diagnose acne vulgaris

Acne vulgaris

How should I diagnose acne vulgaris?

• A person with acne usually presents with a history of troublesome 'spots', most commonly affecting the face, shoulders, back, and chest. The person is most commonly an adolescent or young adult, but acne can occur for the first time in later life.
• Examine all affected areas of skin (including the back and shoulders).
• The skin and hair may have an oily texture and appearance.
• Depending on the severity of the acne, there may be non-inflammatory comedones, inflamed papules or pustules, or a mixture of both.
• Closed comedones (whiteheads) appear as raised bumps on the skins surface, and are skin-coloured or slightly reddened.
• Open comedones (blackheads) have a characteristic black 'plug' caused by oxidised oil and dead skin cells.
• Papules are small, round or oval, inflamed (red), raised elevations of the skin.
• Pustules resemble papules, but have a central pocket of pus.
• Nodules are poorly demarcated swellings that are usually red and tender. They may be fluctuant on palpation. In very severe acne, nodules may track together and form large, deep sinuses (acne conglobata).
• Haemorrhagic acne is caused by bleeding inflammatory lesions, and may be very painful and distressing.
• Look for evidence of scarring and hyperpigmentation.
• Scarring may occur when acne heals, particularly when nodules have been present. It is most commonly atrophic in nature, leading to the formation of 'ice-pick' scars or 'pock marks'.
• Hyperpigmentation may occur after acne resolves, especially in people with darker complexions.
• If the features are atypical of acne vulgaris, consider the possibility of a severe form or clinical variant of acne.
• Images of acne and its clinical variants can be viewed at www.dermnet.org.nz.

[Brown and Shalita, 1998; Thiboutot, 2000; Simpson and Cunliffe, 2004; ICSI, 2006]

Clinical variants

• If acne presents with atypical features, consider the possibility of a rarer form of acne.
• Acne conglobata is very severe acne where inflammatory lesions predominate and run together, often accompanied by exudate or bleeding. This form of acne may cause extensive scarring.
• Acne fulminans is a sudden severe inflammatory reaction that precipitates deep ulcerations and erosions, sometimes with systemic effects (such as fever and arthralgia).
• Acne excoriée mainly affects young women and is characterized by self-inflicted wounds. It is primarily a psychological or emotional problem.
• Acne mechanica is caused secondarily to pressure, friction, or rubbing from clothing (such as a mask or hat).
• Acne cosmetica is caused by contact of the skin with comedogenic products.
• Chloracne is caused by occupational exposure to halogenated hydrocarbons. It is characterized by the presence of numerous, large comedones.

Basis for recommendation

Recommendations for the diagnosis of acne vulgaris and its clinical variants are based on an international guideline [ICSI, 2006] and expert opinion from narrative reviews [Brown and Shalita, 1998; Thiboutot, 2000;Wolf, 2002; Simpson and Cunliffe, 2004].

What else might it be?

• Acne vulgaris is rarely misdiagnosed. Conditions which may mimic the signs of acne include:
• Rosacea is the condition most commonly mistaken for acne vulgaris. It usually occurs in older people and its main symptom is flushing and the presence of inflammatory papules, with a central facial distribution. However, there is an absence of comedones, nodules, or scarring. 
• Folliculitis and boils may present with pustular lesions similar to those seen in acne. Swabs usually yieldStaphylococcus aureus. Sycosis barbae is persistent folliculitis of the beard area. 
• Milia are small keratin cysts that may be confused with whiteheads. They tend to be whiter than acne whiteheads, they do not have a central punctum, and they are most commonly found around the eyes.
• Perioral dermatitis presents as erythema and small papules around the mouth, nasolabial folds, and sometimes the lower eyelids. It can have both eczematous and acneiform features, and when acneiform features predominate it may be mistaken for acne. In these cases, the perioral distribution gives the best clue as to its nature.
• Demodex folliculitis is caused by mites and usually occurs in older people. It predominantly affects the face.
• Pityrosporum folliculitis is caused by a yeast-like organism. It tends to affect younger people and predominates on the trunk.

Basis for recommendation

Information on the differential diagnosis of acne vulgaris is from expert opinion described in narrative reviews[Healy and Simpson, 1994; Layton, 2000; Thiboutot, 2000; Wolf, 2002].

How should I investigate the cause of acne in a woman?

• Diagnostic investigations are not necessary for the management of acne vulgaris unless it is suspected as being secondary to an underlying cause in women. Hyperandrogenism should be suspected if the woman has:
• Irregular periods, androgenic alopecia (hair thinning on the front of the scalp), or excessive facial or body hair (hirsutism).
• Acne resistant to conventional treatment (including oral antibiotics), or there is a rapid relapse after a course of oral isotretinoin.
• A sudden onset of severe acne.
• If hyperandrogenism is suspected, consider the following investigations:
• Total and free testosterone — elevated levels may indicate polycystic ovarian syndrome (PCOS) or, rarely, ovarian cancer.
• Luteinizing hormone/follicle-stimulating hormone (LH/FSH) ratio — may be altered in PCOS, with elevated LH.
• Serum dehydroepiandrosterone (DHEA) — elevated levels may indicate adrenal tumour or congenital adrenal hyperplasia.
• 17-hydroxyprogesterone — elevated levels may indicate congenital adrenal hyperplasia.
• Prolactin — may reveal hyperprolactinaemia.
• 24 hour urinary-free cortisol — elevated levels may indicated Cushing's disease or syndrome.

Basis for recommendation

Recommendations for suspecting and investigating hyperandrogenism in women is based on opinion from expert reviews [James, 2005; Ravenscroft, 2005].

How should I assess a person with acne?

• Ask about the problems the person has experienced with their acne. Enquire about:
• The reasons for the person presenting, how long they have had acne, and whether it is worsening.
• Any treatments the person has already tried (for example over-the-counter medication).
• Possible causes or aggravating factors (for example, occupational exposure to halogenated hydrocarbons).
• In women, consider whether the acne could be secondary to a hormonal cause. Features of hyperandrogenism include: irregular periods; androgenic alopecia or hirsutism; acne resistant to conventional treatment (or relapse immediately after a course of oral isotretinoin); and premenstrual flares of acne or a sudden onset of severe acne.
• Assess the severity of the acne. Physically, acne can be categorized as mild, moderate, or severe, but other factors, such as the extent of acne and evidence of scarring, should also be considered.
• Mild acne predominantly consists of non-inflammatory comedones.
• Moderate acne consists of a mixture of non-inflammatory comedones and inflammatory papules and pustules.
• Severe acne is characterized by the presence of nodules and cysts, as well as a preponderance of inflammatory papules and pustules.
• Scarring often indicates previous episodes of severe acne (its presence may warrant more aggressive treatment to prevent further scarring).
• Acne conglobata and acne fulminans are severe variants that require immediate referral.
• Ask about the psychosocial impact of the acne (such as problems at work or school). If the psychological impact seems to be particularly severe or disproportionate, consider using a validated quality of life scale, such as the Cardiff Acne Disability Index (which can be downloaded from www.dermatology.org.uk). This can be used to monitor the person's psychological state during subsequent management.

Basis for recommendation

These recommendations are based on expert opinion from international guidelines [ICSI, 2006; Strauss et al, 2007] and narrative reviews [Webster, 2002; Wolf, 2002; James, 2005; Ravenscroft, 2005; Acne Working Group, 2008].

Categorizing acne severity

• There is no universal grading system for the classification of acne severity [Strauss et al, 2007]. Grading systems have largely been developed for use in clinical trials and rely on lesion counts, but these are generally not suitable for clinical practice [Webster, 2002]. However, there is general consensus from experts that it is useful to categorize acne into three severity grades in order to guide management of the condition.

Psychosocial impact of acne

• During assessment, it is important to recognize the psychosocial impact of acne. It can have a severe negative impact on the person's life. Although often the person tends to overestimate the severity of their acne, the healthcare professional tends to underestimate it. Estimating the physical severity of acne alone is insufficient to guide management, as it may be appropriate to treat acne associated with a greater psychosocial impact more aggressively, or refer the person [Acne Working Group, 2008]

Treatment of Mild Acne:

What information should I give about acne?

• Reassure the person about the natural course of the condition, but do not trivialize it. Advise that:
• Acne is one of the most common disorders, affecting nearly everyone at some point in their life.
• Acne will improve. It is primarily a skin disorder of the young, and will usually clear up in later life without leaving significant scarring.
• Treatments are effective but take time to work (typically up to 8 weeks) and may irritate the skin, especially at the start of treatment.
• Dispel popular myths about acne. In particular inform the person that:
• Acne is not caused by poor hygiene, and there is no evidence it is improved by cleaning. In fact, excessive washing can aggravate acne.
• Diet has little or no effect on acne. For example, there is no evidence that chocolate or fatty foods cause or aggravate acne. However if the person notices that a particular food triggers flares of acne then it is reasonable to avoid it.
• Picking at acne does not improve it, and may cause scarring. Occasionally it may be beneficial to drain large purulent lesions, but this should be done under medical supervision.
• Stress probably does not cause acne, although there is a correlation between stress and acne, and unsightly lesions may cause increased levels of stress.
• Acne is not infectious and cannot be passed on to other people. The main bacterium involved in the inflammation, Propionibacteria acnes, is naturally present on skin but, in acne, it colonizes follicles.
• Sunlight probably has little benefit in acne, and there is no evidence to support active sunbathing or exposure to other sources of ultraviolet light. Excessive sun exposure should be avoided by all people, especially when taking drugs such as topical or oral retinoids, or oral tetracyclines.

What self-care advice should I give to a person with acne?

• Advise about washing and skin care. In general, it is recommended that people with acne:
• Do not wash more than twice a day.
• Use a mild soap or cleanser and lukewarm water (as very hot or cold water may worsen acne).
• Do not use vigorous scrubbing when washing acne-affected skin, and the use of abrasive soaps, cleansing granules, astringents, or exfoliating agents should be discouraged (advise use of a soft wash-cloth and fingers instead).
• Should not attempt to 'clean' blackheads. Scrubbing or picking acne is liable to worsen the condition.
• Ideally, should avoid excessive use of makeup and cosmetics. If they must be used, advise that a non-comedogenic, water-based product should be used sparingly (advise that details of cosmetic ingredients are displayed on the product label), and that all makeup should be removed completely at night.
• Use a fragrance-free, water-based emollient if dry skin is a problem (several topical acne drugs dry the skin). The use of ointments or oil-rich creams should be avoided as these can clog pores.
• Advise about non-prescription treatments.
• Benzoyl peroxide is a useful topical drug available over-the-counter. However, there is a lack of evidence of benefit for other over-the-counter drugs.
• Complementary and alternative medicines (for example herbal medicines) are not usually harmful but there is a general lack of evidence to support their use.

How should I treat mild acne?

• In mild acne, open and closed comedones (blackheads and whiteheads) predominate. Although the physical severity of the condition is limited and scarring is unlikely, the psychosocial impact may be disproportionate in some people, which is an indication for more aggressive treatment.
• Prescribe a single topical treatment.
• Prescribe a topical retinoid (tretinoin, isotretinoin, or adapalene) or benzoyl peroxide (especially if papules and pustules are present) as first-line treatment.
• Prescribe a topical antibiotic or azelaic acid if both topical retinoids and benzoyl peroxide are poorly tolerated.
• Combined treatment is rarely necessary for mild acne.
• Consider prescribing a standard combined oral contraceptive in women who require contraception, particularly if the acne is having a negative psychosocial impact.

How should I follow up a person with acne?

• Arrange follow up after about 6 weeks, and review the effectiveness and tolerability of treatment, as well as compliance with regimens.
• Advise the person to return sooner if the acne deteriorates significantly despite treatment.

What should I do if mild acne fails to respond to treatment?

• Check adherence to treatment.
• If adherence is poor, this may be because the treatment is poorly tolerated. Consider:
• Reducing the strength of treatment (for example, reducing from 5% to 2.5% benzoyl peroxide).
• Switching to an alternative topical drug that causes less irritation (for example a topical antibiotic or azelaic acid).
• Using a different formulation of drug (for example a cream instead of a drug with an alcoholic base).
• If adherence is adequate, consider:
• Increasing the drug strength and/or frequency of application.
• Combining different topical products (if not already doing so). Benzoyl peroxide combined with erythromycin or clindamycin is particularly effective against both non-inflammatory and inflammatory acne.

When should I refer a person with mild acne?

• People who have severe psychosocial problems, including a morbid fear of deformity (body dysmorphic disorder), or people who have suicidal ideation, should be referred soonto psychiatry.
• Refer for a routine appointment:
• To endocrinology or gynaecology, those women suspected of having an underlying endocrinological cause of acne (such as polycystic ovary syndrome) that needs assessment.
• To dermatology, people with features that make the diagnosis uncertain.

How should I treat moderate acne?

• In moderate acne, inflammatory lesions (papules and pustules) predominate. The acne may be widespread, there may be a risk of scarring, and there may be considerable psychosocial morbidity, all of which are indications for aggressive treatment.
• Treatment options are a single topical drug, a combination of topical drugs, or oral antibiotics.
• Consider a single topical drug in people with limited acne which is unlikely to scar.
• Prescribe benzoyl peroxide or a topical retinoid first-line as they are most effective against inflammatory acne. However, topical retinoids are also effective, and azelaic acid may is an option if other drugs are poorly tolerated.
• Combined treatment should be considered in all people with moderate acne.
• Benzoyl peroxide combined with a topical antibiotic is the usual preferred regimen, as it is proven to be effective and may limit the development of bacterial resistance.
• Other options include a topical retinoid combined with benzoyl peroxide (but this may be poorly tolerated) or a topical retinoid combined with a topical antibiotic (but this may promote bacterial resistance).
• Consider prescribing an oral antibiotic (tetracycline, oxytetracycline, doxycycline, lymecycline, or erythromycin) if topical treatment cannot be tolerated, if there is moderate acne on the back or shoulders (where it may be particularly extensive or difficult to reach), or if there is a significant risk of scarring or substantial pigment change.
• Consider prescribing a standard combined oral contraceptive in women who require contraception
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• How should I treat severe acne?
• • In severe acne, there are nodules and cysts (nodulocystic acne), as well as a preponderance of inflammatory papules and pustules. There is a high risk of scarring (or scarring may already be evident), and there is likely to be considerable psychosocial morbidity.
  • Refer all people with severe acne for specialist assessment and treatment (for example with oral isotretinoin), and consider prescribing an oral antibiotic in combination with a topical drug whilst waiting for an appointment.
  • Oral tetracycline, oxytetracycline, doxycycline, or lymecycline are first-line options. Erythromycin is an alternative if tetracyclines are poorly tolerated or contraindicated (such as in pregnancy). Minocycline is not recommended.
  • Benzoyl peroxide or a topical retinoid are recommended as adjunctive treatment for most people. Azelaic acid is an alternative, but avoid the use of topical antibiotics with oral antibiotics.
  • Consider prescribing a combined oral contraceptive in women who require contraception.

Neck lump

What should I ask about?

• Ask about the site of the lump, including its onset, growth, and changes (and the timescale of these), and any pain.
• Check for red flag symptoms that are suggestive of:
• Local malignancy (for example weight loss, difficulty swallowing or painful swallowing, persistent hoarseness, earache, or sore throat — particularly when unilateral).
• Haematological malignancy:
• Fatigue.
• Drenching night sweats.
• Fever.
• Weight loss.
• Generalized itching.
• Breathlessness.
• Bruising or bleeding.
• Recurrent infections.
• Bone pain, alcohol-induced pain, or abdominal pain.
• Lumps (lymphadenopathy) at sites other than the neck (for example the axillae).
• Consider other features in the history suggesting a cause:
• Combination of symptoms indicative of an upper respiratory tract infection causing lymphadenopathy — fever, cough, and sore throat.
• Recent travel, insect bites, or exposure to pets or other animals — suggestive of an inflammatory or infectious cause of neck mass.
• Smoking, heavy alcohol use, or previous radiation to the neck — increase the risk of malignancy.
• Trauma — may indicate haematoma, or if time has elapsed since the traumatic incident, fibrosis.
• Family history of an endocrine tumour — may be suggestive of multiple endocrine neoplasia (MEN) type 2 (thyroid, adrenal, and parathyroid disease).

What should I look for on examination?

• Look for signs of stridor or superior vena cava compression (swelling of the face and/or neck with fixed elevation of jugular venous pressure).
• Examine the neck.
• Look at the neck to identify visible masses and pulsation.
• Standing behind the person, palpate the different areas of the neck.
• Anterior triangle (borders: midline, anterior border of sternocleidomastoid muscle, and the body of the mandible).
• Posterior triangle (borders: posterior border of sternocleidomastoid muscle, trapezius, and the clavicle).
• Midline.
• If a neck lump is identified:
• Assess its size and mobility (whether it is fixed to underlying structures).
• Assess whether it is subcutaneous or part of the skin.
• Determine the characteristics of the lump, for example whether it is compressible (such as a branchial cyst) or pulsatile (suggesting a vascular cause).
• Ask the person to swallow and assess whether the lump moves (thyroid lumps and thyroglossal cysts move upwards on swallowing).
• Ask the person to protrude their tongue (thyroglossal cysts move superiorly).
• If it is a thyroid lump, determine whether it is nodular or diffuse.
• Also examine:
• The skin of the head and neck — for malignant or premalignant lesions (for example actinic keratoses).
• The ears — for infection (such as otitis externa).
• The nose — for malignancy.
• The tonsils and pharynx — infection may cause lymphadenopathy.
• The oral mucosa and tongue — for occult malignancy in the oral cavity (dentures may have to be removed). Use a tongue depressor to examine the lateral borders of the tongue.
• Specific areas where a suspected lymph node metastasis (a firm lump) may have originated.
• In general, if the suspected lymph node metastasis is in the upper or mid neck, the primary is likely to be a head and neck tumour (including thyroid).
• Lateral lymph nodes may be enlarged because of metastasis from squamous cell cancer of mouth, pharynx, and upper oesophagus.
• If the suspected lymph node metastasis is in the lower neck (supraclavicular lymph nodes), the primary may be from the thyroid, pyriform sinuses, upper oesophagus, or from below the clavicle (for example breast, lung, or intra-abdominal malignancy). An enlarged lymph node in the left supraclavicular fossa may indicate gastric cancer (Virchow lymph node).
• The abdomen for hepatosplenomegaly, and the axillae and groins for lymphadenopathy (if haematological malignancy is suspected).

What investigations should I request?

• If there are features of head and neck malignancy, do not delay referral by undertaking investigations in primary care.
• If glandular fever is suspected (typically fatigue, fever, lymphadenopathy, and sore throat in people younger than 40 years of age), consider a Monospot test during the second week of illness.
• If the person has unexplained lymphadenopathy, request a full blood count and blood film, and erythrocyte sedimentation rate, plasma viscosity, or C-reactive protein 
• If the person has unexplained cervical and/or supraclavicular lymphadenopathy or any of the following unexplained symptoms and signs for more than 3 weeks, urgently refer for chest radiography (the result should be available within 5 days):
• Chest and/or shoulder pain.
• Dyspnoea.
• Weight loss.
• Chest signs.
• Hoarseness.
• Finger clubbing.
• Cough, with or without any of the above.
• Features suggestive of metastasis from lung cancer (for example in the brain, bone, liver, or skin).
• If the person has a suspected thyroid lump and does not require immediate admission to hospital:
• Refer to a centre with a multidisciplinary thyroid team if possible.
• Consider doing thyroid function tests, but do not allow this to delay referral, particularly if the person has urgent referral criteria.
• Do not request further investigations, such as ultrasonography or isotope scanning, in primary care.

Basis for recommendation

Suspected malignancy

• The recommendation that investigations for suspected head and neck malignancy should be done in secondary care is extrapolated from guidelines on referral for suspected head and neck cancer from the National Institute for Health and Clinical Excellence. These state that, with the exception of persistent hoarseness, investigations for head and neck cancer in primary care are not recommended as they can delay referral [NICE, 2005a].

Glandular fever

• Monospot test (heterophile antibodies) — heterophile antibodies are present in approximately 90% of people older than 12 years of age who have glandular fever, and can be detected by the Monospot test [Johannsen et al, 2005].
• Blood should be taken in the second or third week of the illness, because false negatives are common if taken earlier. False-negative rates may be 25% in week 1 of the infection, decreasing to approximately 5% in week 3 [Ebell, 2004;Smellie et al, 2007].

Lymphadenopathy of unknown cause

• The recommendation on which investigations to request when infection has been excluded and the cause of the lymphadenopathy is unknown is based on referral guidelines for suspected haematological cancer from the National Institute for Health and Clinical Excellence [NICE, 2005a].

Cervical or supraclavicular lymphadenopathy with chest signs

• The recommendation on referring for chest radiography when the person has unexplained cervical or supraclavicular lymphadenopathy for more than 3 weeks is based on a referral guideline for suspected lung cancer from the National Institute for Health and Clinical Excellence [NICE, 2005a].

Thyroid lumps

• CKS identified conflicting recommendations based on expert opinion in referral guidelines for suspected cancer from the National Institute for Health and Clinical Excellence (NICE) [NICE, 2005a] and guidelines on the management of thyroid cancer from the British Thyroid Association (BTA) [BTA, 2007].
• NICE recommends only requesting thyroid function tests in primary care for people with a thyroid swelling without stridor or features requiring urgent referral.
• However, the BTA has subsequently recommended that, for people with a thyroid lump who do not need to be immediately admitted to hospital, thyroid function tests should be requested by the primary healthcare professional and the results included with the referral letter.
• CKS acknowledges that it may be beneficial to do thyroid function tests in primary care, because the results can guide to whom to make a referral and may be useful to the specialist. However, rapid access to secondary care is important when cancer is suspected, and requesting tests should not delay referral.
• NICE and the BTA do not recommend requesting other investigations (such as ultrasonography or isotope scanning) in primary care. This is on the basis of findings from non-randomized clinical trials and expert opinion that this is likely to cause unnecessarily delay in diagnosing cancer [NICE, 2005a; BTA, 2007].

How should I make a diagnosis?

• Use the findings from the history and examination to guide diagnosis. The position of the lump should help narrow down the list of likely causes.
• Midline — thyroid swellings (isthmus), thyroglossal cyst, laryngeal swellings, submental lymph nodes, dermoid cysts.
• Lateral (anterior triangle) — thyroid swellings (lobe), pharyngeal pouch, submandibular gland swelling, branchial cyst, lymph nodes, parotid swelling.
• Lateral (posterior triangle) — lymph nodes, carotid artery aneurysm, carotid body tumour, cervical rib.
• Age can also help to determine the likely cause of a neck lump.
• Children are most likely to have reactive lymphadenopathy of cervical nodes. Single masses are often due to a congenital cause or to inflammation. Malignancy is rare, with lymphomas, thyroid cancer, and soft tissue sarcomas being most likely.
• Adults — young adults will usually have an inflammatory, developmental, or congenital cause; malignancy is less common. The likelihood of malignancy increases with age, particularly in people 40 years of age or older.

infantile colic what to do ?

What advice should I give to the parents?

• Reassure the parents that their baby is well, they are not doing something wrong, the baby is not rejecting them, and that colic is common and is a phase that will pass within a few months.
• Holding the baby through the crying episode may be helpful. However, if there are times when the crying feels intolerable, it is best to put the baby down somewhere safe (e.g. their cot) and take a few minutes' 'time out'.
• Other strategies that may help to soothe a crying infant include:
• Gentle motion (e.g. pushing the pram or a ride in the car).
• 'White noise' (e.g. vacuum cleaner, hairdryer, running water).
• Bathing in a warm bath.
• Encourage parents to look after their own well-being:
• Ask family and friends for support — parents need to be able to take a break.
• Rest when the baby is asleep.
• Meet other parents with babies of the same age.

• When should treatment for infantile colic be considered, and with what?

  • The most useful intervention is support for parents and reassurance that infantile colic will resolve.
  • Only consider trying medical treatments if parents feel unable to cope despite advice and reassurance. The options for medical treatments are:
  • A 1-week trial of simeticone drops (breastfed or bottle-fed).
  • A 1-week trial of diet modification to exclude cow's milk protein:
  • Breastfed babies: dairy-free diet for the mother.
  • Bottle-fed babies: hypoallergenic formula.
  • A 1-week trial of lactase drops (breastfed or bottle-fed).
  • Only continue treatment if there is a response (i.e. the duration of crying shortens).
  • If there is no response to one medical treatment, consider trying another.
  • Breastfeeding mothers should take a calcium supplement if they are going to remain on a dairy-free diet long term.
  • If the baby does respond to lactase or hypoallergenic diet, reassure the parents that this does not necessarily mean that they are lactose intolerant or allergic to cow's milk. These are rare conditions that affect very few babies with infantile colic.

  When should I consider stopping treatment?

  • If there is no response to the trial of treatment stop it.
  • If there is a response to treatment: after the age of 3 months (and by 6 months of age at the latest), wean off treatment over a period of about 1 week.

Varicose veins

How do I assess a person with varicose veins?

• Identify why the person is concerned about their varicose veins. For many people, it is because of the cosmetic appearance, or worries that they will get worse or cause complications.
• Ask about symptoms that might be caused by the varicose veins. Itching, discomfort, and swelling of the affected leg are commonly reported, but may be due to other causes. Discomfort after prolonged standing, relief with leg elevation or wearing compression stockings, and discomfort over the varicose veins suggest that the symptoms are due to varicose veins.
• Document the location and the severity of the varicose veins.
• Check for any complications:
• Skin changes — areas of pigmentation, eczema, or lipodermatosclerosis (hardened, tight, red or brown skin, which if circumferentially affecting the ankle area may eventually result in an 'inverted champagne bottle' leg).
• Venous leg ulcers — most commonly seen in the ankle (gaiter) area.
• Thrombophlebitis — a tender, inflamed varicose vein with overlying redness and heat and which feels firm owing to the presence of thrombus within the vein. People with thrombophlebitis usually present acutely.
• If use of compression stockings is being considered, measure the ankle-brachial pressure index using a Doppler machine (some experts suggest that this is unnecessary if foot pulses are easily palpable, the person has no symptoms of arterial disease, and strong compression is not being applied). 

• How should I manage uncomplicated varicose veins?

  • Reassure the person that it is unlikely that the varicose veins will lead to complications.
  • Explain that treatment of varicose veins is only considered if they are severe and causing troublesome symptoms.
  • If the person has leg discomfort or swelling:
  • Consider the use of compression stockings:
  • Class 1 (light) or class 2 (medium) below-knee stockings are suitable for most people, with the choice depending on the severity of the varicose veins and tolerability of the compression chosen.
  • Advise the person to try and avoid sitting or standing for long periods of time, and to elevate the legs when possible.
  • Explain that it is not known whether compression stockings prevent worsening of the varicose veins or prevent new ones from appearing.

  
  

  What should I advise pregnant women?

  
  

  • Explain the reasons why varicose veins can appear or worsen during pregnancy:
  • An increase in blood volume putting increased strain on the venous system.
  • Hormones causing relaxation of the muscular walls of blood vessels.
  • The enlarging uterus putting pressure on the pelvic veins and inferior vena cava.
  • Reassure the woman that after pregnancy varicose veins often improve considerably.
  • Advise the woman not to stand for long periods, and to elevate her legs when resting.
  • Consider compression stockings if the varicose veins seem to be causing leg discomfort or swelling, but explain that it is uncertain how effective these are during pregnancy.
  • Explain that it is not known whether compression stockings prevent worsening of the varicose veins or prevent new ones from appearing.

What is difference between topical steroid vehicles?

Steroid Vehicles Steroids may differ in potency based on the vehicle in which they are formulated. Some vehicles should be used only on certain parts of the body. Ointments provide more lubrication and occlusion than other preparations, and are the most useful for treating dry or thick, hyper-keratotic lesions. Their occlusive nature also improves steroid absorption. Ointments should not be used on hairy areas, and may cause maceration and folliculitis if used on intertriginous areas (e.g., groin, gluteal cleft, axilla). Their greasy nature may result in poor patient satisfaction and compliance. Creams are mixes of water suspended in oil. They have good lubricating qualities, and their ability to van-ish into the skin makes them cosmetically appealing. Creams are generally less potent than ointments of the same medication, and they often contain preservatives, which can cause irritation, stinging, and allergic reac-tion. Acute exudative inflammation responds well to creams because of their drying effects. Creams are also useful in intertriginous areas where ointments may not be used. However, creams do not provide the occlusive effects that ointments provide. Lotions and gels are the least greasy and occlusive of all topical steroid vehicles. Lotions contain alco-hol, which has a drying effect on an oozing lesion. Lotions are useful for hairy areas because they pene-trate easily and leave little residue. Gels have a jelly-like consistency and are beneficial for exudative inflamma-tion, such as poison ivy. Gels dry quickly and can be applied on the scalp or other hairy areas and do not cause matting. Foams, mousses, and shampoos are also effective vehi-cles for delivering steroids to the scalp. They are easily applied and spread readily, particularly in hairy areas.

what is the degree of this burn?

what is the degree of this burn?
what is the management?
what is the prognosis?

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Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women

harmacologic Treatment of Abnormal Uterine Bleeding

Medication	Dosage	Cost of generic (brand)[*]	Comments
Anovulatory bleeding
Combination oral contraceptives[4]	≤ 35 mcg of ethinyl estradiol monophasic or triphasic pills	NA ($9 to 92)	Provides contraception Contraindications include smokers older than 35 years, personal history or high risk of deep venous thrombosis or pulmonary embolism, multiple risk factors for arterial cardiovascular disease, history of breast cancer, and severe cirrhosis or liver cancer[33]
Medroxyprogesterone acetate (Provera)[9]	10 mg per day for 10 to 14 days per month	$13 ($38)	Does not provide contraception Caution in patients with severe hepatic dysfunction
Endometrial hyperplasia without atypia
Medroxyprogesterone acetate[14]	10 mg per day for 14 days per month	$13 ($38)	Does not provide contraception Caution in patients with severe hepatic dysfunction
Megestrol (Megace)[11]	40 mg per day	$25 (NA as tablets)	Does not provide contraception Caution in patients with severe hepatic dysfunction
Levonorgestrel-releasing intrauterine system (Mirena)[31]	Releases 20 mcg per 24 hours	NA ($562[‡])	96 percent regression rate for hyperplasia without atypia[31] Provides contraception for five years May cause irregular bleeding or amenorrhea Contraindications include breast cancer; uterine anomaly that distorts the cavity; acute pelvic or cervical infection; and severe cirrhosis or liver cancer[33] More expensive initially, but similar to other therapies when averaged over five years

Ovulatory bleeding
Levonorgestrel-releasing intrauterine system [34] , [35]	Releases 20 mcg per 24 hours	NA ($562[‡])	FDA-approved for menorrhagia in 2009; see additional comments above
Medroxyprogesterone acetate[34]	10 mg per day for 21 days per month	$16 ($40)	Does not provide contraception Effective short-term therapy for decreasing heavy flow Not tolerated as well long term as levonorgestrel-releasing intrauterine system Caution in patients with severe hepatic dysfunction
NSAIDs [36] , [37]
Ibuprofen	600 to 1,200 mg per day, five days per month	$4 ($16)	Begin first day of menses and continue for five days or until menses ceases Treats dysmenorrhea
Naproxen sodium (Anaprox)	550 to 1,100 mg per day, five days per month	$4 ($50)	Caution in patients with gastrointestinal risks
Mefenamic acid (Ponstel)	1,500 mg per day, five days per month	$429 ($553)
Tranexamic acid (Lysteda) [38] , [39]	650 mg; two tablets three times per day, five days per month	NA ($170)	FDA-approved for menorrhagia in 2009 Begin first day of menses and continue for five days [38] , [39]  Caution in patients with history or risk of thromboembolic or renal disease Contraindicated if patient has active intravascular clotting or subarachnoid hemorrhage Considerably more expensive than other available therapies