MEDICAL EFFECT FOR ALL

Study links gum disease to delayed pregnancy

noreply@blogger.com (DR PRESEGSpepperSERVER) — Tue, 16 Aug 2011 21:12:00 +0000

Various studies establish a link between gum disease and other ailments that include infertility, diabetes and arthritis
As simple as it sounds, a ‘good old toothbrush’ and proper oral hygiene may be the solution to a number of ailments associated with gum disease. These, according to experts, include inability by many women to conceive as early as their counterparts not suffering from gum disease.

Because the gum appears to be a pretty harmless part of the body and quite hidden to the eye, most people do not pay attention to it, as they concentrate on polishing the teeth. The outcome of this habit is usually bad breath, tooth decay and gum disease, with new studies and researches linking such to a number of ailments that include heart disease, miscarriage and erectile dysfunction. In July, a team of Australian researchers discovered that gum disease can even make it harder for women to conceive.

According to Prof. Roger Hart of University of Western Australia, women with gum disease take on average 7.1 months to get pregnant compared with just five months for those with healthy mouths.

“All women should have gum disease treated before trying to conceive. It usually involves no more than four dental visits,” he said at a reproductive conference in Stockholm.

In the first study of its kind, researchers found that women with gum disease took an extra two months to get pregnant compared with those who had healthy teeth and gums. It took around seven months on average for those with poor oral hygiene to conceive, but just five months for those who brushed and flossed their teeth properly.

Gum disease or periodontal disease, as it is sometimes called, in its severe form is caused by a build-up of plaque. It leads to bad breath and bleeding gums and, if untreated, causes cavities, receding gums and tooth loss. Bleeding gums caused by failure to brush properly can allow up to 700 different types of bacteria to get into the bloodstream.

Although it is not clear how gum disease may trigger problems with conception, the study suggests that infected gums may release inflammatory chemicals, which activate the immune system and inflame the lining of the womb. This could affect implantation of a fertilised egg .Experts at the University of Western Australia in Perth, who carried out the study said the delay was similar to that posed by being obese.

Hart, who is the lead researcher, said, ‘For the first time, periodontal disease has been linked with inability to conceive. Women should be encouraged to see their dentist to have any gum disease treated before trying for a baby. It is easily treated, usually involving no more than four dental visits.”

More than a quarter of pregnant women have gum disease, he added, and there was evidence it is linked with miscarriage, stillbirth and premature birth.

The researchers questioned almost 4,000 women who were 12 weeks pregnant. A total of 26 per cent were confirmed to have gum disease.

They found delays in conceiving among those aged 35 and over, smokers and obese women – which are already known risk factors. But there was a higher level of gum disease – one in three – among the women who took more than a year to get pregnant. Of those who had healthy gums, only one in four took longer than a year, while Hart added that there was also evidence gum disease in men impaired their sperm quality.

“I would advise any couple wanting to start a family to visit a dentist first,” he noted.

A study conducted in Germany in 2009 had also showed that those with rheumatoid arthritis — an incurable condition which causes the joints to become hot and inflamed — are eight times more likely to have gum disease than otherwise healthy people. The researchers found the link after examining 57 patients with the condition. The cheering news, however, is the fact that treating gum disease might reduce the symptoms.

A small study published in 2009 found that removing tartar and plaque helped reduce the symptoms, as six weeks later, patients had lower levels of a compound in their blood that acts as a marker for the severity of rheumatoid arthritis.

“Gum disease and the link to rheumatoid arthritis is a subject that is really gaining international attention,” says Dr Paola De Pablo, a rheumatologist at the University of Birmingham. “We believe what happens is that the bacteria from the gums secrete proteins and these proteins prompt a response from the immune system which kick-starts the arthritis,” he said.

Erectile Dysfunction

Erectile dysfunction has also been linked to poor gum health. Earlier this year, Indian researchers reported that the worse the gum disease, the worse the erectile problem. Their study, published in the Journal of Periodontology, involved 70 men.

Other researches have suggested that gum disease may hinder production of a chemical called nitric oxide, which relaxes blood vessels and increases blood flow to the penis. The researchers think inflammation produced by gum disease may reduce nitric oxide levels.

Dementia

In 2009, researchers from the University of Columbia tested a group of men and women over 60 and found that those with diseased, receding gums and loose teeth were more likely to struggle with memory exercises. “There have been a few studies linking poor dental health to an increased risk of dementia,” said Clive Ballard, a professor of age-related diseases at King’s College, London. “Colleagues of mine are investigating this further and the theory is that untreated gum disease may kick-start the inflammatory process in the brain that leads to the production of amyloid plaque [a form of protein that attacks the brain cells.”

Heart disease

Having gum disease doubles the patient’s chance of developing coronary disease. In 2010, a Scottish study of 11,000 people found that simply brushing one’s teeth less than twice a day increases the risk of having heart disease. Until recently, it was suspected that when the gums became inflamed, bacteria leaked into the blood stream and caused inflammation and damage in the blood vessels leading to cardiovascular disease. “This has been the theory but it is not yet proven,” noted John Cleland, a professor of cardiology at Hull University.

It is thought that bacteria directly cause infection in the valves of the heart. “If we are sending a patient for surgery to their valves, we will have any gum disease treated first to reduce the risk of subsequent infection,” added Cleland.

Diabetes

Gum disease can increase the symptoms of type 2 diabetes.

In 2010, researchers from Edinburgh University reviewed seven previous studies and concluded that treating gum disease and reducing the inflammation around the teeth helped reduce the complications that include eye problems. It is thought the inflammation in the mouth leads to chemical changes that make insulin (which mops up excess sugar from the blood) less effective than normal.

Treating the gum disease, therefore, helps bring the blood sugar levels back to normal and stops the risk of long-term complications. A study in the Journal of Periodontology found that poorly controlled type 2 diabetic patients are more likely to develop periodontal disease than well-controlled diabetics are.

Some experts have observed that the relationship between periodontal disease and diabetes goes both ways - periodontal disease may make it more difficult for people who have diabetes to control their blood sugar. This is supported by a study reported in the Journal of Periodontology in 1997 involving 113 Pima Indians with both diabetes and periodontal disease. The study found that when their periodontal infections were treated, the management of their diabetes markedly improved.

SAQ in embryology

noreply@blogger.com (DR PRESEGSpepperSERVER) — Thu, 21 Jul 2011 13:41:00 +0000

SAQ in Embryology

PREVALENCE AND RISK FACTORS OF ERECTILE DYSFUNCTION

noreply@blogger.com (DR PRESEGSpepperSERVER) — Sat, 25 Jun 2011 08:29:00 +0000

1.1 BACKGROUND

Erectile Dysfunction(ED) was defined in 1992 by the National institute of Health Consensus panel on ED as the repeated inability to develop or maintain erection of penis sufficient for a satisfactory sexual intercourse or activity in the absence of an ejaculatory disorder such as premature ejaculation.[1]

Erectile dysfunction is a common public health problem that is said to affect 152 million men worldwide. It was initially called impotence but was reversed due to set backs incurred as it causes confusion and lead to inability to interpret result in both clinical and basic science investigations.[2] It is more prevalent in patients with associated medical conditions such as diabetes and hypertension and among cigarette smokers.[3] For many men, erectile dysfunction creates mental stress that affects their interactions with their family members and associates. However, its various aspects remain poorly understood by the general population and by most health care professionals. The fact that results have not been effectively communicated to the public has compounded this situation.⁴

1.2 STATEMENT OF THE PROBLEM

Prevalence varies according to individual characteristics- age, race, ethnicity, socioeconomic status, and concomitant disease conditions.

It was estimated in 1995 that over 152 Million men worldwide have experienced erectile dysfunction and was projected that by the year 2005, about 322 Million men would be affected with the largest projected increase in the developing world i.e. Asia, Africa, and South America.

In France, the estimated prevalence of ED is 32%; 56% in West Virginia, USA; 37.55% of men ranging from 40-70 years in Thailand; 37% in Korea; 52% among men with chronic disease in Japan; 49% of men with chronic prostration in Anhui, China; 88% of men with end-stage renal disease in Ontario, Canada; 69% of men with Peyroni’s disease in Porto Alegre, Brazil; 47% of men with hypertension in Valencia, Spain; 68% of men with Diabetes Mellitus in Japan; and 48% of men with Rheumatoid arthritis in USA and Canada⁵.

Prevalence of ED in developing countries is largely unknown. However, the age adjusted prevalence rates of ED among men attending primary health care clinic is 57.4% in Nigeria, 63.5% in Egypt, 80.8% in Pakistan and 47% in Burkina Faso.⁶

An assessment of andropause (also known as androgen decline in ageing male) and erectile dysfunction awareness among married men with diabetes mellitus in Ile-Ife, Nigeria has a prevalence of 51.3%.⁷

Andropause has implications on the reproductive health and quality of life in older males. However, very few studies have been recorded among the Nigerian populace on andropause related issues.

In Nigeria, sufferers are unable to freely discuss the problem of ED with their doctors because of the fear of stigmatization. Also, data on the issue of erectile dysfunction is generally scarce on the scientific literatures and studies on clinical roles in the diagnosis and management of ED are extremely limited.

In USA, it has been established that ED affects 50% of males older than 45 years with various degrees of dysfunction. Approximately 152 million men worldwide suffer from the disease and the prevalence may be as high as 30 million in USA alone. An increase in prevalence in ED in ageing male is well documented in studies such as Massachusetts male aging study and others. Several recent studies have looked at the prevalence of ED. The Massachusetts male aging study ,conducted from 1987-1989 in areas around Boston , was a cross- sectional random sampling community based survey of 1290 men ages from 40- 70. ED was self reported and the condition was classified as mild, moderate or complete. The combined prevalence of mild, moderate and complete ED was 52%; the study demonstrated that ED increases in prevalent with age, at age 40, there is an approximately 40% prevalence rate, increasing to almost 70% in men at age 70. The prevalence of moderate ED increases from 17% to approximately 34% the prevalence of complete ED increases from 5% to 15% as age increases from 40 to 70 years⁸.

The prevalence in an Italian Study increased from 2% for men aged 18-39 years to 48% in those over 70 years.

URTICARIA / PAPULAR URTICARIA

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:44:00 +0000

Urticaria is a reactive phenomenon which is characterised by itching
wheals (hives). These may be any shape or size, appear anywhere on the
body and as angioedema in the face, at any interval. Sometimes there is
a single attack of urticaria, sometimes there are attacks every few hours.
Urticaria may come and go during a few days or persist for many years.
There are many types of urticaria and possible causes of urticaria: contact
urticaria (e.g. stinging nettles, caterpillars, formaldehyde); physical
urticaria (cold, heat, pressure); cholinergic urticaria (sweat, exerciseinduced);
Drug-induced non-allergic urticaria (aspirin, pethidine, morphine,
hydralazine); allergic urticaria by drugs (see drug eruptions), food
(fish, milk, nuts, tomatoes, citrus fruits, cocoa, strawberries), insect allergens
(bee, wasp), vaccines, worm infestations, and internal diseases.
This list is not complete.
Papular urticaria is a specific form of urticaria which occurs again and
again in susceptible children. It presents as very itchy persistent hives
and papules, sometimes with vesicles on top. It is an exaggerated
response to contact with insects, their vomits and bites. When extensive
the rash may resemble HIV related papular pruritic eruption (though this
usually occurs in adults) or scabies (in papular urticaria other family
members are not affected).
Management of urticaria /
papular urticaria
- Avoid or treat the cause if possible.
A thorough history is essential.
- Calamine lotion or phenol-zinc lotion.
- Antihistamines, a low or high dose may be
required, this varies per patient.
- Topical steroids if necessary.
- Avoid the use of aspirin.
- Papular urticaria: Insect repellents and
impregnated bednets.

PSORIASIS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:42:00 +0000

Psoriasis is a chronic recurrent, inherited, non-infectious skin disease
caused by an abnormally fast turnover of the epidermis. The turnover may
be up to 40 times the normal and as a result the epidermis is not able to
develop normally. All layers become too thick and the most obvious one
is the horny layer, the outer layer of the skin. The skin is red, inflamed,
and the scales are thicker than normal. They produce a so-called candlewax
phenomenon: when you scratch such a patch it becomes silverywhite.
Psoriasis also displays a Koebner phenomenon, i.e. it appears in
traumatised skin. Classical psoriasis occurs on the scalp, the extensor
areas of extremities (esp. elbows, knees), the umbilicus and the buttocks.
Finger- and toenails may show pitting, thickening of the nailbed or distal
onycholysis (brownish oil-like changes on the distal nail where the nail is
detached from the nailbed). Palms and soles may also show thickening;
callus, scales and cracks. Treatment is often effective but you can never
cure the patient of the disease as such. It may always recur, after weeks,
months or years. Psoriasis may flare up after an infection (flu, angina) or
drug use (e.g. antimalarial drugs, beta blockers, lithium). There is also a
pustular psoriasis and an inverse form with lesions in skin folds rather
than extensor areas, the latter may be difficult to distinguish from seborrhoic
eczema.
Psoriatic arthritis of the small joints of the hands and feet occurs in 5-
10% of patients. The arthritis may be mutilating and eventually become
widespread.
Management of psoriasis
- Explain to the patient the recurrent nature of the disease.
- Salicylic acid 2-10% ointment twice daily to reduce scaling.
- Coal tar 5-10% ointment or sulphur 5% in coal tar 5-10% ointment nightly.
- Moisturise (vaseline, urea 10% ointment or cream) and expose to sun. In psoriasis
coal tar ointment may be tried in combination with sunlight.
- Salicylic acid and coal tar should not be applied on body folds unless the skin is
dry and thickened. They can be mixed together as ointments, or with zinc paste.
- In body folds sulphur added to a mild steroid cream is often effective.
- A strong topical steroid once or twice daily, cover with salicylic acid 2-10% ointment
if necessary.
- Urea 10% cream or ointment as an emulsifier, aqueous cream in folds.
- Treat any superinfection with betadine or antibiotics if necessary.
86
- Psoriatic arthritis: NSAID’s e.g. ibuprofen 400 mg 4-6 x daily, indomethacin 75-100
mg daily, naproxen 500-750 mg daily or salazosulphapyridine 250 - 500 mg twice
daily.
- Methotrexate is often effective in severe and arthropathic psoriasis and may be
used in HIV infected patients.

PORPHYRIA CUTANEA TARDA

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:41:00 +0000

Porphyria cutanea tarda is a chronic disturbance of the metabolism of
porphyrins, manifested by liver damage and skin lesions. The disease
affects more men than women, generally over the age of 40. Skin which
is exposed to the sun is affected, mainly the face and the backs of the
hands. Exposure to sunlight or trauma induces small blisters which lead
to erosions, crusts, atrophy, flat or depressed scars and pigmentation
changes. Milia are often present. Increased hairgrowth is also a feature.
The urine of these patients is red in colour after sun exposure due to
increased porphyrin excretion.
Management of porphyria cutanea tarda
- Avoid triggering agents, e.g. alcohol, drugs, oral contraceptives.
- Avoid trauma, avoid sun exposure.
- Phlebotomy, not to be performed in liver cirrhosis. A specialist should decide.
- Chloroquine in low doses (e.g. 150 mg weekly) for a long time.

PEARLY PENILE PAPULES

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:40:00 +0000

Pearly penile papules are not a disease, they are an anatomical variant.
Small, usually whitish or skin coloured papules are found at the border of
the glans penis, just before the coronary sulcus. They are very regularly
spaced and regular in size. They are often a great worry to young men
who think they have penile warts or another sexually transmitted
infection and may have caused them to seek all sorts of treatments.
Management of pearly penile papules
Explain to the patient that no treatment is necessary

PAPULAR PRURITIC ERUPTION

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:39:00 +0000

The phrase "papular pruritic eruption" defines an itchy, persistent or chronic
recurrent rash which is found in HIV-infected patients and for which
no other cause (e.g. urticaria, scabies, folliculitis etc.) can be found.
There are usually widespread inflammatory papules, hyperpigmented
scars and scratch marks. The patient may or may not show other signs of
HIV-infection.
Management of papular pruritic eruption
Treatment is symptomatic, any of the options below may be tried:
- Calamine lotion, phenol zinc lotion, menthol 0,5% cream or lotion or
phenol 1% + menthol 0.5% preparation.
- Antihistamines e.g. promethazine 25 mg nightly or chlorpheniramine 4 mg
2 or 3 times daily.
- Betadine scrub in case of infected lesions.
- Hydrocortisone or betamethasone cream once to twice daily.
- Dapsone 100 mg once daily may be tried in severe cases.

MALIGNANT MELANOMA

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:37:00 +0000

This is a very malignant tumour which in Africans usually arises on the
foot, less often on the hand (usually acro-lentiginous melanoma). It can
start as a small pigmented papule or nodule which grows, often showing
typical blue-grey-black shades of colour, and sometimes bleeding or ulcerating.
It spreads to other organs rapidly and the diagnosis is often made
when the tumour has already spread to at least regional lymph nodes and
it is too late for cure. Early diagnosis is therefore important. Keep a
melanoma in mind when someone presents with a chronic ulcer on the
foot especially when it shows typical pigmentation or when it does not
respond to ulcer-treatment.
An incision biopsy should not be performed in a lesion which is suspect
for malignant melanoma, the lesion needs to be excised in total.
Management of malignant melanoma
- Wide surgical excision and histological examination.
- Refer to a specialised centre.

KELOIDS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:35:00 +0000

Keloids are fibrous tumours caused by overgrowth of connective tissue.
They usually occur in a scar, weeks to months after the skin is
traumatised. The keloid spreads beyond the boundary of the original
injury to form a hard, irregular, shiny, sometimes painful or itchy ridge or
plaque. In primary keloids there is no apparent preceding trauma. Once
formed keloids remain stationary for years after which, some become
partially flattened. They are especially common in Africans.
Management of keloids
- Treatment is difficult, especially in older lesions. Surgical excision will lead to
recurrence and more severe deformity!
- Strong topical corticosteroids under occlusion are sometimes effective as are
intralesional corticosteroids, with or without cryotherapy. Radiotherapy is an option
in some cases. Pressure garments may be used to prevent and treat keloids
especially after extensive trauma e.g. burns.

INFANTILE ACROPUSTULOSIS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:33:00 +0000

Infantile acropustulosis is a condition of unknown cause which occurs in
infants, usually under the age of 1 year. Intensely itchy vesicles which
quickly progress to pustules appear on the soles and the sides of the feet
and on the palms, often in the first 3 months of life. The pustules last for
one to several weeks and then subside only to reappear two to four
weeks later. Attacks recur with diminishing severity and frequency in
time and stay away at the end of the second or third year. The pustules
are sterile and the condition does not warrant antibiotic treatment, which
is a common misconception. Anti scabies treatment is also ineffective.
The condition often sééms to appear after successful treatment of scabies,
which should make you wonder whether it was scabies which was
treated in the first place.
Management of infantile acropustulosis
- Early use of topical corticosteroids is usually effective for itch and lessens the
severity of the attack.
- For severe itch antihistamines may be required.
- Antibiotics and antiscabies treatment are ineffective

HEMANGIOMA (CONGENITAL)

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:31:00 +0000

Congenital hemangioma’s are benign tumours of blood vessels which
become manifest in the first few days of life. They can be single or multiple
and vary in size from less than 1 cm to more than 10 cm. The preferred
site is the face though they can occur anywhere on the skin. The
mucous membranes i.e. the lip and tongue can be affected.
Hemangioma’s may grow rapidly in the first months causing great concern
to the parents. However, they regress spontaneously in about 70%
of the patients. Regression starts in the first year of life and takes 5-10
years. Sometimes a hemangioma may bleed easily or it may become
(partly) necrotic after trauma or during a period of fast regression.
Regression may show no scarring, there may be a slack, baggy area of
skin if the hemangioma was large or the skin may be hypopigmented and
atrophic.
Management of congenital hemangioma
- In most cases no treatment should be given. The parents need to be told that
spontaneous regression is to be expected and that this gives the best cosmetic
outcome. This is in contrast to surgery which may leave disfiguring scars.
Treatment is indicated in:
1 a lesion which does not disappear or gets bigger in a child > 7 years of age,
2 impaired function of vital organs, e.g. vision (by large lesions in the orbital region
or on the eyelid), hearing, breathing,
3 bleeding and/or ulcerating lesions.
Refer to a skin specialist or paediatrician for treatment. In some cases
intralesional steroids may be tried.

DRUG ERUPTIONS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:30:00 +0000

Most common are maculo-papular exanthema’s, which are usually itchy.
Drugs with a > 1‰ incidence of drug-induced exanthema are: penicillins,
sulphonamides (fansidar, trimethoprim), NSAID’s (like aspirin,
indomethacin), isoniazid, erythromycin, hydantoin derivatives (e.g. phenytoin),
carbamazepine, allopurinol, streptomycin and gold salts. They
may occur soon after taking the drug (in previously sensitised patients),
on finishing a course of drugs, or up to 3 weeks after taking a drug.
Urticaria is also a common reaction, often caused by penicillins,
NSAID’s, acetylsalicylic acid and X-ray contrast media.
Fixed drug eruptions recur on exactly the same spot every time the
responsible drug is taken. There is usually one, sometimes two or more
macules or plaques, reddish-purple in colour. They may show blistering
and leave persistent hyperpigmentation on healing. Most frequent
causes: barbiturates, paracetamol, pyrazolon derivatives, sulphonamides
and tetracyclines.
Some drugs cause photosensitivity, commonly implicated are:
amiodarone, chlorothiazide, fluoroquinolone derivatives, NSAID’s,
phenothiazines, psoralens, sulphonamides and tetracyclines.
Stevens-Johnson syndrome and toxic epidermal necrolysis are
serious blistering eruptions which may affect large areas of skin and
mucous membranes and may be fatal. Common causes: sulphonamides,
hydantoins, pyrazolon derivatives, carbamazepine and NSAID’s.
Erythema exsudativum multiforme (EEM) shows characteristic
"target" or "iris" lesions and is considered a minor form of Stevens
Johnson syndrome. EEM and Stevens-Johnson syndrome are commonly
caused by herpes simplex infections, only in second instance by drugs
and other infections such as mycoplasma infections.
Patients with HIV-infection are more susceptible to all drug eruptions.
Nearly all drugs can cause drug eruptions. Only the most commonly
implicated drugs have been mentioned here.
Management of drug eruptions
- Identify the responsible drug and stop the use of that drug.
- For itchiness and drying in: Calamine lotion with or without menthol 0.25% and/or
phenol 1% , or zinc oxide cream.
- Burn cream or honey.
76
- Oral antihistamines e.g. promethazine 25 mg once or twice daily or
chlorpheniramine 4 mg 3 times daily.
- In severe reactions a short course of prednisolone may be given starting at 30-60 mg
daily and quickly reducing the dose in 2 weeks.
- When there is extensive skin loss the patient should be hospitalised, given i.v. fluids
and treated like a burn case i.e. given betadine baths, dressed with silver
sulphadiazine 1% burn cream and given antibiotics and analgesics as required.

DERMATOSIS PAPULOSA NIGRA

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:28:00 +0000

A very common papular eruption in Africans which is probably genetically
determined. Dark brown to black papules appear on the upper part of the
face, especially on the cheeks and the temples. The first papules may
appear from early teens and they increase in number with age. Forty
percent of Africans over 30 years of age have this eruption in a limited or
extensive form. It is more common in women than in men.
Management of dermatosis papulosa nigra
Treatment is not necessary and usually not requested.
- Cauterisation / diathermy which may be followed by curettage is possible. This may
however leave undesired hypo- or hyperpigmentation. In extensive cases it is
therefore advisable to treat a few lesions as a trial first.

ALBINISM

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:26:00 +0000

Albinism is an inherited disorder of melanocytes, which do not
synthesise melanin (pigment). This results in absence of pigmentation of
skin, hair and eyes, combined with photophobia and nystagmus from
birth. The skin is white, the hair white or yellow and the iris light blue.
These patients are very light sensitive because they have no UVabsorbing
melanin, which usually protects people from solar damage.
After short term sun exposure sunburn, freckling, and early ageing of the
skin already occurs and actinic keratoses with a tendency towards
malignant transformation appear. Squamous cell carcinoma is seen at an
early age, even in children.
Management of albinism
Sunprotection to prevent solar damage:
- Wear protective clothing (long sleeves, long skirts and trousers), a sunhat with a
wide rim, providing protection for face, ears and neck, and sunglasses.
- Stay indoors as much as possible during the hot hours of the day.
- Children with visual impairment should be seated in front rows in classrooms.
- Use sunscreens with a high sun protection factor (SPF), e.g. PABA (para amino
benzoic acid) which has SPF 15. Total sunblockers have even higher SPF’s. Zinc oxide
cream/paste/ointment blocks out sunlight and can be used for the lips. Apply
sunscreen whenever going outdoors.
Regular skin check-ups for early detection and treatment of pre-cancerous
keratoses and skin cancer. Single keratoses can be treated with liquid nitrogen,
curettage and electro-dissecation, shave excision followed by electrosurgery.
Multiple and/or extensive lesions can be treated with topical 5%
5-fluoro-uracil. The extract from the fruit of the sausage tree (Kigelia Africana)
is an effective alternative (ready-made cream at many pharmacies). The rough
skin can be softened with urea 10% ointment or salicylic acid 2-5% ointment.

ACNE VULGARIS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:24:00 +0000

Acne is very common in puberty and it usually regresses in early adulthood.
Sometimes it persists up to age 30 or lifelong. Sebum production
(patients complain of "oily skin") is the most important factor in acne. It
occurs on the face and the upper trunk as blocked sebaceous gland ducts
(forming comedones= blackheads and whiteheads), which may progress
to inflammatory papules, pustules and nodules. Acne may be very mild to
very severe. In severe acne conglobata, acne lesions blend together to
form large inflammatory areas with cysts and scar formation.
Management of acne
- Stop the use of vaseline, oil or ointments and greasy cosmetics which further block
sebaceous ducts.
- "Peeling" of the comedones with benzoylperoxide 5-10% gel or tretinoin 0.01-0.1%
cream or gel, apply at night since both are photosensitisers. Salicylic acid 1-10% in
an alcoholic solution. Alcoholic solutions remove excess sebum. Dilute methylated
spirits with an equal amount of water to a 35% solution.
- For pustular/inflammatory lesions: topical clindamycin 1% lotion, erythromycin 2%
lotion. If severe, use systemic tetracyclines, e.g. doxycycline 100 mg twice daily until
substantial improvement (may be a month or more) followed by 100 mg once daily
until acceptable or cleared, which may take many months.

VITILIGO

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:23:00 +0000

Vitiligo is a relatively common, sometimes familial disorder in which
depigmentation of the skin occurs. It may start at any age but often starts
in young adults. Lesions start as small white macules and become
progressively larger and confluent, leading to bizarre shapes. Common
localisations are the hands and feet and the skin around body openings,
e.g. around the eyes, nose, mouth and lips, the umbilicus, and around the
genitals and the anus. Vitiligo also occurs in traumatised skin and can
affect hair bulbs, leading to streaks of white hair. The condition is usually
slowly progressive and seldom regresses spontaneously. Vitiligo of the
genital area should be distinguished from lichen sclerosis, in which
depigmentation and atrophy are usually limited to this area.
Management of vitiligo
- There is no satisfactory treatment. Reassure the patient; there is only colour
change, vitiligo is not a sign of abuse.
- Sometimes the combination of topical steroids and sun exposure results in
repigmentation.

LICHEN PLANUS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:22:00 +0000

Lichen planus presents with very typical itchy papules, which are small
(1-3 mm) and are demarcated by the natural skin lines, making them
polygonal. They have a sharp, elevated border, a flat surface (hence the
name "planus") and they shine by reflecting light. They are often a shade
of red, later reddish blue to purple and show "Wickham’s striae", a fine
milky-white network on the papule’s flat surface. Neighbouring papules
may join together to form plaques which resemble lichen growing on
trees, explaining the name "lichen". They may occur anywhere on the skin
but are most common on joint flexures (especially wrists), genitals, sacral
region and inner thighs. A Koebner phenomenon is present. The oral
mucosa and lips may be affected and show a network of white lines.
Actinic lichen planus occurs on sun-exposed areas. In hypertrophic lichen
planus there are thick, hyperkeratotic papules and nodules or thickened
wart-like plaques on the shins. Lichen planus is self-limiting, it will disappear
spontaneously, sometimes in months but it may take many years.
Management of lichen planus
Treatment can be very difficult.
- For severe itch: calamine lotion and/or antihistamines.
- Coal tar 2-6% ointment nightly.
- Strong topical steroids combined
with salicylic acid 5% once to twice
daily.
- Refractive lesions: Apply strong
steroid at night and cover with
plastic 2 nights a week (see lichen
simplex). This improves penetration
of the steroid.
- Widespread, severe forms: a short
course of prednisolone may be tried:
start with 30 mg daily for a week
then reduce to zero in two weeks

CHRONIC DISCOID LUPUS ERYTHEMATODES

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:20:00 +0000

Chronic discoid lupus erythematodes (CDLE) is a chronic scarring skin disease
which occurs on sun-exposed areas. The face is the commonest
site, but scalp, upper trunk and distal extremities may also be affected.
On the face there may be a "butterfly distribution" on the cheeks and
bridge of the nose, the lips may also be affected. The lesions are welldefined
reddish patches with thick or hyperkeratotic scaling and hyper-,
hypo- or depigmentation, they feel rough on palpation. They slowly increase
in size and form atrophic hypopigmented scars. Exposure to sunlight
aggravates the lesions and causes an increase in symptoms, such as itch
and irritation.
Management of chronic discoid lupus erythematodes
- Sunprotection! Wear a sunhat, protective clothing, and stay out of the sun as much
as possible. Use a sunscreen when outdoors (see albinism).
- Topical steroids e.g. betamethasone 0,1% once daily. If this is not effective after
2 months, this treatment should be stopped, as there is already a high risk of
skin atrophy.
- Chloroquine 150 mg/hydroxychloroquine 200 mg once daily for 6-8 weeks. If
improving continue until maximum improvement (i.e. no active lesions, scars will not
disappear), then slowly decrease the dosage (over months). If no improvement
occurs a double or triple dose may be tried for a short time. Do not use antimalarials
for more than 9 months at a time.
- Sometimes dapsone, with or without antimalarials is effective.

CHRONIC BULLOUS DERMATOSIS OF CHILDHOOD

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:16:00 +0000

This is a chronic blistering disease which occurs in children. It usually
starts before the age of 5 years. Small and large blisters appear predominantly
on the lower trunk, genital area and thighs, often also on the
scalp and around the mouth. They may spread all over the body. New
blisters form around healing old blisters, forming "a cluster of jewels".
There is often some itchiness. The course is chronic, spontaneous remission
usually occurs after an average of 3-4 years.
Management of chronic bullous dermatosis of childhood
- Dapsone in doses from 12,5 to 125 mg daily or Sulphapyridine 250 mg to 3 grams
daily usually control the eruption. After it clears you can slowly reduce the dosage to
a maintenance dose but you may need to increase it again when disease activity
flares up.
- Treat any superinfection with betadine, GV paint or if severe antibiotics.
- If there is no response to the above treatment, topical (strong) or systemic corticosteroids
may need to be added. Take care not to overtreat, especially regarding the
side effects of systemic steroids in children.

ALOPECIA AREATA

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:15:00 +0000

Alopecia areata occurs in adults and in children and generally presents
as one or more round or oval bald patches on the scalp or beard area. The
hair is lost suddenly, the bald patch extends until it is usually some centimetres
in diameter, and as a rule after weeks to months new hairs
begin to grow within the lesion. The skin remains normal, showing hairfollicle
openings without scaling or atrophy. The re-growing hair may be
white in colour, giving the impression of "turning white overnight" when
a large area is affected.
In progressive cases new bald patches develop as others heal, or patches
do not heal for years. In alopecia areata totalis there is baldness of the
whole head; in alopecia areata universalis all body hair including scalp,
beard, eyebrows, eyelashes, pubic and axillary hair falls out.
Management of alopecia areata
- Explain to the patient that the condition is not serious and that the hair is likely to
grow back after some time. This may take weeks or months and is different in each
individual.
- A topical irritant such as garlic may be tried.
- People with very extensive alopecia areata or alopecia which does not heal may be
referred to a skin specialist.

ONCHOCERCIASIS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:14:00 +0000

Onchocerciasis or river blindness is a chronic infection of the skin and the
eyes by the filaria Onchocercus volvulus. It is transmitted by female
blackflies which are typically found near fast moving water. People living
in these areas get infected again and again, thereby accumulating
hundreds to thousands of microfilariae in the skin and the eyes, where
they move around freely. In the skin this causes severe itch as the major
presenting complaint. In the first stages there are only a few erythematous
hyperpigmented papules and scratch marks. Later the whole skin
thickens and becomes dry and lichenified. There is loss of elasticity
(hanging groins). Skin hyper-, hypo- and depigmentation may occur in
chronic cases. Onchonodules, which represent the adult worms, can be
seen and palpated, in particular above the hipbones but also elsewhere.
Biopsy or skin snip may show microfilariae. Eye involvement is a well
known cause of blindness.
If the history is suspect but microfilariae have not been demonstrated a
Mazotti test can be performed. Under careful conditions (cave:
anaphylactic shock) 50-100 mg diethylcarbamazepine (DEC, Hetrazan) is
given. A positive test yields intolerable itch within a few hours.
Management of onchocerciasis
- Treat secondary infection with antiseptics or antibiotics as impetigo and secondary
lichenified eczema as lichen simplex.
- Ivermectin kills microfilariae with a single oral dose. The adult worms are not
affected however. A patient staying in an endemic area will therefore need repeated
treatment every 3 to 12 months depending on the amount of itching. If the patient
moves out of the endemic area repeated treatment may cure the infection as the
adult worms will die after a few
years.
-When there is eye involvement
steroid treatment should preceed
ivermectin.
- Single dose of ivermectin (6 mg
tablets) according to body weight in
kilograms: under 30 kg: 0,5 tablet,
30 to 50 kg: 1 tablet, 50 to 70 kg: 1,5
tablet, over 70 kg: 2 tablets.

LYMPHATIC FILARIASIS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:12:00 +0000

Elephantiasis in the tropics may have a number of causes ranging from
bacterial or fungal lymphangitis and adenitis to Price’s disease. In the
latter silicates in red volcanic soil which enter the skin through the soles
cause an immune reaction which blocks the lymph nodes. A common
cause of elephantiasis is the parasitic worm Wuchereria Bancrofti, which
is transmitted by mosquitoes. It presents after an incubation period of 5
to 15 months with mild lymphangitis and lymphadenitis, and pitting
oedema of one or more extremities or genitals. The lymphadenitis is
descending rather than ascending. At first there are attacks of swelling
but later the symptoms become chronic. Adult worms are present in the
lymphatics and the resulting inflammatory response is thought to be the
cause of the obstruction. The late effects include firm lymphoedema of
the extremities, the vulva, scrotum, arms and breasts. The legs at this
stage often have a warty appearance with folds and cracks in the lower
legs and feet. Active infection can be diagnosed with a rapid card test
using fingerprick blood.
Management of lymphatic filariasis
- Keep clean and manage intercurrent infections.
- Exercises to improve lymphatic flow.
Lymphmassage, intermittent compression,
elastic compression bandages and stockings or
lace-up boots may all be helpful.
- Ivermectine 12 mg plus albendazole 400 mg in a
single dose for adults (see onchocerciasis) will
kill microfilariae but not the adult worms.
This treatment therefore needs to be repeated
yearly until all adult worms have died of old age
(3-4 years).

LEISHMANIASIS

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:11:00 +0000

Leishmaniasis is caused by an infection with the leishmania parasite,
after the bite of an infected sandfly. After an incubation period of two
weeks to four months an erythematous or skin coloured nodule appears.
This ulcerates and then becomes crusted or even verrucous, in most
cases eventually leaving an ugly scar. The sandfly likes to bite on moist
areas, preferably around the eyes, ears, nose and mouth. Lesions may be
found on the skin, the mucous membranes or both. The latter,
mucocutaneous leismaniasis, may completely destroy the nose and does
not heal spontaneously.
Leishmaniasis may cause lymphadenitis or become visceral, Kala Azar.
After Kala Azar it may cause PKDL, Post Kala Azar Dermal Leishmaniasis.
In a few cases leishmaniasis becomes generalised, showing infiltration
and nodules over the whole body. This persists for life.
Management of leishmaniasis
The sore type of leishmaniasis:
- Cryosurgery.
- Excision.
- In some cases itraconazole or ketaconazole may be tried.
Leishmaniasis with lymphadenitis:
- Pentavalent antimonium prepararions
(stibogluconate) Glucantine or Pentostam
20 mg/kg/day for 20-30 days i.v. or i.m.
- Pentamidine isothionate 4 mg/kg/week for 4 weeks to
8 months.
- Amphotericine B 1 mg/kg on alternate days for
2 months
PKDL: stibogluconate.
Diffuse generalised leishmaniasis: repeated
courses of pentamidine isothionate

NORWEGIAN (CRUSTED) SCABIES

noreply@blogger.com (DR PRESEGSpepperSERVER) — Fri, 24 Jun 2011 13:10:00 +0000

This is a variant of scabies where the skin lesions are extremely massive
and extensive. Thick, grey keratoses and crusts develop on the hands,
elbows, knees and ankle joints and also extend to areas not normally
affected by scabies such as the face and scalp, and nail beds. Norwegian
scabies is seen in severely immunocompromised patients such as in
AIDS patients. The crusts are teeming with scabies mites and thus very
infective to others.
Management of Norwegian scabies
- Treatment is as for scabies though it may need to be prolonged.
- Keratolytics need to be applied to remove the thick crusts: salicylic acid 5-10%
ointment or urea 10% ointment.
- Ivermectine 3-12 mg depending on bodyweight plus sulphur 5-20% ointment.