1- Which one of the following component causes contact dermatitis in children? a- Citric acid b- Cinnamon c-poison ivy d- ...

(name of very strange tree which is very unrecognizable) Causes The causes of contact dermatitis are innumerable and increase daily. The items listed below are some of the more common causes and may help expand the list of possible etiologies, which might need to be researched. Items identified in the history can be further researched either in the medical literature or in one of the extensive textbooks on contact dermatitis. Irritant contact dermatitis o Irritant contact dermatitis is a direct local cytotoxic effect of an irritant on the cells of the epidermis, with a subsequent inflammatory response in the dermis. o Examples of irritants include acids; alkalis (eg, sodium, potassium, ammonium, calcium hydroxide compounds), which are frequently associated with hand eczemas following exposure to soaps, detergents, bleaches, ammonia preparations, lye, drain pipe cleaners, toilet bowl cleaners, or oven cleansers; bromine and chlorine, which are commonly used in hot tubs and swimming pools; and hydrocarbons such as crude petroleum, lubricating oils, and cutting oils. Longterm exposure may cause pruritus, folliculitis, calcifications, or acneiform eruptions. Creosote, asphalt, and other tar products may result in melanoderma. Creosote is a contact irritant, sensitizer, and photosensitizer. o Irritant dermatitis from plants usually occurs after exposure to a particular part of the plant, and the degree of toxicity may vary with the season, type of exposure, stage of maturity of the plant, and locality. o The spurge plant family includes the most plants capable of producing irritant contact dermatitis and includes the poinsettia, crown-of-thorns, candelabra cactus, and pencil tree. These plants contain a highly irritating white milky sap that may cause erythema, desquamation, and bulla formation. Calcium oxalate is an irritant found in a number of plants, including Dieffenbachia, daffodils, hyacinths, and pineapples. Allergic contact dermatitis o This type of dermatitis is an acquired type IV hypersensitivity response generated after exposure to an allergen. o Causes include plants of the family Anacardiaceae (eg, poison ivy, poison oak, poison sumac, mango), nickel sulfate (eg, earrings, buckles, zippers, buttons, metal clips, various metal alloys), potassium dichromate (eg, cements, household cleansers, leather, some matches, paints, antirust products), formaldehyde (common preservative in creams), ethylenediamine (eg, dyes, medications), mercaptobenzothiazole (eg, rubber), thiram (eg, fungicides), and paraphenylenediamine (PPD) (eg, hair dyes, photographic chemicals, "black" Henna tattoos). Henna extract has long been used as a stain or dye that produces a temporary tattoo when applied to the skin. Sensitivity to ordinary henna tattoos that are brown in color is rare. However, PPD may be added to henna extract to darken the tattoo and reduce fixation time. PPD in the black henna tattoo mixture is at a significantly higher concentration than is found in commercial hair dye preparations and can induce severe sensitivity to PPD and severe allergic reactions. o In almost all studies, nickel is the most common allergen and is even more common in females. Depending on the study population, the most common allergens

following nickel are fragrance mix, rubber accelerators, thimerosal, paraphenylenediamine, cobalt, lanolin, and neomycin. o Allergic reaction to topical steroids used to treat eczema is not rare. As with any topical therapy, it may initially be soothing, but if the eczema continues to worsen, the patient may have developed a sensitivity to the active ingredient or a preservative. In patients suspected of having corticosteroid allergy, patch testing confirms allergy in 10%. o As mentioned above, harsh soaps most commonly cause an irritant reaction, but allergic reactions to perfumes, dyes, lanolin, deodorants, or antiperspirants can occur. Allergic plant dermatitis o The family Anacardiaceae, which includes poison ivy, probably accounts for more cases of allergic contact dermatitis than all other plant families combined. The antigen in these plants is in an oleoresin known as urushiol (you-ROO-shee-ol). o In poison ivy and poison oak, the antigen in urushiol is pentadecylcatechol. Slight molecular variations in catechols may result in large variations in the degree of antigenicity. Poison ivy and poison oak sap contains a near maximal percentage of the most allergenic catechols. o Uninjured plants do not induce dermatitis. The plant must be injured or bruised before the oleoresin containing the urushiol can contact the skin. Smoke from burning plants may cause a severe dermatitis. All parts of the plant are antigenic, and under controlled conditions, more than 70% of the population in the United States reacts to the urushiol in poison ivy and oak. o The plant family Anacardiaceae contains other species that also contain urushiol and cross-react with poison ivy. Mango contact dermatitis develops most commonly in the perioral region and on the hands and results from exposure to the peel, not the juice. Poison sumac is highly antigenic, resulting in severe contact dermatitis in sensitized patients. Photo contact dermatitis o Symptoms occur as a result of direct exposure of skin to a photosensitizing agent followed by direct sun exposure. o Many plants are known to cause a phototoxic response. These include the citrus family (eg, limes), the mulberry family (eg, figs), and the Umbelliferae family (eg, parsnip, celery). Lime juice exposure is most common when limes are squeezed into beverages. Excess juice dribbles down the arm or neck. Sun exposure of this lime juice produces linear streaks of dermatitis or hyperpigmentation. Perfumes also are common sources of photo contact dermatitis. Contact urticaria o Agents that can produce allergic contact urticaria include silk, wool, rubber, animal hair, dander, saliva, serum, seminal fluid, cockroaches, moths, insect stings, milk, eggs, fish, meat, fruits, potatoes, beer, penicillin, neomycin, nickel, formaldehyde, and rubber. o Contact urticaria from rubber occurs almost exclusively from the use of rubber gloves. Nonimmunologic contact urticaria results in local edema and erythema. It is more common than the immunologic mechanism. o Agents that produce nonimmunologic contact urticaria include jellyfish; Portuguese man-of-war; balsam of Peru; caterpillar hair; moths; insect stings; benzoic, sorbic, cinnamic, or nicotinic acid; and nettles (plants). In one report, 18 out of 20 children aged 1-4 years developed perioral contact urticaria after smearing food around their mouths.7 This was traced to sorbic acid and benzoic acid in a salad dressing.

Contact urticaria must be distinguished from environmentally associated urticaria, including cold urticaria, cholinergic urticaria, dermatographism, pressure urticaria, aquagenic pruritus, aquagenic urticaria, solar urticaria, heat urticaria, papular urticaria, and exercise-induced urticaria. Contact reactions to pharmacologically active agents: Most of these reactions are produced by plants in the family Urticaceae (eg, stinging nettles). 2- Hirsutism associated with which of the following? a. Anorexia b.Juvenile hypothyroidism c. Digoxin Toxicity d. C/o citrate?? Hirsutism is a human hair growth and development disorder that affects approximately 5 percent to 15 percent women. Its main signs are dense, coarse and excess hair growth in a male-like pattern in various body parts of women, like in the face, neck, chest, lower abdomen etc. At least 5 percent of women of reproductive age suffer from this ailment. Hirsutism is the cause of substantial social and psychological agony, apart from the associated ailments and risks. Drug induced hirsutism is a rare cause and other causes of this disease must be ruled out before it is confirmed. First let us check out the three sets of causes of hirsutism to understand the drug induced type better: 1. Androgenic causes. 2. Idiopathic hirsutism. 3. Nonandrogenic factors are the ones that are not related to disproportionate androgen activity. Under this category comes the drug induced type of hirsutism. Androgenic causes: They are mainly a result of androgen excess disorder, since this hormone plays a vital role in the production and development of human hair. Among the androgenic causes, the Polycystic Ovarian Syndrome (PCOS) is the most common and accounts for 7080% of hirsute cases. The rarer syndromes and their percentage of prevalence are as below: Hyperandrogenism - 6.8% Hypothyroidism - 0.7% The hyperandrogenic insulin-resistant acanthosis nigricans syndrome (HAIR-AN) 3% 21-hydroxylase non-classic I adrenal hyperplasia (late-onset CAH) - 1.6% 21-hydroxylase-deficient congenital adrenal hyperplasia - 0.7% Hyperprolactinemia - 0.3% Androgenic tumors - 0.2% Cushings syndrome - 0-1% Idiopathic hirsutism: The idiopathic cause is traced in 4.7 percent patients and its associated symptoms are hirsutism and probable overactive 5a-reductase action in skin and hair follicle. However, menses are regular. Non-androgenic causes: They are less prevalent and can be divided in the following forms: 1. Unnecessary hair growth of acromegalics. 2. Coarsening of the hairs associated with chronic skin problems, since a major function of the hair is to protect the skin 3. Non-androgenic anabolic drugs often cause a general increase of many tissues, particularly hair. This can also result in vellus hypertrichosis and not hirsutism. To evaluate this cause a detailed drug history must be conducted. The process must include clinical investigations about the use of the following drugs (exogenous pharmacologic agents) that cause hirsutism as a probable side effect: Danazol (Danocrine) Norplant Metoclopramide (Reglan) Anabolic steroids
o

Methyldopa (Aldomet) Phenothiazines Progestins Reserpine (Serpasil) Testosterone Oral contraceptives (OCs) that contain levonorgestrel, norethindrone and norgestrel induce more powerful androgen activity, while those that include ethynodiol diacetate, norgestimate and desogestrel have lesser androgenic activity. Some drugs that also result in hyperprolactinemia can also cause hirsutism. However, one must exclude the possibility of vellus hypertrichosis, that is also often medication related, before confirming a case of drug induced hirsutism. 3- A 70-year-old patient presented with a skin lesion in the left thigh for many years. This lesion is black, size lx1 cm. It started to be more pigmented with bleeding. You will advice: A. Cryotherapy. B. Incisional biopsy. C. Wide excision. D. Immunotherapy. E. Radiotherapy.

WARNING SIGNS OF MELANOMA A common warning sign of melanoma is change. Melanoma often begins in or near an existing mole. A change to the shape, color, or diameter of a mole can be a warning sign of melanoma. Other changes that could indicate melanoma include a mole that becomes painful, or begins to bleed or itch. DIAGNOSIS AND TREATMENT Diagnosis begins with the dermatologist examining the suspicious lesion. If this visual examination leads the dermatologist to suspect melanoma or another type of skin cancer, the dermatologist will perform a biopsy. This is the only way to know with certainty if the lesion is melanoma or another type of skin cancer. A biopsy is a simple procedure that a dermatologist can perform in the office. To perform a biopsy, a dermatologist will numb the area and remove the entire lesion, or a portion of it, so that the tissue can be examined under a microscope. If melanoma cells are visible under the microscope, the diagnosis is melanoma. 14) You have received the computed tomography (CT) scan report on a 34-year-old mother of three who had a malignant melanoma removed 3 years ago. Originally, it was a Clerks level I and the prognosis was excellent. The patient came to your office 1 week ago complaining of chest pain and abdominal pain. A CT scan of the chest and abdomen revealed metastatic lesions throughout the lungs and the abdomen. She is in your office, and you have to deliver the bad news of the significant spread of the cancer. The FIRST step in breaking news is to: A. Deliver the news all in one blow and get it over with as quickly as is humanly possible. B. Fire a warning shot that some bad news is coming. C. Find out how must the patient knows. D. Find out how much the patient wants to know it. E. Tell the patient not to worry. 37- 42years old male presented with history of sudden appearance of rash maculopapular rash including the sole,& the palm, the most likely diagnosis is : a- syphilis b- erethyma nodosum c- erythema marginatum

d- pitryasis rocae e- drug induced 13. Most common association with acanthosis negricans (one): hodgkin lymphoma. non-hodgkin lymphoma. internal malignancy. DM. insulin resistance. Acanthosis nigricans is divided into 2 broad categories, benign and malignant. Patients with the benign form of acanthosis nigricans experience very few, if any, complications of their skin lesions. However, many of these patients have an underlying insulin-resistant state that is the cause of their acanthosis nigricans. The severity of the insulin resistance is highly variable and ranges from an incidental finding after routine blood studies to overt diabetes mellitus. The severity of skin findings may parallel the degree of insulin resistance, and a partial resolution may occur with treatment of the insulin-resistant state. Insulin resistance is the most common association of acanthosis nigricans in the younger age population. Malignant acanthosis nigricans is associated with significant complications because the underlying malignancy is often an aggressive tumor. Average survival time of patients with signs of malignant acanthosis nigricans is 2 years, although cases in which patients have survived for up to 12 years have been reported. In older patients with new-onset acanthosis nigricans, most have an associated internal malignancy. 14. Xanthoma: on lateral aspect of the upper eyelid. hard plaque. around arterioles. is not related to hyperlipidemia. deposited in dermis. xanthoma a papule, nodule or plaque in the skin due to lipid deposits; the color of a xanthoma is usually yellow, but may be brown, reddish, or cream. Microscopically, the lesions show light cells with foamy protoplasm (foam cells, xanthoma cells). They occur most commonly in White Leghorn chickens and rarely in other species. The formation of xanthomas may indicate an underlying disease, usually related to abnormal metabolism of lipids, including cholesterol. In reptiles they are associated with high cholesterol diets. Xanthelasma palpebrarum is the most common of the xanthomas. The lesions are asymptomatic and usually bilateral and symmetric. The lesions are soft, velvety, yellow, flat, polygonal papules around the eyelids. Xanthelasmas are most common in the upper eyelid near the inner canthus. Usually, the lesions have evolved for several months and enlarged slowly from a small papule. Xanthelasma may be associated with hyperlipidemia. When associated with hyperlipidemia, any type of primary hyperlipoproteinemia can be present. Some secondary hyperlipoproteinemias, such as cholestasis, may also be associated with xanthelasmas.

Xanthelasma. Courtesy of Duke University Medical Center. Tuberous xanthomas are firm, painless, red-yellow nodules (see Media File 3). The lesions can coalesce to form multilobated tumors. Tuberous xanthomas usually develop in pressure areas, such as the extensor surfaces of the knees, the elbows, and the buttocks. Tuberous xanthomas are particularly associated with hypercholesterolemia and increased levels of LDL. They can be associated with familial dysbetalipoproteinemia and familial hypercholesterolemia, and they may be present in some of the secondary hyperlipidemias (eg, nephrotic syndrome, hypothyroidism).

Tuberous xanthomas. Courtesy of Duke University Medical Center. Tendinous xanthomas appear as slowly enlarging subcutaneous nodules related to the tendons or the ligaments. The most common locations are the extensor tendons of the hands, the feet, and the Achilles tendons. The lesions are often related to trauma. Tendinous xanthomas are associated with severe hypercholesterolemia and elevated LDL levels, particularly in the type IIa form. They can also be associated with some of the secondary hyperlipidemias, such as cholestasis. Eruptive xanthomas most commonly arise over the buttocks, the shoulders, and the extensor surfaces of the extremities. Rarely, the oral mucosa or the face may be affected. The lesions typically erupt as crops of small, red-yellow papules on an erythematous base (see Media File 2), and they may spontaneously resolve over weeks. Pruritus is common, and the lesions may be tender. Eruptive xanthomas are associated with hypertriglyceridemia, particularly that associated with types I, IV, and V (high concentrations of VLDL and chylomicrons). They may also appear in secondary hyperlipidemias, particularly in diabetes.2

Eruptive xanthomas. Courtesy of Duke University Medical Center. Plane xanthomas are mostly macular and rarely form elevated lesions. They can occur in any site. Involvement of the palmar creases is characteristic of type III dysbetalipoproteinemia. They can also be associated with secondary hyperlipidemias, especially in cholestasis. Generalized plane xanthomas can cover large areas of the face, the neck, and the thorax, and the flexures can also be involved. They may be associated with monoclonal gammopathy and hyperlipidemia, particularly hypertriglyceridemia. Xanthoma disseminatum and verruciform xanthoma are particular forms of xanthomas that occur in normolipemic patients.3 Xanthoma disseminatum develops in adults as red-yellow papules and nodules with a predilection for the flexures. Characteristically, the mucosa of the upper part of the aerodigestive tract is involved. It has a benign clinical course and usually resolves spontaneously. Verruciform xanthoma predominantly occurs in the oral cavity of adults as a single papillomatous yellow lesion. Verruciform xanthoma is considered to be a reactive condition with benign behavior, and it is treated with local excision.

Causes 26. A middle aged man having black spots on his thigh for years, it is starting to become more black with bloody discharge, the best management is to: wide excision. incisional Bx. cryotherapy. radiotherapy. immunotherapy. 2- 45 y.o man, sudden eruption all over the body with palm and foot involvement. Most likely Dx is: a. Syphilis b. Erythema multiforme most probably c. Erythema nodosum d. Fixed drug eruption ?? e. Pityriasis rosea Erythema multiforme o Sudden onset of rapidly progressive, symmetrical, and cutaneous and/or mucocutaneous lesions, with concentric color changes in some or all lesions o Centripetal spread o Burning sensation in affected areas o Pruritus generally absent o Nonspecific prodromal symptoms suggestive of a viral syndrome in at least 50% of cases, usually 1-14 days before skin lesions develop. Symptoms may include fever, malaise, myalgias, arthralgias, headache, sore throat, cough, nausea, vomiting, and diarrhea. SJS/TEN o Generalized cutaneous and/or mucocutaneous lesions with blisters o May include symptoms of fever, malaise, myalgias, arthralgias, headache, sore throat, cough, nausea, vomiting, and diarrhea o Oral pain, which may be severe enough to result in difficulty eating, drinking, or opening the mouth o Eye pain, edema, and drainage o Breathing difficulty resulting from tracheobronchial involvement o Dysuria Physical Erythema multiforme o Symmetrically distributed, erythematous, expanding macules or papules evolve into classic iris or target lesions, with bright red borders and central petechiae, vesicles, or purpura. o Lesions may coalesce and become generalized. o Vesiculobullous lesions develop within preexisting macules, papules, or wheals. o Rash favors palms and soles, dorsum of the hands, and extensor surfaces of extremities and face. o Postinflammatory hyperpigmentation or hypopigmentation may occur. o Eye involvement occurs in 10% of EM cases, mostly bilateral purulent conjunctivitis with increased lacrimation. o Mucous membrane blistering occurs in about 25% of cases of EM, is usually mild, and typically involves the oral cavity. SJS/TEN

Fever is common. Skin findings may be similar to EM but often are more variable and severe. Inflammatory vesiculobullous lesions, often with hemorrhage and necrosis, are typical. Fixed macules and target lesions may be larger and more confluent than in EM. o Facial edema or central facial involvement o Mucous membranes are strongly affected, most commonly mouth, lips, and bulbar conjunctivae; less often, anogenital mucosae are affected. Lips may be edematous, bloody, or crusted. A minimum of 2 mucosal surfaces must be involved; 3 mucosal surfaces are involved in about 40% of cases. o Blisters or epidermal detachment less than 10% BSA for SJS and more than 30% for TEN; the outer layer of the epidermis separates readily from the basal layer with lateral pressure (positive Nikolsky sign). o Bullae and shallow ulcers resembling aphthous ulcers are common. When bullae rupture, mucosal lesions become deeply erythematous erosions, often covered by gray pseudomembranous exudates. o Salivation often is increased. o Nasopharynx, respiratory tract, GI tract, and genitourinary (GU) tract are sometimes affected. o Genital involvement consists of hemorrhagic, bullous inflammation; urinary retention and phimosis may occur. o Eye involvement occurs in approximately 85% of cases. These range from hyperemia to extensive pseudomembrane formation. Synechiae between eyelid and conjunctiva often occurs. Keratitis and corneal erosions are less frequent.
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17-A 12 yr old female, non pruritic annular eruption in the it foot for 8 months, looks pale and not scaling. Had no response to 6 wks of miconazole. a. Discoid lupus erythramatosis d. Granulomatous annulare b. Erythema nodosum e. Choricum marginatum c. Tinea corporis Granuloma annulare (GA) is a benign inflammatory dermatosis. Granuloma annulare is relatively common disease that occurs in all age groups, but it is rare in infancy. Granuloma annulare is characterized clinically by dermal papules and annular plaques. The precise cause of granuloma annulare is unknown. Histological examination reveals foci of degenerative collagen associated with palisaded granulomatous inflammation. The following clinical variants are recognized: Localized granuloma annulare: This is the most common form. Localized granuloma annulare is characterized by skin-colored to violaceous lesions up to 5 cm in diameter. Usually, the epidermis has attenuated surface markings. Annular rings with solitary firm papules or nodules may be present. Localized granuloma annulare has a predilection for the feet, ankles, lower limbs, and wrists. Generalized granuloma annulare: This form occurs predominantly in adults. The trunk is usually involved, as well as the neck, extremities, face, scalp, palms, and soles. Lesions range from widespread papules to annular plaques to large, discolored patches with a variety of coloration from yellow to violaceous. Subcutaneous granuloma annulare1,2 : This form occurs predominantly in children. Subcutaneous granuloma annulare is characterized by firm or hard asymptomatic nodules in the deep dermis or subcutaneous tissues, with individual lesions measuring from 5 mm to 4 cm in diameter. They are prevalent on the anterotibial plateau, ankles, dorsal feet, buttocks, hands, scalp, and eyelids.

Perforating granuloma annulare3 : This form is very rare. Perforating granuloma annulare is usually localized to the dorsal hands and fingers or may be generalized on the trunk and extremities. A variety of superficial umbilicated papules develop, with or without a discharge, that heal with scarring. Arcuate dermal erythema: This is an uncommon form of granuloma annulare that manifests as infiltrated erythematous patches that may form large, hyperpigmented rings with central .

Pathophysiology Proposed pathogenic mechanisms for granuloma annulare include cell-mediated immunity (type IV), immune complex vasculitis, and an abnormality of tissue monocytes. Some other possible mechanisms include primary degeneration of connective tissue leading to granulomatous inflammation, lymphocyte-mediated immune reaction with macrophage activation, and cytokinemediated degradation of connective tissue. Frequency The frequency of granuloma annulare is in the general population is unknown. Granuloma annulare does not favor a particular race, ethnic group, or geographical area. Localized granuloma annulare is the most common among the various subtypes. Of all patients with granuloma annulare, 9-15% have the generalized variant. Perforating granuloma annulare has been reported to have a prevalence of 5% among granuloma annulare subtypes; further, reports suggest that this variant may be more common in the Hawaiian Islands. Mortality/Morbidity Most cases of granuloma annulare resolve without adverse medical sequelae. Sex Women are affected by granuloma annulare twice as often as men. Age Localized granuloma annulare is most commonly found in children and in adults younger than 30 years. Generalized granuloma annulare demonstrates a bimodal age distribution, occurring in patients younger than 10 years and in patients aged 30-60 years. Although subcutaneous granuloma annulare can occur in adults, it is predominantly a disease of otherwise healthy children, who are typically aged 2-10 years. Similarly, perforating granuloma annulare most often affects children. Medical Care Localized granuloma annulare Localized granuloma annulare (GA) is not often symptomatic and it has a tendency towards spontaneous resolution. Reassurance is often all that is necessary. Painful or disfiguring lesions have been treated by various methods, although the level of evidence supporting these methods is low. Localized lesions have been treated with potent topical corticosteroids with or without occlusion for 4-6 weeks, as well as with intralesional corticosteroids with varying total doses of steroid. Cryotherapy using liquid nitrogen or nitrous oxide as refrigerants has been shown in a prospective, uncontrolled trial to be an effective treatment for localized granuloma annulare. Secondary dyschromia may be a complication of cryotherapy.11 Other anecdotes of therapeutic efficacy in both localized and generalized granuloma annulare involve tacrolimus and pimecrolimus12,13,14 and imiquimod cream.15,16

Generalized granuloma annulare Generalized granuloma annulare tends to be more persistent and unsightly. Treatment of the generalized disease is unfortunately fraught with a lack of consistently effective options. While the treatment of choice remains to be defined, the available literature supports the use of isotretinoin or phototherapy with oral psoralen and UV-A (PUVA) as first-line options for generalized granuloma annulare.17,18 Piaserico et al report successful therapy for long-standing generalized granuloma annulare using methyl aminolevulinate photodynamic therapy.19 Weisenseel et al reported moderate success with photodynamic therapy using 20% 5-aminolevulinic acid (ALA) gel.20 Marcus et al report on 6 patients with granuloma annulare that was refractory to standard treatment. The patients were treated with monthly combination therapy including rifampin at 600 mg, ofloxacin at 400 mg, and minocycline hydrochloride at 100 mg monthly for 3 months. Three to 5 months after the initiation of treatment, the plaques were cleared completely. Postinflammatory hyperpigmentation was reported by some patients. Although the treatment was successful, the authors suggested further studies may be needed to confirm this combination therapy as a successful option for recalcitrant granuloma annulare.21 Other anecdotal reports and small series describe successful treatment with dapsone, systemic steroids, pentoxifylline, hydroxychloroquine, cyclosporine, fumaric esters, interferon-gamma, potassium iodide, nicotinamide, etanercept, infliximab, adalimumab, and efalizumab.22,23 ng. 11- Female pt developed lesions on the cheeck & nose and diagnosed as Rosacea. Rx is: a) Amoxacillin b) Tetracycline Rosacea is a common condition characterized by symptoms of facial flushing and a spectrum of clinical signs, including erythema, telangiectasia, coarseness of skin, and an inflammatory papulopustular eruption resembling acne. 36.Cellulitis oc Treatment Medical Care Before the initiation of therapy, the triggering factors that exacerbate the patient's rosacea should be identified and avoided if possible. These factors may be unique to each individual patient. Common triggering factors include hot or cold temperatures, wind, hot drinks, caffeine, exercise, spicy food, alcohol, emotions, topical products that irritate the skin and decrease the barrier, or medications that cause flushing.9,10 Some patients find that regular facial massage reduces lymphedema. Rosacea fulminans is treated with moderately high doses of prednisolone (30-60 mg/d) followed by oral isotretinoin. Sunscreen11 The use of daily broad-spectrum sunscreen is recommended for all patients with rosacea. A sunscreen that protects against both UV-A and UV-B light should be selected. Physical blockers such as titanium dioxide and zinc oxide are well tolerated. Additionally, the sunscreen should contain protective silicones such as dimethicone or cyclomethicone. Green-tinted sunscreens can provide coverage of the erythema. The patient is encouraged to avoid astringents, toners, menthols, camphor, waterproof cosmetics requiring solvents for removal, or products containing sodium lauryl sulfate. Laser12

Nonablative laser is effective against rosacea by remodeling of the dermal connective tissue and improving the epidermal barrier. The major disadvantage of this therapy is its cost because it is not covered by insurance. It requires 1-3 treatments 4-8 weeks apart to achieve the best results. Vascular lasers are the mainstay of rosacea therapy. These include pulsed dye laser (585 or 595 nm), the potassium-titanyl-phosphate laser (532 nm), and the diode-pumped frequency-doubled laser (532 nm). These wavelengths allow selective absorption by oxyhemoglobin, leading to vessel reduction with minimal damage to surrounding tissue or scarring. To be effective against deeper facial vessels, longer wavelengths of lasers are required, including the diode laser (810 nm), the long-pulsed Alexandrite laser (755 nm), and the long-pulsed Nd:YAG laser (1064 nm). Intense pulsed-light therapy is a multichromatic laser with different targets, including melanin and hemoglobin. Therefore, it is also useful for facial rejuvenation, affecting vascular lesions, pigmented lesions, and hair. Surgical Care Permanent telangiectasia may be treated by electrosurgery or the 585-nm pulsed dye laser. However, facial erythema is not improved, and new telangiectasias develop with the passage of time. Cosmetic improvement of rhinophyma may be produced by mechanical dermabrasion, carbon dioxide laser peel, and surgical shave techniques. Diet Dietary modulation should aim at avoidance of triggers. Medication The goals of pharmacotherapy are to reduce morbidity and prevent complications. Topical metronidazole is commonly used as a first-line agent. Topical azelaic acid, sulfacetamide products, and topical acne medications are also commonly used. Retinoids are advocated by some authorities.13,14,15 In addition to the agents listed below, anecdotal evidence indicates effective treatment of rosacea with medications that reduce flushing, including beta-blockers, clonidine, naloxone, ondansetron, and selective serotonin reuptake inhibitors. Oral contraceptive therapy has been helpful in patients who provide historical information of worsening rosacea with their hormonal cycle. Dapsone has been used in severe, refractory rosacea, and dapsone has been particularly beneficial for patients who cannot take isotretinoin.16 Immunosuppressants These agents inhibit immune reactions resulting from diverse stimuli.17 Tacrolimus (Protopic) ointment 0.1% or 0.03% Mechanism of action in atopic dermatitis not known. Reduces itching and inflammation by suppressing release of cytokines from T cells. Also inhibits transcription of genes encoding IL-3, IL-4, IL-5, GM-CSF, and TNF-alpha, all of which are involved in early stages of T-cell activation. Additionally, may inhibit release of preformed mediators from skin mast cells and basophils, and may down-regulate expression of FCeRI on Langerhans cells. Can be used in patients as young as 2 y. Drugs of this class are more expensive than topical corticosteroids. Available as ointment in concentrations of 0.03% and 0.1%. Indicated only after other treatment options have failed. Dosing Interactions Contraindications Precautions Adult Apply thin layer to affected skin areas bid. Pediatric

<2 years: Not established 2-15 years: Apply 0.03% ointment bid to affected area(s) >15 years: Administer as adults Short-term and intermittent use only Dosing Interactions Contraindications Precautions None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity to tacrolimus or components of ointment Dosing Interactions Contraindications Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Patients may experience a burning sensation during first few days of application; may cause rosacealike eruption, and patients must be monitored; skin can become photosensitive, and patients should be cautioned about exposure to direct or artificial sunlight and to use sunscreen; safety and efficacy in infected atopic dermatitis is not known; application under occlusion, which may promote systemic exposure, has not been evaluated (do not use with occlusive dressings) Absorption following topical applications is minimal (relative to systemic administration), but tacrolimus is excreted in human milk and, thus, a decision should be made whether to discontinue nursing or to discontinue drug, taking into account importance of drug to mother (potential for serious adverse reactions in nursing infants should also be a concern) Caution with conditions that suppress immune system (eg, AIDS, cancer); possible risk of lymph node or skin cancer based on animal studies and a small number of patients; may increase risk of viral infections; other adverse effects include headache, sore throat, flulike symptoms, fever, and cough Antibiotics Since the 1950s, oral antibiotics have been prescribed off label for treatment because microorganisms were thought to be the underlying cause of disease. In current practice, experts do not believe bacterial infection plays a part in the pathogenesis of rosacea; however, the observed clinical benefits of oral antibiotics have allowed this treatment option to remain in favor for both physicians and patients. Since 2006, nonantibiotic dosing of doxycycline has become first-line treatment for many clinicians. In many cases, oral and topical antibiotics are used in combination; the oral treatment is eventually withdrawn and the topical treatment is used alone as maintenance therapy.16 Azithromycin (Zithromax) Semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl tRNA from ribosomes, causing bacterial growth inhibition. Dosing Interactions Contraindications

Precautions

Adult 500 mg PO on day 1, followed by 250 mg PO qd for next 4 d Pediatric Not established Dosing Interactions Contraindications Precautions Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, and HMG-CoA reductase inhibitors Plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increases in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents; decreases metabolism of repaglinide, thus increasing serum levels and effects Dosing Interactions Contraindications Precautions Documented hypersensitivity; coadministration of pimozide; hepatic impairment Dosing Interactions Contraindications Precautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals Metronidazole gel 0.75% or 1% (MetroGel, Noritate, Flagyl, Protostat) Imidazole ringbased antibiotic active against various anaerobic bacteria and protozoa. Oral metronidazole has been shown to be beneficial against papules and pustules of acne rosacea. Topical applications are helpful for mild disease and as an adjuvant to systemic therapy. Dosing Interactions Contraindications Precautions Adult Oral: 200 mg bid Topical: Wash affected area and apply a thin film to affected area bid Pediatric Oral: 15-35 mg/kg/d divided q8h Topical: Apply as in adults Dosing Interactions Contraindications Precautions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy; gel dosage form is for external use only; do not apply directly to eyes Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab) tab or 2% topical solution Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose. Can be used when tetracyclines are not tolerated or are contraindicated. Used for the treatment of ocular rosacea. Dosing Interactions Contraindications Precautions Adult Oral: 500 mg bid Topical: Apply to affected area bid for 2 wk Pediatric Oral: 30-50 mg/kg/d divided qid Topical: Apply as in adults Dosing Interactions Contraindications Precautions None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions

Discontinue if irritation or sensitivity occurs Fusidic acid (Fucithalmic) Ophthalmic susp as 10 mg/g (1%) (0.2 g) unit-dose, without preservative; 3 g and 5 g in multidose contains benzalkonium chloride. For the treatment of ocular rosacea. Topical antibacterial that inhibits bacterial protein synthesis, causing bacterial death. Rosacea may respond to topical fusidic acid for at least 3 mo. Dosing Interactions Contraindications Precautions Adult Apply to affected area bid for 2 wk Pediatric Apply as in adults Dosing Interactions Contraindications Precautions None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Discontinue if irritation or sensitivity occur Clindamycin lotion or gel 1% Semisynthetic antibiotic produced by 7(S)-chloro substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in body without penetration of CNS. Protein bound and excreted by liver and kidneys. Upon application to skin, drug is converted to active component, which inhibits the microorganism. Available as topical solution, lotion, or gel for external use. Solution contains equivalent of 10 mg/mL clindamycin. Effective against mild-to-moderate papulopustular rosacea. Dosing Interactions Contraindications Precautions Adult Apply to affected area qd Pediatric Apply as in adults Dosing

Interactions Contraindications Precautions

None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Prolonged use may result in overgrowth of nonsusceptible organisms (eg, fungi); discontinue use if superinfection occurs

Tetracycline (Sumycin) Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Improvement is evident within 2-4 mo after commencement of therapy. Dosing Interactions Contraindications Precautions Adult 250 mg PO qd to 500 mg PO tid Pediatric <8 years: Not recommended >8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid Dosing Interactions Contraindications Precautions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants Dosing Interactions Contraindications Precautions Documented hypersensitivity; severe hepatic dysfunction Dosing Interactions Contraindications Precautions Pregnancy D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines Minocycline (Dynacin, Minocin) Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma. Dosing Interactions Contraindications Precautions Adult 50-100 mg PO qd/bid Pediatric <8 years: Not recommended >8 years: 4 mg/kg PO initially, followed by 2 mg/kg q12h Dosing Interactions Contraindications Precautions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants Dosing Interactions Contraindications Precautions Documented hypersensitivity; severe hepatic dysfunction Dosing Interactions Contraindications Precautions Pregnancy D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur Doxycycline (Oracea, Bio-Tab, Doryx, Periostat, Vibramycin) Broad-spectrum, synthetically derived, bacteriostatic antibiotic in tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations. Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Dosing Interactions Contraindications Precautions

Adult 40-100 mg PO qd/bid Pediatric <8 years: Not recommended >8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d Dosing Interactions Contraindications Precautions Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants. Dosing Interactions Contraindications Precautions Documented hypersensitivity; severe hepatic dysfunction Dosing Interactions Contraindications Precautions Pregnancy D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus Precautions Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines Clarithromycin (Biaxin) Semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl tRNA from ribosomes, causing bacterial growth inhibition. Dosing Interactions Contraindications Precautions Adult 250 mg PO bid Pediatric Not established Dosing Interactions Contraindications Precautions Coadministration with pimozide, cisapride, or moxifloxacin may increase risk of malignant arrhythmias; toxicity increases with coadministration of fluconazole or pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, and HMG-CoA reductase inhibitors Plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increases in QTc intervals occur with disopyramide; coadministration with omeprazole may

increase plasma levels of both agents; decreases metabolism of repaglinide, thus increasing serum levels and effects Dosing Interactions Contraindications Precautions Documented hypersensitivity; coadministration with pimozide, ergot derivatives, or cisapride Dosing Interactions Contraindications Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzyme levels and cholestatic jaundice; caution in patients with prolonged QT intervals or pneumonia; give half dose or increase dosing interval if CrCl <30 mL/min; caution in hospitalized, geriatric, or debilitated patients Retinoids These agents decrease the cohesiveness of abnormal hyperproliferative keratinocytes and may reduce the potential for malignant degeneration. They modulate keratinocyte differentiation, and they have been shown to reduce the risk of skin cancer formation in patients who have undergone renal transplantation. Tretinoin (Avita, Retin-A, Retin-A Micro) Structurally related to vitamin A. May be helpful for recalcitrant disease, but recurrence is common. Long-term, low-dose therapy may be suitable for selected patients. May cause skin irritation in some patients. Has been linked to promotion of angiogenesis; however, has not demonstrated increased telangiectasias. Inhibits microcomedo formation and eliminates lesions. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels. Dosing Interactions Contraindications Precautions Adult Begin with lowest concentration and increase as tolerated; apply hs or qod; lower frequency of application if irritation develops Pediatric <12 years: Not established >12 years: Apply as in adults Dosing Interactions Contraindications Precautions Toxicity may occur with vitamin A coadministration; toxicity increased when coadministered with sulfur, benzoyl peroxide, resorcinol, or any product with strong drying effects; phototoxicity increased when coadministered with tetracyclines, fluoroquinolones, or thiazides Dosing Interactions

Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Photosensitivity may occur with excessive sunlight exposure; burning, stinging, peeling, pruritus, or erythema has been reported at site of application; caution with eczema (may cause severe irritation); avoid contact with mucous membranes, mouth, and angles of nose

Isotretinoin (Accutane) Oral agent that treats serious dermatologic conditions. Synthetic 13-cis isomer of naturally occurring tretinoin (trans -retinoic acid). May be helpful for recalcitrant disease, but recurrence is common. Long-term, low-dose therapy may be suitable for selected patients. A US Food and Drug Administrationmandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy. Dosing Interactions Contraindications Precautions Adult 0.5-1 mg/kg/d PO divided bid for 4 mo Pediatric Not established Dosing Interactions Contraindications Precautions Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; may reduce plasma levels of carbamazepine and contraceptive efficacy Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy X - Contraindicated; benefit does not outweigh risk Precautions May decrease night vision; inflammatory bowel disease may occur; may be associated with development of hepatitis; occasional exaggerated healing response of acne lesions (excessive

granulation with crusting) may occur Diabetes patients may experience problems in controlling blood glucose while on isotretinoin; avoid exposure to UV light or sunlight until tolerance achieved; discontinue treatment if rectal bleeding, abdominal pain, or severe diarrhea occur Mood swings or depression may occur; caution if history of depression Corticosteroids These agents are relatively contraindicated, except as a short course in rosacea fulminans. Prednisolone (AK-Pred, Delta-Cortef, Articulose-50, Econopred) Moderately high doses may be helpful in rosacea fulminans. Decreases inflammation by suppressing migration of PMN leukocytes and reducing capillary permeability. Use in combination with isotretinoin. Rosacea fulminans is treated with moderately high doses of prednisolone (30-60 mg/d) followed by oral isotretinoin. Dosing Interactions Contraindications Precautions Adult 30-60 mg PO qd Pediatric 0.1-2 mg/kg/d PO qd or divided tid/qid Dosing Interactions Contraindications Precautions Decreases effects of salicylates and toxoids (for immunizations); phenytoin, carbamazepine, barbiturates, and rifampin decrease effects Dosing Interactions Contraindications Precautions Documented hypersensitivity; viral, fungal, or tubercular skin lesions Dosing Interactions Contraindications Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Caution in hyperthyroidism, osteoporosis, cirrhosis, nonspecific ulcerative colitis, peptic ulcer, diabetes mellitus, and myasthenia gravis Antihypertensive agents Potassium-sparing diuretics can be used to reduce morbidity. Spironolactone (Aldactone) Competes with aldosterone for receptor sites in distal renal tubules, increasing water excretion while retaining potassium and hydrogen ions. Aldosterone inhibitors help block the renin-angiotensin system and help prevent potassium loss in distal tubules. The body conserves potassium, and less oral potassium supplementation is needed. Dosing Interactions

Contraindications Precautions

Adult 50 mg PO qd Pediatric Not established Dosing Interactions Contraindications Precautions May decrease effect of anticoagulants; potassium and potassium-sparing diuretics may increase toxicity of spironolactone Dosing Interactions Contraindications Precautions Documented hypersensitivity; anuria; renal failure; hyperkalemia Dosing Interactions Contraindications Precautions Pregnancy D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus Precautions Caution in renal and hepatic impairment Acne Products Some products in this category can be effective in patients with papules, pustules, and the phymatous and glandular types of rosacea. Benzoyl peroxide (Benoxyl, Benzac, Oxy-5, Fostex) Free-radical oxygen is released upon administration and oxidizes bacterial proteins in sebaceous follicles, decreasing quantity of irritating free fatty acids and of anaerobic bacteria. Converted on skin into benzoic acid, which has keratolytic and comedolytic effects. However, can be quite irritating in patients with barrier dysfunction and can cause further erythema. Available over the counter and by prescription. Available in 2.5%, 5%, and 10% gels, lotions, creams, or washes. Dosing Interactions Contraindications Precautions Adult Apply sparingly qd; gradually increase to bid/tid prn; reduce dose, frequency, or concentration if excessive dryness or peeling occurs Pediatric Not established Dosing Interactions Contraindications Precautions Potentiates adverse effects of tretinoin Dosing Interactions

Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Avoid contact with lips, eyelids, mucous membranes, and eyes; for external use only; discontinue if swelling, burning, or excessive dryness occurs

Azelaic acid (Azelex, Finacea) Available in 2 strengths azelaic acid 15% gel (Finacea) or azelaic acid 20% cream (Azelex). Effective against mild-to-moderate papulopustular rosacea. Can be used twice daily as initial treatment. May reduce production of ROS by neutrophils. Some patients report transient burning or stinging. Dosing Interactions Contraindications Precautions Adult Wash area and apply sparingly bid; duration of use can vary from person to person and depends on severity of acne Pediatric Not established Dosing Interactions Contraindications Precautions None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Avoid contact with eyes; discontinue use if severe irritation develops Sodium sulfacetamide and sulfur (Plexion, Clenia, Rosanil wash, Rosula gel or wash, Rosac cream, Sulfacet-R lotion, Clarifoam EF) Contains 5% sulfur and 10% sodium sulfacetamide. Used topically for acne rosacea. Sodium sulfacetamide has antibacterial properties, whereas sulfur is considered an antiseptic with keratolytic action.

curring about the face in young children (6-24 months) and associated with fever and purple skin discoloration is MOST often caused by: a)group A beta haemolytic streptococci b)heamophilis influenza type B c)slreptococcus pneumoniae d)streptococcus aureus e)pseudomonas The term "cellulitis" is commonly used to indicate a nonnecrotizing inflammation of the dermis and hypodermis related to acute infection that does not involve the fascia or muscles, and that is characterized by localized pain, swelling, tenderness, erythema, and warmth. Pathophysiology Cellulitis usually follows a break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound. Facial cellulitis of odontogenic origin may also occur. Patients with toe web intertrigo and/or tinea pedis and those with lymphatic obstruction, venous insufficiency, pressure ulcers, and obesity are particularly vulnerable to recurrent episodes of cellulitis. Organisms on the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis. The vast majority of cases are caused by Streptococcus pyogenes or Staphylococcus aureus. Occasionally, cellulitis may be caused by the emergence of subjacent osteomyelitis. Cellulitis may rarely result from the metastatic seeding of an organism from a distant focus of infection, especially in immunocompromised individuals. This is particularly common in cellulitis due to Streptococcus pneumoniae and marine vibrios. Neisseria meningitidis, Pseudomonas aeruginosa, Brucella species, and Legionella species have also been reported as rare causes of cellulitis resulting from hematogenous spread.5 Frequency United States Because cellulitis is not a reportable disease, the exact prevalence is uncertain; however, it is a relatively common infection. A 2006 study found an incidence rate of 24.6 cases per 1000 personyears.6 In a large epidemiological hospital-based study on skin, soft tissue, bone, and joint infections, 37.3% patients were identified as having cellulitis.7 International Cellulitis has been found to account for approximately 3% of emergency medical consultations at one United Kingdom district general hospital. Mortality/Morbidity Cellulitis generally is a localized infection. Most patients treated appropriately recover completely. Mortality is rare (5%) but may occur in neglected cases or when cellulitis is due to highly virulent organisms (eg, P aeruginosa). Factors associated with an increased risk of death are the presence of concurrent illness (eg, congestive heart failure, morbid obesity, hypoalbuminemia, renal insufficiency) or complications (eg, shock).8 Race No racial predilection has been noted. Sex No predilection for either sex is usually reported, although a higher incidence among males has been reported in some studies.6,9 Age No age predilection is usually described; however, studies found a higher incidence of cellulitis in general among individuals older than 45 years.2,6,9 Moreover, cellulitis at certain anatomic sites may show a predilection for persons in certain age groups. Facial cellulitis is more common in children younger than 3 years. Perianal cellulitis is predominantly a disease of children.10 Clinical History

The incubation period is somewhat organism dependent. Postoperative cellulitis at the surgical site due to group A beta-hemolytic streptococci may develop rather rapidly. On the other hand, cellulitis due to staphylococci usually is delayed in onset. Patients report local pain and swelling at the site of cellulitis. The patient may report a history of trauma to the site. Severe bacterial cellulitis may occur as a postsurgical complication, such as following hip replacement11 or liposuction, or secondary to lymphatic occlusion following either radical mastectomy12,13 or conservative breast surgery14 ; impaired lymphatic drainage and edema are also considered predisposing factors to leg cellulitis following saphenous vein resection for coronary artery bypass.15 However, cellulitis may follow a trivial injury to the skin (eg, scratch, abrasion, animal bite, intravenous or subcutaneous drug injection, body piercing).16,17,18 Cellulitis has also rarely been reported as a possible postprocedural complication of radiation therapy.19 Fever is common, and chills may be noted, particularly if suppuration has occurred. Malaise may be present. Medical Care Patients with mild cases of cellulitis may be treated in an outpatient setting. Oral agents with activity against staphylococci and streptococci (eg, dicloxacillin or flucloxacillin, cephalexin, cefuroxime axetil, erythromycin, clindamycin, cotrimoxazole, amoxicillin/clavulanate) are usually effective for the treatment of cellulitis in immunocompetent hosts.3 Levofloxacin may also represent an alternative, but the prevalence of resistant strains has increased and fluoroquinolones are best reserved for organisms with sensitivity demonstrated by culture.4,70 Severely ill patients and those unresponsive to standard oral antibiotic therapy should be treated with intravenous antibiotics in the hospital. This is also recommended in immunosuppressed individuals, in those with facial cellulitis, and in any patients with a clinically significant concurrent condition, including lymphedema and cardiac, hepatic, or renal failure. Additionally, consider hospitalization when laboratory investigations reveal elevated creatinine, creatine phosphokinase, or C-reactive protein and/or low serum bicarbonate levels or marked left-shift polymorphonuclear neutrophils.4 Elevating limbs with cellulitis expedites resolution of the swelling. Cool sterile saline dressings may be used to remove purulent discharge from any open lesion. Usually, cellulitis is presumed to be due to staphylococci or streptococci infection and is treated with antibiotics (eg, nafcillin, cefazolin). Other options in allergic patients include clindamycin or vancomycin. Ceftriaxone may be useful in the outpatient setting because it can be administered once daily.71 Agents with a broader spectrum of activity are recommended in selected patients, such as diabetic patients.51 More specific antibiotic therapy may be indicated in patients who develop cellulitis in special settings (eg, after a human or animal bite, exposure to potentially contaminated fresh water or seawater).51 Treatment of cellulitis caused by uncommon organisms, such as Vibrio species or gram-negative bacteria, should be individualized to those recovered organisms.72 In general, these organisms require treatment with drugs other than those discussed above. For instance, cellulitis due to Vibrio infection may be treated with tetracyclines, chloramphenicol, or aminoglycosides.73 Cutaneous cellulitis and soft tissue infections due to community-acquired MRSA represent an emerging problem also among patients who lack traditional risk factors.25 o In such cases, management with standard gram-positive antibiotics may be ineffective, also because concomitant multiresistance to other antibiotics widely used in common empiric therapy, including erythromycin, may occur. Bacterial strains are usually susceptible to gentamicin, tetracyclines, rifampin, trimethoprim/sulfamethoxazole, and vancomycin.55,74 Clindamycin may be used in

areas where inducible resistance is not prevalent. Daptomycin may also represent a cost-effective alternative for complicated skin infections.75 o A randomized, open-label, comparator-controlled, multicenter, multinational study has demonstrated the efficacy of linezolid therapy and its superiority to vancomycin in the management of skin and soft tissue infections, including cellulitis, due to MRSA.76 However, bacterial culture is still considered essential in order to determine the antibiotic susceptibility of the bacterial isolate and to adjust the systemic antimicrobial therapy according to sensitivity data. If mycologic investigations performed to rule out tinea pedis as a possible cause of recurrent episodes of cellulitis detect the presence of fungal infection in toe webs or feet, treatment with topical antifungals is recommended. With severe chronic changes or if onychomycosis is providing a source for repeated infection, oral antifungals such as itraconazole or terbinafine may be considered. Surgical Care Incision and drainage are indicated if suppuration has occurred. 43) Which of the following is MOST commonly seen in patients with acanthosis nigricans? A. An underlying internal cancer. B. An underlying non-Hodgkins lymphoma. C. An insulin resistant state. D. Diabetes mellitus. E. An underlying Hodgkins lymphoma. :the following drugs can be used for acne treatment except-11 a-ethinyl estradiol b-retin A c-vitA d-erythromycin ointment e-azelenic acid Acne vulgaris(treatment) * The triphasic formulation of norgestimate and ethinyl estradiol is indicated to treat moderate acne vulgaris in females 15 years of age or older who need contraception .and whose acne is unresponsive to other antiacne therapy 40 Copyright 2001 Micromedex, Inc. All rights reserved. 5 Treatment Medical Care Treatment should be directed toward the known pathogenic factors involved in acne. These include follicular hyperproliferation, excess sebum, P acnes, and inflammation. The grade and severity of the acne help in determining which of the following treatments, alone or in combination, is most appropriate. When a topical or systemic antibiotic is used, it should be used in conjunction with benzoyl peroxide to reduce the emergence of resistance. Topical treatments Topical retinoids are comedolytic and anti-inflammatory. They normalize follicular hyperproliferation and hyperkeratinization. Topical retinoids reduce the numbers of microcomedones, comedones, and inflammatory lesions. They may be used alone or in combination with other acne medications. The most commonly prescribed topical retinoids for acne vulgaris include adapalene, tazarotene, and tretinoin. These retinoids should be applied once daily to clean, dry skin, but they may need to be applied less frequently if irritation occurs. Skin irritation with peeling and redness may be associated with the early use of topical retinoids. The use of mild, nondrying cleansers and noncomedogenic moisturizers may help reduce this irritation. Alternate-

day dosing may be used if irritation persists. Topical retinoids thin the stratum corneum, and they have been associated with sun sensitivity. Instruct patients about sun protection. Also see Sunscreens and Photoprotection. Topical antibiotics are mainly used for their role against Propionibacterium acnes. They may also have anti-inflammatory properties. Topical antibiotics are not comedolytic, and bacterial resistance may develop to any of these agents. The development of resistance is lessened if topical antibiotics are used in combination with benzoyl peroxide.18 Commonly prescribed topical antibiotics for acne vulgaris include erythromycin and clindamycin alone or in combination with benzoyl peroxide. Clindamycin and erythromycin are available in a variety of topical agents. They may be applied once or twice a day. Gels and solutions may be more irritating than creams or lotions. Clindamycin has maintained better efficacy than erythromycin. Benzoyl peroxide products are also effective against P acnes, and bacterial resistance to benzoyl peroxide has not been reported.19 Benzoyl peroxide products are available over the counter and by prescription in a variety of topical forms, including soaps, washes, lotions, creams, and gels. Benzoyl peroxide products may be used once or twice a day. These agents may occasionally cause a true allergic contact dermatitis. More often, an irritant contact dermatitis develops, especially if used with tretinoin or when accompanied by aggressive washing methods. If intensive erythema and pruritus develop, a patch test with benzoyl peroxide is indicated to rule out allergic contact dermatitis. Systemic treatments Systemic antibiotics are a mainstay in the treatment of acne vulgaris. These agents have antiinflammatory properties, and they are effective against P acnes. The tetracycline group of antibiotics is commonly prescribed for acne. The more lipophilic antibiotics, such as doxycycline and minocycline, are generally more effective than tetracycline. Greater efficacy may also be due to less P acnes resistance to minocycline. However, P acnes resistance is becoming more common with all classes of antibiotics currently used to treat acne vulgaris.20 P acnes resistance to erythromycin has greatly reduced its usefulness in the treatment of acne. Subantimicrobial therapy or concurrent treatment with topical benzoyl peroxide may reduce the emergence of resistant strains. Other antibiotics, including trimethoprim alone or in combination with sulfamethoxazole, and azithromycin, reportedly are helpful.21,22 Some hormonal therapies may be effective in the treatment of acne vulgaris. Oral contraceptives increase sex hormonebinding globulin, resulting in an overall decrease in circulating free testosterone. Combination birth control pills have shown efficacy in the treatment of acne vulgaris.23,24,25,26 Spironolactone may also be used in the treatment of acne vulgaris.27 Spironolactone binds the androgen receptor and reduces androgen production. Adverse effects include dizziness, breast tenderness, and dysmenorrhea. Dysmenorrhea may be lessened by coadministration with an oral contraceptive. Periodic evaluation of blood pressure and potassium levels is appropriate. Pregnancy must be avoided while taking spironolactone because of the risk of feminization of the male fetus. Isotretinoin is a systemic retinoid that is highly effective in the treatment of severe, recalcitrant acne vulgaris. Isotretinoin causes normalization of epidermal differentiation, depresses sebum excretion by 70%, is anti-inflammatory, and even reduces the presence of P acnes. Isotretinoin therapy should be initiated at a dose of 0.5 mg/kg/d for 4 weeks and increased as tolerated until a cumulative dose of 120-150 mg/kg is achieved. Coadministration with steroids at the onset of therapy may be useful in severe cases to prevent initial worsening. Isotretinoin is a teratogen, and pregnancy must be avoided. Contraception counseling is mandatory, and 2 negative pregnancy test results are required prior to the initiation of therapy in women of childbearing potential. The baseline laboratory examination should also include cholesterol and triglyceride assessment, hepatic transaminase levels, and a CBC count. Pregnancy tests and laboratory examinations should be repeated monthly during treatment.

Associated mood changes and depression have been reported during treatment. Although a cause-and-effect relationship has not been established, patients should be informed of this potential effect and must sign a consent form acknowledging they are aware of this potential risk.28,29 A US Food and Drug Administrationmandated registry is now in place for all individuals prescribing, dispensing, or taking isotretinoin. For more information on this registry, see iPLEDGE. This registry aims to further decrease the risk of pregnancy and other unwanted and potentially dangerous adverse effects during a course of isotretinoin therapy. While using isotretinoin, the patient is considered at high risk for abnormal healing and the development of excessive granulation tissue following procedures. Many dermatologists delay elective procedures, such as dermabrasion or laser resurfacing (eg, with carbon dioxide laser or erbium:YAG laser), for up to 1 year after completion of therapy. Other procedures to be avoided during therapy include tattoos, piercings, leg waxing, and other epilation procedures.

Acne with reactive hyperpigmentation; before treatment.

Acne with reactive hyperpigmentation; after treatment. [ CLOSE WINDOW ] A summary of the American Academy of Dermatology treatment guidelines, Guidelines of care for acne vulgaris management, may be of interest.30 Also see the Medscape Acne Resource Center. Surgical Care Procedural treatments include manual extraction of comedones and intralesional steroid injections.

Additionally, some patients may benefit from superficial peels that use glycolic or salicylic acid. Phototherapy using red light or blue light and photodynamic therapy are being assessed as potential treatments for acne.31,32 The usefulness of some fractional laser treatments in the management of acne is also being evaluated. Consultations If the patient is feeling depressed while taking isotretinoin, refer him or her to a specialist for help. Diet Diet therapy has been suggested. Drs Kligman, Fulton, and Plewig performed a study on chocolate, having teenage patients with acne consume 1 bar of chocolate each day. Some of the patients improved and some worsened, but the vast majority were unchanged. This study helped decrease the emphasis on diet as a causal factor in acne vulgaris. However, investigators always returned to the diet question. Data suggest that the westernization of certain Native American populations and the consumption of unhealthy "junk" foods (eg, potato chips, soft drinks) has had a negative impact on general and skin health, resulting acne flares.

Investigators have also focused on a low-glycemic diet to avoid stress from high-carbohydrate diets and to reduce insulin levels. Studies have been encouraging,33 so the author recommends the "South Beach Diet"34 and provides patients with the glycemic index of foods. The author recommends that acne patients eat nothing higher than 70 on the glycemic index. 1. Scabies infestation, all true except:- Rarely involve head and neck - 5% lindane is effective - Benzobenzoates is equally effective to 5% lindane - Itching occurs 1 week after infestation prim Scabies is caused by a microscopic (<1 mm) mite called Sarcoptes scabiei var. hominis. The scabies mite causes symptoms when it digs a little tunnel below the skin (referred to as a burrow) and causes a type of allergic reaction. If the person has never been exposed to scabies before, he or she may not show symptoms until four to six weeks after the initial infestation. Individuals who have been exposed in the past usually show symptoms within a few days.ary lesions of scabies o Burrows, papules, pustules, nodules, occasionally urticarial papules and plaques14 located between web space of fingers, flexor aspects of the wrists, axilla, antecubital area, abdomen, umbilicus, genital and gluteal areas, and feet15 Burrows A short elevated pink or gray, straight or tortuous line, serpiginous (Sshaped) track in the superficial epidermis, with a small vesicle at the tip is known as a burrow; this is pathognomonic of scabies infestation.14 A burrow appears as a thin (approximately the width of a human hair), short (perhaps 2-3 mm in length), gray brown, wavy channel on the skin. In women, the nipples and areola of the breasts often are affected. In men, red papules or nodules on the penile glans, shaft, and scrotum are typical of scabies.
o

Scabies on the penis. Courtesy of William D. James, MD.

Compared with adults, scabies in infants and young children tend to be more disseminated and, while the head and face usually are spared in adults, they may be affected in the very young. o Geriatric scabies demonstrates a propensity for the back, often appearing as excoriations. o Occasionally, the mite is visible to the naked eye as a small white dot. o A small vesicle or papule may appear at the end of the burrow, where the mite enters the skin. o Nodular scabies may erupt on covered parts of the body as either few or many lesions. They are characterized by firm, red nodules approximately 0.5 cm or larger. These can form during or after the infestation has been treated. Usually no organisms are found in the lesions. The nodules are suspected to represent an immune reaction to the scabetic antigens.6 o Norwegian scabies presents with extensive crusting of the skin with thick, hyperkeratotic scales overlying the elbows, knees, palms, and soles. o Bullous lesions may be observed in immunocompromised patients. o Canine scabies does not exhibit the classic burrow. Instead, papules and vesicles are the most prominent lesions surfacing on the arms, chest, abdomen, and thighs. Secondary lesions that may occur include urticaria, impetigo, and eczematous plaques.16 Pyoderma: One study found aerobic and anaerobic bacteria were grown from specimens obtained from children with secondary infections. Aerobes were present in 47% of children: Staphylococcus aureus, group A streptococci, and Pseudomonas aeruginosa. Anaerobes were found to be present in 20% of children: Peptostreptococcus, Prevotella, and Porphyromonas species. Mixed anaerobicMode of transmission Transmission of scabies is predominantly through direct skin-to-skin contact, and for this reason, scabies has been considered a sexually transmitted disease. Those at high risk include men who have sex with men and men with sexual contacts.4 A person infested with mites can spread scabies even if he or she is asymptomatic.1 There may be a prolonged interval (up to 10 wk) between the primary infection, when the patient becomes contagious, and the onset of clinical manifestations.5 It is less frequently transmitted by indirect contact through fomites such as infested bedding or clothing. However, the greater the number of parasites on a person, as in crusted scabies, the more likely that indirect contact will transmit the disease. o aerobic flora were present in 33% of patients.1 Treatment Emergency Department Care Prescribe an appropriate scabicide (eg, permethrin, lindane). Provide relief of symptoms. o Itching may persist for 1-2 weeks, even following successful treatment. Pruritus may be alleviated partially with an oral antihistamine, such as hydroxyzine hydrochloride (Atarax), diphenhydramine hydrochloride (Benadryl), or cyproheptadine hydrochloride (Periactin), or with a short course of topical or oral steroids. o The rash is often misdiagnosed and treated with only steroids, and long-term use with steroids can cause crusting and diffuse erythema.15 Treat secondary infections with the appropriate antibiotics. Treat household members and close personal contacts. Notify infection control personnel and a dermatologist when an epidemic in a nursing home or a hospital is suspected. Provide reassurance that scabies is not a reflection of poor personal hygiene. Consultations
o

Consultation with a dermatologist or an infectious disease specialist may be required for severe, refractory scabies or for disseminated scabies in patients who are immunocompromised. Caution must be exercised when treating pregnant patients and children. Medication The goals of pharmacotherapy are to reduce morbidity and prevent complications. Scabicides Treatment options include either topical or oral medication. Topical options include permethrin cream (drug of choice), lindane, benzyl benzoate, crotamiton lotion and cream, sulfur, Tea tree oil, or oil of the leaves of Lippia multiflora Moldenke, a shrub found growing in West Africa Savannah. Oral options include ivermectin (not approved by FDA for treatment of scabies). A second course of treatment is often recommended 7-10 days later because of some developing larvae that may survive the initial treatment.15 Special population recommendations are as follows:3 Infants - Permethrin 5% cream (>2 months age) (Ivermectin and lindane contraindicated) Children - Permethrin 5% cream, benzyl benzoate 12.5% Pregnant and breastfeeding women - 6% sulfur (Ivermectin, permethrin, and lindane contraindicated) Crusted or Norwegian scabies - Oral ivermectin (may require 3-7 doses, or in combination with a topical scabicide depending on the severity of the infection5 ); hyperkeratosis treated with a keratolytic agent (5-10% salicylic acid in petrolatum) improves penetration of the topical agent5 The Centers for Disease Control and Prevention recommends treatment with either permethrin lindane or ivermectin. Permethrin is the drug of choice in the United States and the United Kingdom, but it is not available in France. In some studies, it has been shown to be more effective than a single dose of oral ivermectin, although it has equivalent efficacy when 2 doses of ivermectin are used at time zero and 2 weeks later. In severe cases, a topical medication may be used with oral medication (ivermectin). A 2007 Cochrane Review that focused on interventions for treating scabies recommended the following:18 Topical permethrin appeared to be the most effective treatment for scabies. Topical permethrin appeared more effective than oral ivermectin, topical lindane, and topical crotamiton. Drug resistance is emerging as a concern with repeated administration. Clinical resistance has not been documented for permethrin use, but it has been documented in 2 people with crusted scabies who had repeated regimens of multiple doses of ivermectin.5 Permethrin cream 5% (Elimite) CDC recommends as first-line treatment. Drug of choice particularly for infants >2 months old and small children. Highly effective, minimally absorbed and minimally toxic.15 Even after successful treatment, post scabietic nodules and pruritus may persist for months. In vitro resistance and treatment failures have been documented. Most expensive of all topical scabicides.3 Dosing Interactions Contraindications Precautions Adult Apply 30 g to entire body from chin to toes; shower off the medication 8-14 h after initial application; repeat in 7 d if necessary Pediatric

Apply as in adults; can apply to head and neck in children <5 y; not recommended for children <2 mo Dosing Interactions Contraindications Precautions None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Avoid contact with the mouth, eye, and nose; may transiently exacerbate redness, swelling, and itching Lindane 1% (Kwell, gamma benzene hexachloride) Stimulates nervous system of parasite, causing seizures and death. Considered second-line treatment if other agents fail or are not tolerated. Not very safe in children due to transcutaneous absorption leading to neurotoxicity. The systemic absorption rate of lindane is 10 times greater than permethrin, and its serum levels are more than 40 times higher.14 Overall, permethrin is a safer choice. Dosing Interactions Contraindications Precautions Adult Apply a thin layer on cool dry skin from chin to toes (estimated dermal absorption factor 10-20%), and shower off 6-10 h later; do not leave on skin for more than 12 h; repeat in 1 wk Pediatric Not recommended Dosing Interactions Contraindications Precautions Oil-based hairdressings may increase toxicity Dosing Interactions Contraindications Precautions Documented hypersensitivity; neonates; acutely swollen skin or damaged skin; Norwegian scabies Dosing Interactions Contraindications Precautions Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Caution if history of seizures; do not apply to eyes, face, or mucous membranes; caution if history of keratinization/ichthyosis disorders, or any condition that has altered skin integrity due to the increased systemic absorption Sulfur in petrolatum (2 -10%, with 6% preferred, cream or ointment) Not FDA approved for treatment of scabies. The oldest antiscabietic. One of a few scabicidal treatments that may be used safely in very small children (<2 mo) and in pregnant women.14,19 Sulfur is messy, malodorous, stains clothes, and requires repeat applications, thus reducing compliance.19 Sulfur should only be used when a patient cannot tolerate permethrin, lindane, or ivermectin.19 It is inexpensive and can be used for mass therapy in resource-poor economies.19 Dosing Interactions Contraindications Precautions Adult Apply to entire body below the head on 3 successive nights and bathe 24 h after each application Pediatric Apply as in adults Dosing Interactions Contraindications Precautions None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity Dosing Interactions Contraindications Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Crotamiton 10% cream or lotion (Eurax) For the treatment of scabies. Mechanism of action is unknown. Weak antipruritic agent. Success rates vary 50-70%.3 Dosing Interactions Contraindications Precautions Adult Apply thin layer on to skin of entire body from neck to toes; repeat in 24 h; take a cleansing bath 48 h after last application; may need to apply twice daily for 5 consecutive days after bathing and changing clothes3 Pediatric Apply as in adults

Dosing Interactions Contraindications Precautions

None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity; can cause seizures Dosing Interactions Contraindications Precautions Pregnancy C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus Precautions Do not apply to face, urethral meatus, eyes, mucous membranes, or swollen skin; can cause seizures

Benzyl benzoate Ester of benzoic acid and benzyl alcohol. Neurotoxic to mites. Not available in the United States4 and not FDA approved as a scabicide, but used in Europe. Cheaper alternative to other treatments.3 Dosing Interactions Contraindications Precautions Adult Use 25% emulsion; apply below neck 3 times within 24 h without an intervening bath Pediatric May reduce adult dose to 12.5% or less due to stinging Dosing Interactions Contraindications Precautions None reported Dosing Interactions Contraindications Precautions Documented hypersensitivity; pregnancy, breastfeeding women; infants and children <2 y Dosing Interactions Contraindications Precautions Pregnancy X - Contraindicated; benefit does not outweigh risk Precautions May cause stinging

Ivermectin (Mectizan, Stromectol) Binds selectively with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, resulting in paralysis and cell death. Half-life is 16 h; metabolized in liver. Single oral dose has similar efficacy to permethrin and may be most successful in patients with immunodeficiency or crusted scabies,16 and in patients with skin conditions that should not use topical medications. Not FDA approved for the treatment of scabies. Dosing Interactions Contraindications Precautions Adult 150-200 mcg/kg/d (0.2 mg/kg) PO once; may repeat in 10-14 d; commercially available as 3 mg tab Pediatric <5 years: Not recommended >5 years: Administer as in adults 52. All of the following cause photosensitivity except: - Lithium - Propranolol - Tetracycline - Chloropromazine - Chloropropamide 54. Blistering skin rash is a feature of the following dermatoses except: - Erythema herpiticum - Erythema multiforme - Sulphonamide allergy - Erythema nodosum 59.Dysplastic nevus syndrome all of the following are true except: - Autosomal dominant - Without family history of melanoma, risk of malignant transformation in 0.6% as whole life risk Atypical moles can be inherited or sporadic. Formal genetic analysis has suggested an autosomal dominant mode of inheritance but genetic studies have not shown consistent data. A personal or family history of melanoma is more predictive for the future development of a melanoma than is the number of atypical moles. Among whites in the United States, the lifetime risk of developing a cutaneous melanoma is approximately 0.6%, or 1 in 150 individuals. In some studies of patients with FAMM, the overall lifetime risk of melanoma has been estimated to be 100%.23 The risk of melanoma is greater for those individuals who have 1 relative with melanoma than for those with no affected relative. The lifetime risk of melanoma may approach 100% in individuals with atypical moles who are from families prone to melanoma (ie, families having 2 or more first-degree relatives with melanoma). Individuals who have nevi with clinical or histologic characteristics of atypical moles but no family history of atypical moles or melanoma might also be at an increased risk for the development of melanoma. Several prospective studies have demonstrated that patients with atypical moles without an obvious family history of melanoma have an increased risk for the occurrence of melanoma.19,24 However, the relative risks for melanoma are lower than in those individuals with a clear family history of melanoma. Thus, the

presence of atypical moles (sporadic or familial) may identify patients at increased risk for melanoma, much like fair skin or UV exposure. 61. Psoralin ultraviolet ray A (PUVA) all of the following are true except: - useful in vitiligo - contraindicated in SLE - Used to treat some childhood intractable dermatosis - Increase the risk of basal and squamous cell cancer