection.
Symptomatic therapy helps to reduce intoxication, desensitization, inflammation and fastest epithelization of affected skin. Among the used drugs, such desensitizing agents can be distinguished as Dimedrol, Supratin and Tuesegil, Claritin.
Anesthetic (lidocaine, trimecain) and antiseptic (furaciline, chlorine, etc.) are used locally used, as well as proteolytic enzymes (tripsin, chymotrypsin). Effectively use of keratoplasty (sea buckthorn butter, rosehip and this kind of product).
In the treatment of syndrome, the use of vitamins, including the group B, as this kind of funds are strong allergens.
In the form of supplement to the main therapy, calcium and potassium preparations are effective.
Complications
The Stevens-Johnson syndrome can be complicated by such dangerous states as:
- bleeding from the bladder;
- pneumonia;
- bronchitis;
- colitis;
- acute renal failure;
- secondary bacterial infection;
- loss of view.
According to official statistics, about 10% of patients who have diagnosed with Stevens-Johnson syndrome, die due to the developed complications.
Statistics
The disease can be observed in patients of almost any age, however, the most common Stevens-Johnson syndrome is considered in the category of 20-40 years, whereas extremely rarely found in early childhood (up to three years).
According to various sources, the diagnosis frequency of the syndrome is annually from 0.4 to 6 cases per 1 million population. At the same time, Stevens-Johnson syndrome more often amazes men.
Stevens Johnson's syndrome is a bullous lesion of the skin and mucous membranes. It has an allergic nature and is distinguished by an acute manifestation.
This disease flows against the background of the severe condition of the person. It affects the oral mucosa and the urinary organs.
Also, this syndrome is called "malignant exudative erythema". As well as, allergic contact, etc. It is a bullous dermatitis and is distinguished by a large number of bubbles on the skin and mucous membranes.
Most often, this syndrome develops in people from 20 to 40 years. It is very rare in children.
Men from this disease suffer more often than women.
The reasons
The reasons for the development of Stephen Johnson's syndrome lies in the immediate allergic reaction of the body. There are four groups of reasons that can cause the beginning of such a reaction:
- infections;
- medicines;
- malignant diseases;
- unidentified factors.
In children, this syndrome is most often developing due to viral diseases (herpes, viral hepatitis, windmills, measles, etc.)
Bacterial infections and fungi (tuberculosis, gonorrhea, histopathy, tricoephyms, etc.) can also provoke development.
Adults mostly suffer from such a syndrome due to the admission of some medicines or malignant neoplasms in the body.
Of the drugs, antibiotics, regulators of the central nervous system, etc. can cause a similar reaction.
Of the oncological diseases most often the cause of lymphoma or carcinoma becomes.
Symptoms
With the beginning of the disease, the symptoms are manifested very quickly and sharply. Human has:
- general malaise;
- the temperature rises to 40s;
- headache;
- artralgia arise;
- pain in muscles;
- tachycardia.
The patient can hurt the throat, torment diarrhea or vomiting, cough.
For a few hours in the throat, bubbles begin to swell, which, after opening, form large defects. They are covered with white or yellow films and blood crusts.
Also in the process can be tipped lips.
The eye damage resembles conjunctivitis, but if infection falls, purulent inflammation can develop. It can also lead to blufaritis, keratitis, affecting the iris.
In the genital organs, urethritis, vulvit or vaginite develops.
Numerous elements appear on the skin, which rise above the rest of the skin and have a rounded form. Externally, they look like blisters. Can reach about 5 cm in diameter.
The rashes continue to appear for a couple of weeks. Ulcers who remain after opening bubbles heal a month and a half.
Because of complications that can cause this syndrome, approximately 10% of patients die.
Diagnostics
The diagnosis of this syndrome includes a large comprehensive study, during which the patient carefully examines, conduct an immunological examination of blood, make the skin biopsy, coagulogram. The pulmonary x-ray, urinary bubble, kidneys, as well as urine biochemical analysis are also carried out.
Treatment
Treatment under the syndrome of Stevens Johnson is appointed complex and intensive. Must prescribe glucocorticoids in large doses. Since these substances may affect the mucous membranes, they are injected injectable. The dose begins to reduce only after the symptoms decrease, and the person begins to feel better.
To clean blood use methods of extracorporeal hemocorrection:
- cascade plasma filtering;
- membrane plasmapheres;
- hemosorption;
- immunosorption.
Man make plasma transfusion and protein solutions.
Be sure to provide the body with plenty of liquid and maintain daily diuresis.
Also use potassium and calcium preparations.
Secondary infections are treated with antibacterial drugs.
Under the name of SDD (Layella and Johnson syndrome) implies severe inflammation of the skin and mucous membranes - multimolon erythema. The disease was opened in the USA in 1922. She described her two pediatricians Layelles and Johnson, in honor of which the syndrome got its name. The disease is distinguished by a sharp move, with the damage to the mucous and skin of at least two organs.
Currently, Layella and Stevens Johnson syndrome meets all over the world in people mostly over the age of forty years. Recently, the disease has become diagnosed in children and even babies.
Prerequisites to the disease:
1. Reception of certain drugs;Often, signs of Lailel and Stevens Johnson syndrome occur with the overdose of drugs. Cases of the disease are found due to the reception of only one and the correct dose of the medicine. Most cases of the disease were provoked by the intake of antibiotics, more often - when making antibiotics from a number of penicillin.
The smaller probability of the disease is present in the reception of local anesthetics, sulfonamide drugs, non-steroidal anti-inflammatory drugs.
2. Infectious diseases;
Increased risk factors - bacterial and fungal infections. The acute allergic reaction of SSDs can develop after contact with herpes, HIV, influenza and hepatitis viruses.
3. Oncological diseases;
4. idiopathic form.
This disease, the causes of which specialists failed to reveal. Layella and Stevens Johnson syndrome may arise for an unknown reason.
The main symptoms of the SSD
In most cases, the syndrome begins to manifest a sharp pain in the joints. The SSD is an acute, or quick form of allergies, so it starts unexpectedly.The patient first might think that he suffers from respiratory disease. At this stage there is a strong incredit weakness, articular pains, fever. A fellow man may suffer from nausea and vomiting. The initial state in the syndrome lasts several hours or a few days. Then there are strong rashes on mucous membranes and skin cover.
Rash appears in different places. The feature of the syndrome is symmetric rashes. An allergic reaction makes itself felt a strong itching and a feeling of burning.
The rash is localized in different ways. Most patients have rashes in the field of face, the sounds of the brushes and stop, on the knee and elbow bends. More often suffer mucous membranes in the mouth and a little less often - the eyes.
Layella and Stevens Johnson syndrome is determined by a swamp in the shape of papural, a diameter of two to five millimeters. Each papula is visually divided into two parts. In the center of the bubble, a small cavity with blood (hemorrhagic content) and protein fluid (serous substance) is clearly determined. The outer part of the bubble has a bright red color.
Papulas that are formed on mucous membranes are more painful. They quickly burst, leaving in place painful erosion with a yellow unhealthy raid.
The damage to the mucous membranes in intimate places can lead to men to the manifestation of urethra stricture and in women to develop vaginite.
With eye damage, blophies and other eye diseases are developing, worsening vision.
With any form of Layella and Stevens, Johnson's syndrome, patients feel pain and an increasing feeling of anxiety. Painness with rash on mucousse leads to refusal of food.
Diagnostics of SDD syndrome
It is necessarily a detailed and correct history. The SSD is one of the severe forms of an allergic reaction, so you can reveal some patterns in early allergic manifestations from a sick person. The patient must provide the attending physician the most complete information - to tell if allergic reactions occurred. The doctor should also know which agent and how hard the allergy flowed.The attending physician prescribes a general blood test, a biochemical study. The results of the analyzes will be revealed in blood aminotransferase, bilirubin and urea.
By careful external inspection, the strength and nature of allergic lesion is detected. Often, the correct diagnosis is impossible without putting the Imunnogram. This study is aimed at searching in the blood of antibodies of a specific class.
The diagnosis of Layella's syndrome and Stevens Johnson syndrome is not an archent task. Almost all appointed studies are aiming to eliminate disease with a bubble or other diseases with similar clinical manifestations.
How CZD is treated
The identification of Lailel's syndrome and Stevens Johnson requires urgent medical qualified assistance.
What urgently needs a patient to the stationary department? The following urgent events are held:
Catheterization of Vienna;
Infusion therapy (suspension or colloidal solutions are introduced to reduce the concentration of allergens in the blood);
Intravenous administration of prednisolone by a single dose of volume of 60-150 mg;
Due to the pronounced edema of the mucous membrane, the patient is translated into an artificial ventilation of the lungs.
After the patient's room and the stabilization of its condition in the hospital department, it is prescribed the main treatment. The attending physician will register analgesics for anesthesia, glucocorticosteroid drugs against inflammation. When infected with the skin or mucous membranes, strong antibiotics are prescribed, except for preparations based on penicillin and vitamins.
Complications accompanying Lailel and Stevens Johnson syndrome require additional therapy.
Skin lesions and mucous membranes are processed by antiseptic solutions and anti-inflammatory ointments.
The patient should receive hypoallergenic food, eliminating the use of all types of fish, coffee, citrus, honey and chocolate.
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