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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

Surrounding healthy skin should be pro tected during treatment (see ‘Practical points’ below) bacteria quotes buy generic clindamycin 150mg online. Salicylic acid Salicylic acid may be considered to xanthomonas antibiotics clindamycin 150 mg with amex be the treatment of choice for warts; it acts by softening and destroying the skin infection medication buy cheap clindamycin on line, thus mechanically removing infected tissue bacterial infection symptoms purchase clindamycin 150mg line. Preparations are available in a variety of strengths, sometimes in collodion-type bases that help to retain the salicylic acid in contact with the wart. Ointments, gels and plasters containing salicylic acid provide a selection of methods of application. Preparations should be kept well away from the eyes and applied with an orange stick or other applicator, not with the fingers. Formaldehyde Formaldehyde is used for the treatment of verrucae; it is considered to be less suitable for warts on the hands because of its irritant effect on the skin. The thicker skin layer on the sole of the feet protects against this irritant action. A gel formulation is available for the treatment of verrucae and is applied twice a day. Both formaldehyde and glutar aldehyde have an unpredictable action and are not first-line treat ments for warts, though they may be useful in resistant cases. Glutaraldehyde Glutaraldehyde is used in a 5% or 10% gel or solution to treat warts; it is not used for anogenital warts and is generally used for verrucae. Patients should be warned that glutar aldehyde will stain the skin brown, although this will fade after treatment has stopped. Practical points Application of treatments Treatments containing salicylic acid should be applied daily. The treatment is helped by prior soaking of the affected hand or foot in warm water for 5–10 min to soften and hydrate the skin, increasing the action of the salicylic acid. Removal of dead skin from the surface of the wart by gentle rubbing with a pumice stone or emery board ensures that the next application reaches the surface of the lesion. Occlusion of the wart using an adhesive plaster helps to keep the skin macerated, maximising the effectiveness of salicylic acid. Protection of the surrounding skin is important and can be achieved by applying a layer of petroleum jelly to prevent the treatment from making contact with healthy skin. Application of the liquid or gel using an orange stick will help to confine the substance to the lesion itself. Warts and skin cancer Premalignant and malignant lesions can sometimes be thought to be warts by the patient. In this group, which is more likely to occur in the elderly, the signs might include a persisting small ulcer or sore that slowly enlarges but never seems to heal. In the case of a basal cell carcinoma (rodent ulcer), the lesion typically has a circular, raised and rolled edge. Changes in nature or appearance of pigmented skin lesions that war rant referral for further investigation include: increase in size irregular outline (surface and edge) colour change, especially to black itching or bleeding satellite lesions (near main lesion) Length of treatment required Several weeks’ continuous treatment is usually needed up to 3 months for both warts and verrucae. Patients need to know that a long period of treatment will be required and that they should not expect instant or rapid success. An invitation to come back to see the pharmacist and report progress can help the pharmacist to monitor the treatment. If treatment has not been successful after 3 months, referral for removal using liquid nitrogen may be required. Verrucae and swimming pools Viruses are able to penetrate moist skin more easily than dry skin, and it has been suggested that the high level of use of swimming pools has contributed to the high incidence of verrucae. Theoretically, walking barefoot on abrasive surfaces by the pool or changing area can lead to infected material from the verruca being rubbed into the flooring. There has been controversy about whether wearing rubber socks can protect against the spread of verrucae. Also, the wearing of this conspicuous article might in itself create stigma for the child involved. The itch of scabies can be severe and scratching can lead to changes in the appear ance of the skin. Scabies goes through peaks and troughs of prevalence, with a peak occurring every 15–20 years, and pharmacists need to be aware when a peak is occurring. What you need to know Age Infant, child, adult Symptoms Itching, rash Presence of burrows History Signs of infection Medication Significance of questions and answers Age Scabies infestation can occur at any age from infancy onwards. The pharmacist may feel it best to refer infants and young children to the doctor if scabies is suspected. The presence of the mites sets up an allergic reaction, thought to be due to the insect’s coat and exudates, resulting in intense itching. A characteristic feature of scabies is that itching is worse at night and can lead to loss of sleep. Commonly infested sites include the web space of the fingers and toes, wrists, armpits, buttocks and genital area. It is more commonly found around the midriff, underarms, buttocks, inside the thighs and around the ankles. In adults, scabies rarely affects the scalp and face, but in children aged 2 or under and in the elderly, involvement of the head is more common, especially the postauricular fold. Burrows may be indistinct or may have been disguised by scratching which has broken and excoriated the skin. Scabies can mimic other skin conditions and may not present with the classic features. Mites survive under the crust and any sections that become dislodged are infectious to others because of the living mites they contain. History the itch of scabies can take several (6–8) weeks to develop in someone who has not been infested previously. The scabies mite is transmitted by close personal contact, so patients can be asked whether anyone else they know is affected by the same symptoms. Signs of infection Scratching can lead to excoriation, so that secondary infections such as impetigo can occur. The presence of a weeping yellow discharge or yellow crusts would be indications for referral to the doctor for treatment. Medication It is important for the pharmacist to establish whether any treatment has been tried already and, if so, its identity. The patient should be asked about how any treatment has been used, since incorrect use can result in treatment failure. The itch of scabies may continue for several days or even weeks after successful treatment, so the fact that itching has not subsided does not necessarily mean that treatment has been unsuccessful. Permethrin cream is an effective scabi cide (acaricide) and malathion can be used where permethrin is not suitable. Aqueous lotions are used in preference to alcoholic versions because the latter sting and irritate excoriated skin. Benzyl benzoate application is less effective than permethrin and malathion and is rarely used these days because of its particularly irritant effect. The treatment is applied to the entire body, from the neck down wards but not the neck, face and scalp in adults. However, in children under 2 and the elderly, the advice now is to include the scalp, neck, face (avoiding eyes and mouth) and ears in the application unless the product packaging contraindicates this. This recommendation is because treatment failure has occurred as the head, neck and scalp were not treated. Patients are sometimes unsure about how to apply the preparation they have been told to use. If it is a lotion, they should pour the preparation into a bowl, then apply it to cool, dry skin using a clean, broad paintbrush, cotton wool or a shaving brush. Patients should be told to apply the preparation to the whole body, not just to the areas where burrows have been found. Particular attention should be paid to the webs of fingers, toes and soles of the feet, and to brushing lotion under the ends of the fingernails and toenails. Traditionally, patients have been told to have a hot bath before apply ing the scabicide but this is no longer recommended (see below). Malathion Malathion is effective for the treatment of scabies and pediculosis (head lice).

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Differential Diagnosis From undisclosed or missed lesions in psychotic patients antibiotics price buy clindamycin in india, or migraine antibiotic ear drops 150 mg clindamycin, giving rise to virus removal tool kaspersky cheap clindamycin 150 mg fast delivery delusional misinterpretations; from tension headaches; from hysterical antibiotics used for bronchitis discount clindamycin online master card, hypochondriacal, or conversion states. X9a Note: X = to be completed individually according to circumstances in each case. Site May be symmetrical; if lateralized, possibly more often on the left precordium, genitals; may be at any single point over the cranium or face, can involve tongue or oral cavity or any other body region. Frequency increases from general practice populations to specialized headache or pain clinics or psychiatric departments. Estimates of 11% and 43% have been found in psychiatric departments, depending on the sample. Sex Ratio: estimated female to male ratio 2:1 or greater-particularly if multiple complaints occur. Onset: may be at any time from childhood onward but most often in late adolescence. Pain Quality: described mostly in simple sensory terms, but complex or affective descriptions occur in some cases. Time Pattern: Pain is usually continuous throughout most of the waking hours but fluctuates somewhat in intensity, does not wake the patient from sleep. Associated Symptoms Loss of function without a physical basis (anesthesia, paralyses, etc. There may be frequent visits to physicians to obtain relief despite medical reassurance, or excessive use of analgesics as well as other psychotropic drugs for complaints of depression, neither type of remedy proving effective. Psychological interpretations are frequently not acceptable to the patient, although emotional conflict may have provoked the condition. The personality is often of a dependent-histrionic-labile type (“hysterical personality” or “passive dependent personality”). The first is largely monosymptomatic, is relatively rare, and consists of patients who have pain in one or two regions only, who have only recently developed pain, and who have clear evidence of emotional conflicts, perhaps with an associated paralysis or anesthesia, and a relatively good prognosis. Some patients who primarily have a depressive illness also present with pain as the main somatic symptom. Their pain may be interpreted delusionally or may be based on a tension pain, etc. The second type is of patients with more numerous or multiple complaints, often of many and varied types without a physical basis. In the history these often number more than 10, including classical conversion or pseudoneurological symptoms (paralyses, weakness, impairment of special senses, difficulty in swallowing, etc. In the third, or hypochondriacal, subtype, the patient presents excessive concern or fear of the symptoms and a conviction that disease is present despite thorough physical examination, appropriate investigation, and careful reassurance. A hypochondriacal pattern may be observed either alone or with the first or the second subtype, more often with the second. In all types, physical treatments (manipulation, physiotherapy, surgery) tend to produce brief improvements which are not maintained. In the second and third types, a disorder of emotional development is often present. Note: Depressive pain has been distributed among the above three types and also into the delusional and tension pain groups. This is done because there does not seem to be a single mechanism for pain associated with depression, even though such pain is frequent. The words “depressive pain” as indicating a particular type or mechanism should be avoided. Aggravating Factors Emotional stress may be a predisposing factor and is almost always important in the monosymptomatic type. Experience of physical illness or pain due to emotional stress in person or in a family member or close associate may be a predisposing factor. In relatively acute monosymptomatic conditions, environmental change and sometimes individual psychotherapy may promote recovery. Complications Dependence on minor tranquilizers; salicylate addiction; narcotic addiction; drug-induced confusional states; excessive investigations; unsuccessful surgery, sometimes repeatedly. Social and Physical Disability Often associated with marital disharmony, inability to sustain regular employment, sometimes loss of function or limbs due to surgery. Essential Features Pain without adequate organic or pathophysiological explanation. Separate evidence other than the prime complaint to support the view that psychiatric illness is present. Proof of the presence of psychological factors in addition by virtue of both of the following: (1) an appropriate and important relationship in time exists between the onset or exacerbation of the pain and an emotional conflict or need, and (2) the pain enables the individual to avoid some activity that is unwelcome to him or her or to obtain support from the environment that otherwise might not be forthcoming. The condition must not be attributable to any psychiatric disorder other than the following, and it should conform to the requirements for the diagnoses of Dissociative [conversion] Disorders (F44) or Somatoform Disorder (F45) in the International Classification of Diseases, 10th edition, or to those for somatization disorder (300. The differential diagnosis from tension headache usually will be based on one or more of the following: (a) the level of observed anxiety is not sufficient to account for tension which might produce the symptom; (b) the personality conforms to the hysterical or hypochondriacal pattern and the complaint to an acute conflict situation or to a pattern of multiple symptoms; and (c) relaxation exercises and sedation do not provide relief. Likely to appear in the majority of patients with an independent depressive illness, more often in nonendogenous depression, and less often in illness with an endogenous pattern. Pain Quality: may be sensory or affective, or both, not necessarily bizarre; worse with intercurrent stress, increased anxiety. The pain may occur at the site of previous trauma (accidental or surgical) and may therefore be confused with a recurrence of the original condition. Duration and intensity often in accordance with the length and severity of the depression. Signs Tenderness may occur, but may also be found in other conditions and in normal individuals. The response to psychological treatments or antidepressants is better than to analgesics. Etiology A link with reductions in cerebral monoamines or monoamine receptors has been suggested. Differential Diagnosis Muscle tension pain with depression, delusional, or hallucinatory pain; in depression or with schizophrenia, muscle spasm provoked by local disease; and other causes of dysfunction in particular regions. It is important not to confuse the situation of depression causing pain as a secondary phenomenon with depression which commonly occurs when chronic pain arising for physical reasons is troublesome. X9d Note: Unlike muscle contraction pain, hysterical pain, or delusional pain, no clear mechanism is recognized for this category. If the patient has a depressive illness with delusions, the pain should be classified under Pain of Psychological Origin: Delusional or Hallucinatory. If muscle contraction predominates and can be demonstrated as a cause for the pain, that diagnosis may be preferred. Patients with anxiety and depression who do not have evident muscle contraction may have pain in this category. Previously, depressive pain was distributed between other types of pain of psychological origin, including delusional and tension pain groups and hysterical and hypochondriacal pains. The reason for this was the lack of a definite mechanism with good supporting evidence for a separate category of depressive pain. While the evidence that there is a specific mechanism is still poor, the occurrence of pain in consequence of depression is common, and was not adequately covered by the alternative categories mentioned. On the relationship between chronic pain and depression when there is no organic lesion. A Note on Factitious Illness and Malingering (1-17) Factitious illness is of concern to psychiatrists because both it and malingering are frequently associated with personality disorder. No coding is given for pain in these circumstances because it will be either induced by physical change or counterfeit. In the second case, the complaint of pain does not represent the presence of pain. The role of the doctor in this task may be limited to drawing attention to discrepancies and inconsistencies in the history and clinical findings. X l b Systemic Lupus Erythematosis, Systemic Sclerosis and Fibrosclerosis, Polymyositis, and Dermatomyositis (1-27) Code X33. X8e Guillain-Barre Syndrome (1-36) Definition Pain arising from an acute demyelinating neuropathy. Main Features Deep aching pain involving the low back region, buttocks, thighs, and calves is common (> 50%) in the first week or two of the illness. Pain may also occur in the shoulder girdle and upper extremity but is less frequent.

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Signs of infection Usually the first sign that parents notice is the child scratching his or her bottom antibiotics for gall bladder infection order clindamycin 150mg. Perianal itching is a classic symptom of threadworm infection and is caused by an allergic reaction to bacteria of the stomach purchase clindamycin visa the substances in and surrounding the worms’ eggs antimicrobial susceptibility purchase clindamycin without a prescription, which are laid around the anus virus 4 1 09 order clindamycin with a visa. Sensitisation takes a while to develop so in someone infected for the first time itching will not necessarily occur. Itching is worse at night, because at that time the female worms emerge from the anus to lay their eggs on the surrounding skin. If the perianal skin is broken and there are signs of weeping, referral to the doctor for antibiotic treatment would be advisable. Loss of sleep due to itching may lead to tiredness and irritability during the day. Itching without the confirmatory sighting of thread worms may be due to other causes, such as an allergic or irritant dermatitis caused by soaps or topical treatments used to treat the itching. Appearance of worms the worms themselves can be easily seen in the faeces as white or cream-coloured threadlike objects, about 10 mm in length and less than 0. The worms can survive outside the body for a short time and hence may be seen to be moving. Other symptoms In severe cases of infection, diarrhoea may be present and, in girls, vaginal itch. Duration If a threadworm infection is identified, the pharmacist needs to know how long the symptoms have been present and to consider this infor mation in the light of any treatments tried. Recent travel abroad If any infection other than threadworm is suspected, patients should be referred to their doctor for further investigation. If the person has recently travelled abroad, this information should be passed on to the doctor so that other types of worm can be considered. Other family members the pharmacist should enquire whether any other member of the family is experiencing the same symptoms. However, the absence of perianal itching and threadworms in the faeces does not mean that the person is not infected; it is important to remember that during the early stages, these symptoms may not occur. Medication the pharmacist should enquire about the identity of any treatment already tried to treat the symptoms. The pharmacist should therefore also ask how the treatment was used, in order to establish whether treatment failure might be due to incorrect use. When to refer Infection other than the threadworm suspected Recent travel abroad Medication failure Management When recommending treatment for threadworms, it is important that the pharmacist emphasise how and when the treatment is to be used. In addition, advice about preventing recurrence can be given, as described under ‘Practical points’ below. If symptoms do not remit after correct use of an appropriate preparation, patients should see their doctor. Mebenda zole is an effective, single-dose treatment against threadworm, which is also active against whipworm, roundworm and hookworm. The drug is formulated as a single tablet, which can be given to children aged 2 and over and to adults. The mode of action of pipera zine seems to be paralysis of the threadworms in the gut. The incorpor ation of a laxative (senna) in the sachet preparation helps to ensure that the paralysed worms are then expelled with the faeces. Instructions One dose is followed by another 2 weeks later to destroy any worms that might have hatched and developed after the first dose. It should not be recommended for pregnant women because, although a direct causal relationship has not been established, some cases of fetal malformations have been reported. Its use is contraindi cated in epileptic patients since it has been shown to have the potential to induce fits in patients with grand mal epilepsy. Piperazine may also potentiate extrapyramidal side-effects of chlorpromazine and should not be recommended for patients on neuroleptic therapy. In some European countries, piperazine has been removed from the market because of concern about adverse effects. Practical points 1 Parents are often anxious and ashamed that their child has a threadworm infection, thinking that lack of hygiene is responsible. The pharmacist can reassure parents that threadworm infection is extremely common and that any child can become infected; infection does not signify a lack of care and attention. This is because other members may be in the early stages of infection and thus asymptom atic. Hands should be washed and nails brushed after going to the toilet and before preparing or eating food, since hand-to-mouth transfer of eggs is common. Eggs may be transmitted from the fingers while eating food, or onto the surface of food during preparation. What you need to know Age Infant, child, adult, elderly Affected area Appearance Previous history Medication Significance of questions and answers Age Oral thrush is most common in babies, particularly in the first few weeks of life. In older children and adults, oral thrush is rarer, but may occur after antibiotic or inhaled steroid treatment (see ‘Medication’ below). In this older group it may also be a sign of immunosuppres sion and referral to the doctor is advisable. Affected areas Oral thrush affects the surface of the tongue and the insides of the cheeks. Appearance Oral thrush When candidal infection involves mucosal surfaces, white patches known as plaques are formed, which resemble milk curds; indeed, they may be confused with the latter by mothers when oral thrush occurs in babies. The distinguishing feature of plaques due to Candida is that they are not so easily removed from the mucosa, and when the surface of the plaque is scraped away, a sore and reddened area of mucosa will be seen underneath, which may sometimes bleed. Candidal infection is now thought to be an important factor in the development of nappy rash (see p. Previous history In babies recurrent infection is uncommon, although it may sometimes occur following reinfection from the mother’s nipples during breast feeding, or from inadequately sterilised bottle teats in bottle-fed babies. Patients who experience recurrent infections should be referred to their doctor for further investigation. For example, broad-spectrum antibiotic therapy can wipe out the normal bacterial flora, allowing the overgrowth of fungal infection. It would be useful to establish whether the patient has recently taken a course of antibiotics. Immunosuppressives Any drug that suppresses the immune system will reduce resistance to infection, and immunocompromised patients are more likely to get thrush. Patients using inhaled steroids for asthma are prone to oral thrush because steroid is deposited at the back of the throat during inhalation, espe cially if inhaler technique is poor. In a patient with recurrent thrush it would be worth enquiring about previously prescribed therapy and its success. If the symptoms have not cleared up within 1 week, patients should see their doctor. Preparations containing nystatin are also effective, but are restricted to prescription-only status. Miconazole gel is an orange-flavoured product, which should be applied to the plaques using a clean finger four times daily after food in adults and children over 6 years, and twice daily in younger chil dren and infants. For young babies, the gel can be applied directly to the lesions using a cotton bud or the handle of a teaspoon. Treatment should be continued for 2 clear days after the symptoms have appar ently gone, to ensure that all infection is eradicated. There is evidence of an interaction with warfarin leading to an increase in bleeding time. Practical points Oral thrush and nappy rash If a baby has oral thrush, the pharmacist should check whether nappy rash is also present. Where both oral thrush and candidal involvement in nappy rash occur, both should be treated at the same time. An antifungal cream containing miconazole or clotrimazole can be used for the nappy area. Breastfeeding Where the mother is breastfeeding, a small amount of miconazole gel applied to the nipples will eradicate any fungus present.

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