Hector Rodriguez PhD, MPH

• Professor, Health Policy and Management

https://publichealth.berkeley.edu/people/hector-rodriguez/

Longer freezing (over 25 s of continual freeze) is more likely to leave scarring birth control pills 3 weeks cheap 0.18mg alesse free shipping, possibly damage underlying structures and not improve clearance rates [104] birth control that helps you lose weight buy discount alesse on line. After thawing birth control usa purchase alesse 0.18 mg visa, a second freeze cycle will improve the cure rate in plantar warts birth control shot cheap alesse line, although the benefit is less marked in hand warts [106] birth control for women 80 alesse 0.18mg. As well as damaging cells birth control bleeding buy 0.18mg alesse with mastercard, cryotherapy may lead to clearance by stimulating the development of an immune response [107]. The response to treatment with cryotherapy is comparable or slightly better than that achieved with salicylic acid [75,76]. More frequent treatments may improve responses although will induce more pain, and longer intervals are less effective. If this fails, or when a wart is particularly painful or deep, or both, as may occur over a bony prominence on the foot, more prolonged application, typically up to 30 s, perhaps repeated after thawing, may be used to achieve a greater destructive effect at the cost of significantly greater blistering and pain. The common practice of dipping cotton buds for different patients into a common flask containing the liquid nitrogen may carry a risk of crossinfection. This is unpredictable and surprisingly variable between patients, but in some cases, especially with longer freezing times, it may be severe and persist for many hours or even a few days. Swelling of the treated area and the surrounding skin begins within minutes, and where tissues are lax as in the periorbital area it may be dramatic. Occasionally, damage to underlying tissues may result, for example to a tendon [110] or the nail matrix, and excessive freezing times should be avoided over nerves, for example on the sides of the fingers. Depigmentation may occur, and can be a significant cosmetic disadvantage in patients with darkly pigmented skin. As another destructive method, the infrared coagulator can be used to treat warts. The reported cure rate in a series of 44 warts was 70% [125] which compares favourably with cryotherapy. Excision is usually to be avoided since scarring is inevitable and recurrences of the wart in the scar are frequent. Curettage and cautery/electrocoagulation, usually in combination, may be used for painful or resistant warts, but carry a risk of scarring. Systemic or topical aminolaevulinic acid can be taken up by dividing cells, metabolized to protoporphyrin and then photoactivated to produce a damaging effect on the cell. The treatment may need to be repeated two or three times but can be limited by pain [130]. Dinitrochlorobenzene was the first allergen used to treat cutaneous warts but this chemical is no longer used due to the potential risk of carcinogenesis. The side effect of itching at treatment sites is generally tolerated, but some patients develop dermatitis in other areas or widespread urticaria [149]. The use of squaric acid dibutylester as a contact allergen in such regimens may be equally efficacious and better tolerated [150]. Trials using intralesional Candida antigen to produce a local hypersensitivity reaction suggest that this approach could speed wart resolution in recalcitrant cases [152]. Different interferons have been administered by different routes to patients with refractory warts in various sites. These studies are seldom directly comparable, and the use of interferons in warts is still experimental. The majority of studies have involved patients with refractory genital warts and interferon use has mostly been disappointing. Cutaneous warts on the palms and soles may have been treated with intralesional interferon, using a needleless injector [157]. Results from the use of oral cimetidine in wart treatment in adults have been conflicting. Podophyllin and purified podophyllotoxin act as antimitotics, disrupting the formation of the spindle on which chromosomes align at mitosis. They are used mainly for the treatment of anogenital warts but can also have an effect in cutaneous warts, although penetration into keratinized skin may be poor. They have been used with caution under prolonged occlusion [131] or in a strength of 5% in combination with salicylic acid and cantharidin applied every 2 weeks for up to 10 weeks [132,133]. Podophyllin and Part 3: InfectIons & InfestatIons the carbon dioxide laser has a greater risk of producing scarring but has been used to treat a variety of different forms of wart, both cutaneous and mucosal [117]. It can be effective in eradicating some difficult warts, such as periungual and subungual warts which have been unresponsive to other treatments. Carbon dioxide laser therapy is well tolerated, but can cause significant postoperative pain, hypertrophic scarring and temporary loss of function [117] [120]. Infectious virus can be detected in the plume during carbon dioxide laser use [121], so an operator mask and air extraction system are advised. Laser treatment for other indications has been associated with the spread of facial warts [122,123]. Topical immunomodulation with imiquimod 5% cream is licensed for treatment of genital warts, superficial basal cell carcinoma and actinic keratoses. Cutaneous warts have also responded to imiquimod treatment [135], although poor penetration through the keratinized surface may necessitate twice daily application for up to 24 weeks, or combination with salicylic acid to achieve useful results [136]. The treatment can cause irritation, discomfort and occasionally erosion at the point of application with a small risk of causing vitiligolike depigmentation [142]. In children, cimetidine may produce slightly greater benefit [162,163] and combination treatment with levamisole may enhance the effect [164]. Ranitidine has been assessed in an open study in which 49% of patients with common or plane warts cleared whilst taking 300 mg twice daily [165]. Topically, zinc sulphate as a 10% aqueous solution applied three times daily for 4 weeks in a doubleblind trial, produced a cure rate of 86% for plane warts [168]. Oral retinoids, by reducing epidermal proliferation, can help to debulk warts, although the infection may persist making relapse likely. Acitretin and isotretinoin have been reported to be helpful in cases of extensive and hyperkeratotic warts in immunosuppressed patients [170,171]. Hyperkeratotic warts in otherwise healthy patients can respond to oral retinoid therapy [172,173]. This effect may be temporarily useful, perhaps in relieving pain or disability due to exceptionally hyperkeratotic warts, or in facilitating the use of other treatments. Injections are into the wart itself, confirmed by observing blanching in the lesion, the volume per injected lesion ranging between 0. Injections are very painful and preceding or concurrent local anaesthesia should be considered, especially for sensitive sites such as the fingers and soles [181]. In open studies, cure rates for previously refractory warts are reported to be between 20 and 100% [179,180,182], with some superiority over cryotherapy [183,184]. Trials comparing intralesional bleomycin with placebo have shown a useful effect [177,185]. Local complications include nail loss [186] or dystrophy [187] following periungual injections, Raynaud phenomenon in treated fingers and local pigmentation [188] or urticaria [186]. Flagellate hyperpigmentation, more commonly a feature after systemic administration, has been reported after local injection [189] and this potential risk of systemic absorption is a contraindication for intralesional bleomycin in pregnancy [179]. Implantation of the bleomycin from a surface application using a sterile lancet [190] or the Dermojet [191] may be better tolerated. Side effects, mainly seen with systemic administration, include nephrotoxicity, metabolic acidosis and bone marrow suppression. Local application especially on mucosal surfaces can produce erosion and pain but topical treatment of skin lesions is generally well tolerated [194]. Formal hypnosis, however, was reported to clear warts on the suggested (the more severely affected) side only, in nine of 10 patients who achieved a satisfactory depth of hypnosis, the other side of the body acting as an internal control [199]. Persistent refractory warts disappeared following hypnosis in an uncontrolled study of three immunodeficient children [200]. Incidence and prevalence In countries with highly developed medical services, referral rates of genital warts have greatly increased in the last 50 years. Sex the incidence and prevalence in males is higher than in females with a male: female ratio of 1: 0. The thinner mucosal surface is presumably more susceptible to inoculation of virus than thicker keratinized skin, but in addition lesions are commonest in sites subject to greatest coital friction in both sexes. Human papillomavirus transmission has been most closely studied in the case of anogenital warts. Acquisition most commonly follows sexual contact but it is generally agreed that ano genital warts are not always transmitted sexually. Perianal warts may accompany genital warts, either due to local spread of infection or to direct contact during anal coitus. In prospective studies, approximately twothirds of sexual contacts of patients with genital warts developed lesions themselves within 24 months; infectivity seemed highest early in the course of the disease [207,208]. Occasional nonsexual acquisition of anogenital warts in adults is assumed to be possible. With the lack of largescale prospective studies, the possibility of bias in referral or in reporting should be considered, and there remains insufficient information to offer a reliable estimate of the relative frequency of sexual abuse in such cases. Postnatally, transmission from adults with genital warts may occur nonsexually [220] such as by sharing a bath with an infected adult. A review of reports published between 1976 and 1983 [221] found that, of the total of 21 cases, the probable route of infection was believed to be sexual in 11, prepartum or intrapartum in three, and unknown in seven. In studies of children with anogenital warts assessed for possible sexual abuse, the mode of acquisition was thought to be sexual in no more than 5% [222,223]. Thus, on present incomplete information, both sexual and nonsexual routes are significant in the transmission of childhood anogenital warts [224]. The long and variable incubation period, the possibility of latent or subclinical infection in the source and the problems in eliciting an accurate account of sexual contact from the child and of confirming it from the perpetrator, all make it difficult to decide which applies in an individual case. Where sexual abuse is suspected, the case should be referred to a paediatrician or child abuse specialist. The risk of transmission from mother to child with subsequent development of disease in the child has been estimated to be between 1/80 and 1/1500 [226] but only 57% of cases of laryngeal papilloma in children are diagnosed by 2 years of age [227]. The connective tissue is frequently very oedematous and the capillaries tortuous and increased. The typical anogenital wart is soft, pink, elongated and sometimes filiform or pedunculated. The lesions are usually multiple especially on moist surfaces, and their growth can be enhanced during pregnancy [236], or in the presence of other local infections [237]. The commonest sites, the area of the frenulum, corona and glans in men, and the posterior fourchette in women, correspond to the likely sites of greatest coital friction [236]. Most other lesions are flat, though more conspicuous than plane warts elsewhere, and some of these, generally on nonmucosal surfaces such as the penile shaft, pubic skin, perianal skin and groins, may be sufficiently pigmented to resemble seborrhoeic keratoses. Occasionally, only lesions resembling common warts are seen, in men usually on the penile shaft, and these may be the result of contact with common warts elsewhere on the patient or on the sexual partner [238]. Antiretroviral treatment may lead to worsening of the warts rather than improvement [243]. Childhood cases are believed to result from maternal infection, probably at birth during vaginal delivery. Latent or subclinical infection in the laryngeal mucosa presumably explains recurrences after successful treatment, and might explain adultonset cases, although some of these may be due to sexual transmission [249]. Conjunctival papillomas Human papillomavirus of the lowrisk mucosal type is frequently detected in conjunctival papillomas [251] with rare detection of highrisk types [252]. The development of large protuberant masses, induration, pain or serosanguinous discharge should arouse suspicion of malignant change requiring prompt excision or biopsy and also assessment of immune status. Histologically, differentiation from malignant condylomas may be difficult after treatment with podophyllin or podophyllotoxin due to increased mitotic index. Condylomata lata and lymphogranuloma venereum (see Chapter 30) should be considered. Metastatic Crohn disease involving the vulval or perianal area often presents with skin tags on an oedematous or indurated background. Vulval papillomatosis, with a diffuse velvety or granular appearance in the vaginal introitus, and pearly penile papules may cause confusion with the possibility of warts.

However birth control for women hasfit order alesse 0.18mg fast delivery, in most cases birth control implant effectiveness alesse 0.18mg mastercard, the histology shows nonspecific features birth control womens liberation buy online alesse, with epidermal spongiosis birth control pills were first approved by the fda in the generic alesse 0.18 mg fast delivery, papillary oedema birth control pills progesterone only 0.18mg alesse fast delivery, and superficial and deep perivascular inflammatory cell infiltrates with numerous eosinophils [54] birth control japan best order for alesse. Management [8,12,16,44,58,59,60,61,62,63] Indication for therapy Treatment should be prescribed to the patient and close physical contacts, even without pruritus or cutaneous lesions. Patient education Patients should be advised to avoid close physical contact until they and their household members and sexual partners have been treated. A detailed verbal and written information about scabies infestation should be given to the patient [64]. Treatment options Topical and oral products are available although rigorous studies to guide their use are lacking. Topical treatment includes permethrin, lindane, benzyl benzoate, esdepallethrine (bioallethrin), crotamiton and precipitated sulphur. Despite the varied methodological quality of trials, a recent metaanalysis suggested that topical permethrin is the most effective [61]. In one recent trial in which two doses of permethrin were compared with a single dose of ivermectin, only a small and nonsignificant advantage was observed with permethrin (93 versus 86%) [68]. Oral ivermectin interrupts the aminobutyric acid induced neurotransmission of many parasites including mites, but is not licensed for use in scabies in most countries. Because ingestion of food increases the bioavailability of ivermectin by a factor of 2 [72], taking it with food might enhance the penetration of the drug into the epidermis. Many of the reported adverse effects have occurred in individuals given ivermectin for the treatment of filariasis, in whom serious reactions were thought to be related to death of the parasites [73]. In the absence of confirmed mites, diagnosis is currently based entirely on clinical and epidemiological findings. Given the extensive differential diagnoses, the specificity of clinical diagnosis is poor, especially for those inexperienced regarding scabies [46]. Furthermore, there are the difficulties in distinguishing between active infestation, residual skin reaction and reinfestation. Despite the relatively low sensitivity of diagnostic testing, empirical treatment is not recommended for patients presenting with generalized itching [12]. Therefore some authors consider the drug must be contraindicated in children less than 5 years of age or under 15 kg, and during lactation. Finally, permethrin or ivermectin may be used for the treatment of classical scabies. Oral ivermectin is more expensive and not licensed in most countries; however, this agent may be preferred for patients who cannot tolerate topical therapy or are unlikely to adhere to a therapeutic regimen [12,63]. In classical scabies, the combination of topical therapy and oral ivermectin has never been compared with either treatment alone. Materials or fomites that cannot be washed should be treated with insecticidal products. However, it is possible that patients receiving oral ivermectin remain contagious longer than those receiving topical therapies [12,63]. Benzyl benzoate and esdepallethrine are safe in children <2 years of age, but duration of use should be limited to 12 h. If topical treatment is chosen, antibiotherapy against Streptococcus pyogenes and Staphylococcus aureus should be performed before. Permethrin, benzyl benzoate and sulphur appear to be safe in pregnancy, although the evidence is limited [87]. The management of institutional outbreaks is mainly based on consensus expert opinion. It requires coordination and adequate education of all involved personnel and a sustained effort to rapidly control the outbreak. Prompt recognition of the index case, formation of an outbreak management team, determining the extent of the outbreak and risk factors for transmission, immediate implementation of infection control Additional measures Examination and laboratory investigation to search for sexually transmitted infection should be performed as scabies is considered to be a sexually transmitted disease [60]. Topical treatment must be applied to the entire skin surface, including the scalp, all folds, groin, navel and external genitalia, as well as the skin under the nails. Treating the face of babies is essential because transmission may occur by breastfeeding. Hands should not be washed during therapy, otherwise the treatment should be reapplied. If topical treatment is applied by another person, it is recommended that this person wears protective gloves. Followup Itching may persist several weeks after scabies, and this should be clearly explained to the patient. Crusted scabies is a rare and severely debilitating form of the disease, characterized by the infestation of up to millions of mites and the development of hyperkeratotic skin crust. An undiagnosed case of crusted scabies may be the source of an outbreak of common scabies. Causes Cutaneous irritation Overtreatment Eczematization Contact dermatitis Poor compliance: inappropriate or insufficient treatment Resistance to scabicide Reinfestation or relapse Delusions of parasitosis Management Intensive use of emollient Intensive use of emollient Topical steroid Further scabicide application Treatment failure Change scabicide Further scabicide application Antipsychotic drugs (prescribed by dermatologists and/or psychiatrists) Treat the underlying cause pathophysiology [5,6] In common scabies, there are few mites, probably because scratching destroys the burrows. Crusted scabies occurs in people with an inadequate immune response to the mite, allowing them to multiply. It is a severe disease with a significantly higher morbidity than ordinary scabies. Patients who are mentally retarded or suffer from dementia may develop crusted scabies [7], and Down syndrome is a frequent association [3,8]. The reason for this association with mental abnormality is not completely understood, but lack of appreciation of pruritus may be important. Crusted scabies has also resulted from the use of topical steroids [21] and pimecrolimus [22]. Crusted scabies sometimes occurs in otherwise healthy individuals [23,24], and in northern Australia, where crusted scabies is a problem in the Aboriginal population, 42% of a series of 78 patients had no identifiable risk factors [25]. Erythema Psychogenic pruritus Nonparasitic dermatosis Adapted from Chosidow 2000 [14]. A keratolytic agent such as a salicylic acid preparation should be used to treat hyperkeratosis. Expert consensus recommends combining topical and oral therapy [35], although this has never been evaluated. Topical scabicide application should be repeated until two parasitological tests 3 days apart become negative. The administration schedule of ivermectin should be based on the severity of infection [40]; between three and seven doses have been proposed [27]. Recently, a simple clinical grading scale to aid in the management of patients with crusted scabies has been proposed and may be useful [42]. Management If contact with animal scabies is suspected, the diagnosis can only be confirmed by examining and taking scrapings from the suspect animal. Human skin lesions are selflimiting, and will resolve once exposure to the affected animal has ceased, or it has been treated. Despite being selflimited, the skin eruption may be uncomfortable, and topical treatment such as 5% permethrin cream will hasten recovery [20]. Oral ivermectin (200 g/kg single dose) has been used [20,21], as well as topical corticosteroids, menthol preparations, and oral antihistamines for symptomatic relief [22]. Family Knemidokoptidae Knemidokoptes mutans causes scaly leg in domestic poultry, and Mesoknemidokoptes laevis is a closely related mite which causes depluming itch in poultry; both have caused skin lesions in humans [1]. Family Sarcoptidae: animal scabies Family Psoroptidae introduction and general description Transmission of animal scabies to humans is probably rare, because of the relative host specificity of the mites [1]. However, recurrent exposure to animal scabies mites can produce troublesome and diagnostically puzzling lesions. Many varieties of Sarcoptes scabiei have been incriminated, including the following. Exceptionally, scrapings from human skin have shown mites and eggs, and symptoms have persisted after contact with the animal has ceased [15]. Affected animals have areas of scaling and hair loss on the ears, face and limbs [17]. Species of Chorioptes and Psoroptes from cattle, horses and sheep have occasionally affected humans [1,2]. Otodectes cynotis is a common parasite in the ears of cats and dogs, and has been discovered in the ears of a patient suffering from otitis externa [3,4]. It was also considered to be responsible for a pruritic dermatosis in a patient whose dog was infested. The distribution of the dermatitis is dependent upon the areas that come in close contact with the animals [5]. Family Listrophoridae Listrophorus gibbus, a common parasite of the domestic rabbit [6], has been reported as causing papular urticaria in a child [7]. The extent of the erythroderma and the warty plaques varies greatly, and either may predominate. Crusted scabies may be localized, affecting only the scalp, face, fingers, toenails or soles [28]. Generalized lymphadenopathy is present in some cases, and blood eosinophilia and elevated IgE levels are common. Crusted scabies may masquerade as hyperkeratotic eczema, psoriasis, Darier disease [29], contact dermatitis [30] and Langerhans cell histiocytosis [31]. The diagnosis is readily confirmed by examination of scrapings, which will be teeming with mites and eggs. Clinical features Skin lesions resulting from contact with animal scabies vary in extent and distribution, according to the mode of exposure. The eruption is usually composed of small pruritic weals or papules, which are frequently excoriated, and resemble human scabies, but without burrows. Lesions from exposure to sarcoptic mange in dogs and notoedric mange in cats usually occur at sites of contact with the animal, principally the chest, abdomen, thighs and forearms. In addition to respiratory allergy, skin lesions can occur, secondary to bites or contact with allergens. Herbivorous and fungivorous, they subsist on fungi and are pests of stored food products with high moisture content. The appearance of the eruption on the face may suggest an acute contact dermatitis. Housedust mites introduction and general description Dermatophagoides pteronyssinus, the housedust mite, was first discovered by Trouessart in dust shaken from tanned mammal skins [1]. It was subsequently established that it is widely distributed in the human environment in house dust and beds [2,3]. Part 3: InfectIons & InfestatIons epidemiology It occurs worldwide, and has been reported from all inhabited continents [4]. It is commonly associated with Euroglyphus maynei and Dermatophagoides farinae, which are related species in the same family, the Pyroglyphidae. Classification Family Acaridae these mites attack flour, grain, dried meat, cheese and dried fruit. Acarus siro is the most important pest of storage premises, and is found on flour, grain and, occasionally, cheese. Suidasia nesbitti is particularly associated with wheat pollards and bran, and has been recorded as causing dermatitis in humans [8]. Rhizoglyphus species occur on flower bulbs and have caused dermatitis in persons handling stored bulbs. Numbers vary seasonally, increasing in early summer to reach a maximum by early autumn. Xerophylic moulds, especially Aspergillus penicilloides, are essential for the growth and survival of D. The major housedust mite allergens (Der p1 and Der f1) are present in the faecal pellets. Family Carpoglyphidae Carpoglyphus passularum (lactis) is found on all kinds of dried fruit, and may cause dermatitis [9,10]. The allergens of Euroglyphus maynei are thought to play a role in the sensitization and induction of clinical symptoms of atopic eczema [14,15] the mites that most frequently induce atopic eczema are D. One study demonstrated that the houses of patients with moderate to severe atopic eczema had more housedust mites than controls [23]. A recent critically appraised article concluded that there is unsufficient evidence to support housedust mite reduction in the management of atopic eczema [24]. Family Glycyphagidae Glycyphagus domesticus is a widely distributed species, often found in large numbers on plant and animal remains in houses and stables. Extracts from storage mites include endotoxins which may modulate cell adhesion and secretion of cytokines by microvascular endothelial cells.

Secondary infections leading to bronchopneumonia birth control pills make me sick buy cheap alesse 0.18mg line, enteritis and otitis media are most commonly reported birth control insert alesse 0.18 mg online. If the immune response is defective birth control pills case purchase alesse with american express, there may be no rash but viral replication progresses to produce a giantcell pneumonia or a fatal encephalopathy birth control pills 1957 buy alesse 0.18 mg cheap. Infection during pregnancy can lead to spontaneous abortion birth control glasses buy generic alesse 0.18 mg, premature delivery and may carry a risk of more severe disease for the mother [12] birth control pills recommended discount alesse 0.18mg with visa. Presentation [8] the onset is acute with prodromal symptoms of fever, malaise and upper respiratory symptoms of pharyngitis and rhinitis. Fever, catarrh and cough Disease course and prognosis the rash starts on the head and neck, and spreads from upper to lower body. From the fourth to the tenth day the rash fades, to leave some brownish staining and fine desquamation. The transient immunosuppression lasting for a few weeks can increase the risk of bacterial infections in the recovery period. The exanthem characteristically develops on the fourth day on the forehead and behind the ears, and spreads within 24 h to the rest of the face, the trunk and the limbs. The rash, which can be slightly itchy, is at first macular but soon forms dull red papules which tend to coalesce in irregularly concentric patterns but may be more diffusely confluent. Not all features of the illness may be present [9], but the presence of Koplik spots is an almost diagnostic feature of measles infection [10]. Prevention Passive protection is possible using normal human immunoglobulin given within 5 days of exposure, which prevents or attenuates the infection in contacts and is reserved for those children at special risk or for nonimmune pregnant mothers after exposure to an infected contact. Active immunization with live attenuated viral vaccine has reduced the incidence of measles infections. There are two antigenic subtypes, A and B, which differ most in their surface glycoprotein G. Group A viruses are more frequently detected and a higher proportion of severe infections are associated with group A [20]. The virus is especially associated with bronchiolitis in babies with bronchitis and pneumonia occurring in a proportion of infections. In older children and adults, upper respiratory symptoms occur that are indistinguishable from a common cold. A transient fine pink macular rash on the face and trunk has been observed in a few instances in children, but is of no diagnostic significance. Occasionally, it is more extensive and involves the arms, shoulders, chest, back and buttocks [22]. First line the patient should be confined to home and bed and given symptomatic treatment. It presents as an acute acral dermatosis, occurring predominantly in young adults. The cutaneous features are frequently accompanied by oral inflammation with petechiae, vesicopustules and ulceration [17]. Malaise and fever can follow a few days after the onset of the eruption and there may be lymphadenopathy. Incidence and prevalence Usually occurs as an isolated case but has been reported in families [3]. In acute papular pruritic gloves and socks syndrome associated with parvovirus, antiviral IgM is usually detectable at the time of the eruption and IgG is detectable later [21]. Pathophysiology Pathology Epidermal acanthosis and patchy basal cell degeneration with subepidermal oedema and a patchy mixed inflammatory cell infiltrate and extravasated red blood cells are seen [4]. The viral structural protein may be detected in the walls of dermal blood vessels [5]. In practice, there are some distinctions between the manifestations of the various infections, although all may cause cutaneous and disseminated abnormalities. Causative organisms Parvovirus B19 infection is the most commonly associated infection [8]. Clinical features Presentation the hands, wrists, feet and ankles are intensely pruritic and are affected with macular and papular erythema and associated Table 25. Epidemiology Age Part 3: InfectIons & InfestatIons the syndrome mainly affects children between the ages of 6 months and 12 years, though occasional adult female cases have occurred [27,28]. Itch is said not to be a feature of the hepatitis B cases, but may occur in those due to other viruses. Generalized lymphadenopathy, mostly axillary and inguinal, is common but not invariable, and persists for months after the rash. Constitutional symptoms are not usually marked although there may be mild fever and lassitude. Causative organisms the majority of the early cases reported had hepatitis B infection [29], but several other viral and nonviral infections have been associated (Table 25. Differential diagnosis the skin lesions are sufficiently distinctive in morphology, distribution and duration. Differential diagnoses to consider include lichen planus, lichenoid drug eruptions, scabies and erythema multiforme. Clinical features Presentation the eruption starts asymmetrically, affecting the axilla, groin or trunk and then spreads centrifugally [67]. Complications and comorbidities In the hepatitis B cases, liver involvement appears to be invariable, usually mild and anicteric, but occasionally there is jaundice and hepatomegaly, and histological recovery may take between 6 months and 4 years. Disease course and prognosis A lowgrade fever can develop, usually after the onset of the eruption, although malaise and fever can precede the rash [68]. Pityriasis rosea definition and nomenclature Pityriasis rosea is an acute selflimiting disease, probably infective in origin, affecting mainly children and young adults and characterized by a distinctive skin eruption and minimal constitutional symptoms. Although the cause of pityriasis rosea is uncertain, many epidemiological and clinical features suggest that an infective agent may be implicated. The natural history of the disease, with a primary lesion which could correspond to the site of inoculation, a disseminated secondary eruption after an interval, mild constitutional symptoms, a selflimiting course, and the infrequency of second attacks, are all features paralleled by many diseases of proven infective origin. The upper dermis shows mild papillary oedema and a mononuclear cell perivascular infiltrate with focal invasion of inflammatory cells into the epidermis, where they may form pustules, mainly subcorneal. Occasional dyskeratotic keratinocytes are seen, sometimes adjacent to a Langerhans cell. Part 3: InfectIons & InfestatIons Predisposing factors the eruption has been reported during immunosuppressive treatment with oral corticosteroids [78] and after bone marrow transplantation [79], but it is not a common rash seen in such situations. Causative organisms Many infectious agents have been suspected as causative but most speculation now centres on a viral aetiology. Viruslike particles were detected ultrastructurally over 30 years ago and more recently herpesviruslike particles have been found in 71% of pityriasis rosea lesions [106]. Not all groups working in this field have confirmed the presence of these viruses in patients with pityriasis rosea and the strength of the association continues to be debated [109,110]. Pathology [104,105] the herald patch and secondary lesions show similar histological features but these are not diagnostic. Rarely, the herald patch may appear on the face, scalp, penis, palm or sole [115]. It is a sharply defined, erythematous, round or oval plaque, soon covered by fine scale. In its classical form the eruption consists of discrete oval lesions, dull pink in colour and covered by fine dry silverygrey scales. The long axes of the lesions characteristically follow the lines of cleavage parallel to the ribs in a Christmas tree pattern on the upper chest and back. The scaly lesions are commonly associated with pink macules of varying size and the eruption may be exclusively macular. The lesions are usually said to be confined to the trunk, base of the neck and upper third of the arms and legs. These sites are certainly most consistently and severely affected but involvement of the face and scalp is quite common, especially in children, and in one large series of cases lesions were found on the forearms and lower legs in about 12% and 6%, respectively. There may be discrete scaly red patches, diffuse redness and scaling or scattered small vesicles. Oral lesions are not infrequently present [116] and can consist of illdefined red patches with some desquamation or with punctate haemorrhages, or bullae. Subjective symptoms are usually absent but there may be slight or moderate pruritus. Occasionally, slight fever, malaise and enlargement of the lymphatic glands, generalized or confined to the cervical glands, may be present, and, exceptionally, more severe constitutional symptoms have been recorded, although their extreme rarity suggests that they may have been fortuitously associated and not a manifestation of the disease. Clinical variants Pityriasis rosea may be atypical in the appearance or distribution of the lesions or in its course [117]. The more widespread eruption may be almost generalized or may be limited to a few lesions, often around the herald patch. In some cases, the eruption is confined to a single region, or may be maximal on the extremities almost sparing the trunk [118,119]. Especially in children, the lesions may be predominantly papular or urticarial in the early stages, but they are soon surmounted by an inconspicuous ring of fine scales. Papulovesicular, vesicular, purpuric, erythema multiformelike lesions, follicular and pustular forms may rarely occur [121,122]. In a variant of the papular form, more common in Africans than Europeans, small lichenoid papules are thickly set in the edges of the lesions [123]. In pityriasis (rosea) circinata et marginata of Vidal [124], sometimes regarded as a special form of pityriasis rosea and seen mainly in adults, the lesions are few and large, and are often localized to one region of the body, especially the axillae or groins [125]. Rarely, this form may follow a typical generalized pityriasis rosea, but it usually occurs alone. The pattern may be variable in a patient taking a drug which is known to produce reactions of this nature, with a pityriasiform eruption being atypical, progressive and irritable. Histologically, apoptotic keratinocytes in the epidermis and eosinophils in the dermis may be seen. There is no herald patch, the lesions often develop slowly and are most numerous on the upper trunk near the midline, on the neck and in the scalp, and they are duller in colour with thicker and more greasy scales. The acute urticarial forms in childhood can sometimes not be identified with complete certainty on first examination unless a herald patch can be discovered. In pityriasis lichenoides they are polymorphic, some showing haemorrhagic crusting and some adherent scales. The hypopigmented patches with dry, branny scales of pityriasis alba are most frequent on the face, and are seen mainly in young children. The pigmented form of pityriasis versicolor does not show marginal scaling and the chronicity would be very atypical. The herald patch and the localized forms such as pityriasis circinata are easily, and in practice frequently, confused with ringworm. The lesions of ringworm are red and oedematous and may show marginal vesiculation. In case of doubt, scrapings from the edge of the lesions should be examined microscopically for mycelium. Management the common asymptomatic and selflimiting cases require no treatment [127]. The standard dose regimen of aciclovir (400 mg five times a day for a week) or higher doses (800 mg five times daily for 1 week), used early after the onset of the eruption, may lead to a more rapid resolution of skin lesions [130]. The use of oral erythromycin antibiotic (1 g four times a day for 2 weeks for adults) was reported to clear the disease within 2 weeks of treatment [132] but subsequent studies with erythromycin and azithromycin have not confirmed any effect [133,134]. The Munich outbreak of cutaneous cowpox infection: transmission by infected pet rats.

An important differential diagnosis to consider is phytophotodermatitis as there are many similarities between the two conditions including linear asymmetrical erythema birth control 7 7 7 order alesse 0.18mg on-line, blister formation and depigmentation [35] birth control quick start purchase 0.18mg alesse with mastercard. Management Experts agree that affected patients should be managed as irritant contact dermatitis birth control viorele buy alesse online, with removal of the toxin by immediate washing with soap and water birth control for women limited buy generic alesse 0.18 mg. Primary prevention by increasing public awareness during outbreaks birth control for women xxy purchase discount alesse line, decreasing the use of artificial lights at night and using mosquito nets is advocated by several authors [18 birth control pills unhealthy cheap 0.18 mg alesse free shipping,21]. Part 3: InfectIons & InfestatIons and flooding [20], and in a military base in Iraq [21]. A plague of whiplash rove beetles (Paederus australis) forced evacuation of an aboriginal community in the Northern Territory of Australia [22]. Histopathological changes of Paederus dermatitis include intraepidermal and subepidermal blistering, epidermal necrosis and acantholysis [28]. It has been proposed that the biblical third, fourth and sixth plagues of Egypt might have been related to rove beetles and the bullous lesions they cause [29]. The adult beetles are not known to be directly injurious to humans, but their larvae are covered with hairs, which may cause skin lesions. Clinical features Contact urticaria to locusts has been reported by Monk [4] in a laboratory research worker who handled a large number of locusts. The patient produced a positive reaction to locust antigen on prick testing and a wealing reaction at the site of contact with a live locust. Similarly, worsening of asthma, and urticaria in an atopic research laboratory worker, on exposure to grasshoppers, has been described [5]. Papular urticaria in a child, caused by the larvae of Dermestes maculatus DeGeer, has been reported, but it was uncertain whether the reaction to the hairs was irritant or allergic [37]. Dermestes peruvianus was responsible for dermatitis, vasculitis, cervical lymphadenopathy and pulmonary nodular interstitial infiltrates in a man whose bed was colonized by the beetles [38]. There is also a report of the damaging effect of Anthrenus larvae on paraffinembedded tissue specimens, especially the sectioned surface of hyperkeratotic lesions [42]. Part 3: InfectIons & InfestatIons Butterflies and moths (Lepidoptera) definition and nomenclature Many members of this large order are of importance to the dermatologist because of the irritant properties of the hairs or spines of the caterpillars and sometimes of the adults. Skin lesions in the majority of cases are produced by a combination of mechanical and pharmacological effects [1,2]. They belong to one of the primitive orders of insects, being allied to crickets, grasshoppers, preying mantids and stick insects. Cockroaches were originally adapted to hot climates, but a number of species have established themselves in cool climates by living inside warm human habitations. They are active nocturnally, and are attracted to any organic material that may serve as food. This theoretically makes them potential mechanical vectors (by transportation, also called phoresy) of pathogenic organisms [1,2,3]. The Lepidoptera contain probably between 125 000 and 150 000 different species of caterpillars, moths and butterflies [4]. Epidemics of caterpillar dermatitis are frequent, depending on the seasonal abundance of the different species. Winds can also disperse caterpillar setae, which may cause dermatitis or ophthalmia nodosa [13,14]. A large outbreak of dermatitis caused by setae of the Asian mulberry tussock moth (E. Chronic urticaria in a child has been attributed to cockroach hypersensitivity [10]. Locusts (Orthoptera) definition Sensitivity reactions, manifest as asthma and allergic rhinitis, are a recognized occupational hazard in those working with laboratory colonies of locusts [1,2,3]. Granulomas have been demonstrated in cases of ophthalmia nodosa [14], dendrolimiasis and pararamose. Caterpillar dermatitis is quite frequent in children, but the reasons for this elevated frequency remain unknown, and may be due to parental concern and increased reporting [12,17]. Clinical features [1,2,27] Presentation Clinical features induced by caterpillars and moths are wide, ranging from localized stinging reactions, papular urticaria, urticarial weals, haemorrhagic diathesis, ophthalmia nodosa, dendrolimiasis, pararamose and oral exposure [27]. Localized stinging reactions consist in immediate mild to severe pain that lasts hours to days. Contact with Megalopyge caterpillars [28] produces immediate intense burning local pain accompanied by a spreading erythema around the puncture sites. The affected area becomes oedematous, and there is often lymphangitis and regional lymphadenopathy. The local changes may be accompanied by pyrexia, headache, nausea and vomiting, particularly in children [29]. In papular urticaria, there are mild to moderate localized pruritic papules or eczematous lesions, predominantly in exposed area. Lesions are caused by the setae from hairy or bristly caterpillars or from adult moths. Urticarial weals and angio-oedema are seen with three species of processionary caterpillars (all belong to the genus Thaumetopoea). Dendrolimiasis combines dermatitis and rheumatological involvement (arthralgia and arthritis) and is caused by contact with the Masson pine caterpillar (genus Dendrolimus) found in China [36]. Pararamose is quite similar, with skin eruption and arthritis, caused by contact with the Brazilian moth Premolis semirufa [10,37]. In the eye, caterpillar setae may cause a variety of changes ranging from conjunctivitis to ophthalmia nodosa [13,14,38] and even panophthalmitis. They are hollow, and may function as sensory receptors or communicate with a poison gland cell and contain venom. They commonly have barbs, which hold them in place when they have penetrated the skin. The point of attachment to the caterpillar is very narrow and easily fractured; hence, contact with the caterpillar may release huge numbers of these tiny darts. Setae are also woven into cocoons, and into the webs of the silkspinning caterpillars. The spines either have a terminal plug of inspissated material at their open ends, which is released by pressure, or a weak point at which the spine fractures to allow the venom to escape. Poisonous spines occur particularly on the caterpillars of the moth families Cochlididae (Eucleidae; Limacodidae), Saturniidae and Megalopygidae. The venoms present in the setae and spines of caterpillars of a number of families of Lepidoptera have been studied, but not Part 3: InfectIons & InfestatIons fully elucidated. A protein, the thaumetopoein, has been isolated from pine processionary caterpillar hairs [18,19]. This has a direct effect on mast cells, leading to degranulation, and explains the urticating properties of these caterpillars. Immediate and delayedtype reactions to Euproctis pseudoconspersa caterpillar venom extracts have also been demonstrated [24]. Differential diagnosis Differential diagnosis may be broad as cutaneous lesions and histology are not specific. Management [27] in South America, for example Lycosa antibucana, cause severe swelling and lymphangitis. Some colourful species kept as pets, for example Brachypelma smithi, are among several that have urticating hairs capable of causing prolonged pruritus. Many spiders whose bites are dangerous, and sometimes fatal, are small, inconspicuous and unimpressive. Part 3: InfectIons & InfestatIons Management of lepidopterism is mainly based on expert opinion and is largely symptomatic. Topical steroids and oral antihistamines should be used for mild reaction to control pruritus. Specific antivenom against potentially fatal Lonomia genus envenomation is available [39]. The form of arachnidism caused by species of the family Loxoscelidae is known as loxoscelism, and that by widow spiders (Latrodectus species) latrodectism [9]. Air transport of crates of fruit and other materials may introduce exotic species to countries in which they are unable to multiply but can survive long enough to attack humans. Diagnosis [2] the diagnosis of spider bite is based on a clear history of a spider biting, ideally with collection and correct identification of the spider responsible, sometimes requiring the assistance of an entomologist. In areas where the spiders are recognized, the general population may identify a few spiders, such as widow spiders. Unlike insects, where the body is divided into three segments (head, thorax and abdomen), arachnids have only two, the cephalothorax, from which the legs arise, and the abdomen. The Arachnida are classified into seven orders, only three of which are of medical importance as follows. Differential diagnosis Differential diagnosis may be broad including pyoderma gangrenosum, herpes simplex and zoster, staphylococcal or streptococcal infection, lymphomatoid papulosis, chemical burn and squamous cell carcinoma. Family Theridiidae Genus Latrodectus (widow spiders) Spiders (araneae) introduction and general description the appearance of many of the larger spiders inspires terror or disgust, but very few of the many thousands of species are dangerous to humans [1,2]. That is why, when observing a large skin bite, many people suspect a spider bite with no scientific, clinical or entomological evidence. The myth that bites from various species cause necrotic ulceration may not be completely true [2]. In fact, bites by spiders from the genus Loxosceles can result in necrotic arachnidism and sometimes systemic illness, but many cases of necrotic arachnidism are only suspected and not proven [3]. Almost all are venomous and bite, but only a few have chelicerae strong enough to penetrate human skin, and in most cases the bites are trivial. A recent Australian study describing 750 cases of spider bite, involving 26 spider families, showed that most of the time there were only a few symptoms [4]. The European tarantula, Lycosa tarantula, which inspired the tarantella in Italy in the Middle Ages, inflicts a temporarily painful but harmless bite. Some lycosid spiders Epidemiology Spiders of this genus are widely distributed throughout the world. Latrodectus mactans, the black widow spider, occurs throughout subtropical and tropical regions. Other species have a similar, but more limited, range, although some extend to the temperate regions of Russia and Canada. It is the adult female spiders that produce the most damaging bites in humans, but bites by male spiders have been reported in Australia [10]. She normally spins her web in empty burrows or under stones, but may be found in dark corners of barns, garages, store rooms or outdoor lavatories. Latrodectus venom is considered to be one of the most potent toxins, exceeding that of snake venoms, but the dose injected is minute in relation to the body weight of a human victim. The toxins of all species of Latrodectus that have been studied appear to be closely related, and the symptoms from envenomation are similar. It normally lives under rocks and logs, but the spread of the Sydney suburbs into its habitat provided similar hiding places under houses. Funnel web spider antivenom should be given urgently to any patient with severe envenomation, because it probably reduces the risk of death and the length of hospital stay [24]. The bite of Latrodectus species is fairly painless, but within a few minutes increasingly severe pain develops, usually at the site of the bite but also spreading to the adjacent region or even to the back, chest or abdomen. Puncta may be visible at the site of the bite, and there is local erythema and oedema. There is frequently profuse sweating, and neuromuscular involvement causes paraesthesiae, incoordination and paralysis. Identification of a Loxosceles spider is based on six eyes in a curved row on the upper part of the body (the prosoma). Loxosceles reclusa is active mainly at night and most bites occur when the spider is trapped against the person [3]. It is also found in homes, in areas that are dark, dirty and undisturbed, such as attics, cupboards and garages. Loxosceles rufescens is widespread in southern Australia or in Mediterranean regions [26]. Management [2] There is no consensus concerning the management of latrodectism as evidence to support therapies is scarce, and there are no controlled trials. Treatments that have been used include general measures such as analgesics and benzodiazepines, and more specific measures such as antivenom [18,19], calcium and magnesium. Furthermore, there are some concerns regarding the tolerance of these antivenoms with reported cases of anaphylaxis following administration [20,21,22]. From the majority of bites, especially those of female spiders, no general symptoms follow, and recovery is uneventful. However, the large amount of venom from male spiders may cause severe systemic symptoms.

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