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The use of antibiotics in acne is based not only on their antibacterial effects but also on anti-inflammatory properties purchase seroflo 250 mcg allergy attack, which can be significant for some antibiotics buy seroflo 250 mcg without prescription allergy medicine hong kong, such as the tetracyclines buy cheap seroflo 250mcg allergy treatment 10. For oral tetracyclines 250mcg seroflo overnight delivery allergy shots for hives, common adverse effects are gastrointestinal disturbances and photosensitivity, and for the macrolides, gastrointestinal disturbances are common. The most significant concern in the use of both topical and oral antibiotics is the development of bacterial resistance. Some measures that can be taken to limit the development of resistance include using antibiotics only in combination with other acne agents, using oral antibiotics for the shortest time possible, and using low-dose oral antibiotics (subantimicrobial dosing) when possible. Also, once acne lesions are clear, patients should follow with topical maintenance therapy with effective nonantibiotic topical agents, such as benzoyl peroxide and the retinoids. Antibiotics are covered in more detail in the chapters on anti-infective therapy (see Chapter 30). It also exhibits anti-inflammatory activity, inhibits the division and differentiation of keratinocytes, and shows comedolytic activity. Azelaic acid exhibits a lightening effect on hyperpigmented skin, which makes it useful in patients who experience dyspigmentation as a consequence of inflammatory acne. It is available as a cream and a gel, and the major adverse effects are mild and transient pruritus, burning, stinging and tingling. The major adverse effects are dry skin, irritation, and bleaching of bedding and clothing. Dapsone is available as a topical gel with the most common adverse effects being transient oiliness, dryness, and erythema, which may be at least in part due to the nondrug part of the formulation. Retinoids Retinoids are vitamin A derivatives that interact with retinoid receptors to regulate gene expression in a manner that normalizes keratinocyte differentiation and reduces hyperproliferation (giving them comedolytic activity). These diverse effects make retinoids useful for acne, as well as a variety of other conditions, including psoriasis and severe rosacea. Adverse effects of the topical retinoids include erythema, desquamation, burning, and stinging. Other potential adverse effects include dry mucous membranes and photosensitivity. Though their systemic absorption is generally limited, use should be avoided during pregnancy, particularly topical tazarotene, which is the most teratogenic of the three topical retinoids for acne. Oral isotretinoin, used in severe acne, has potentially serious adverse effects including psychiatric effects and birth defects. The drug has mild anti- inflammatory activity and is keratolytic at higher concentrations. Salicylic acid is used as a treatment for mild acne and is available in many over-the-counter facial washes and medicated treatment pads. The product is available as cleanser, cream, foam, gel, lotion, pads, suspension, and a wash. The most common adverse effects include contact dermatitis, erythema, pruritus, Stevens-Johnson syndrome, and xeroderma. Agents for Superficial Bacterial Infections Several gram-positive and gram-negative bacteria can cause various superficial skin infections, such as folliculitis and impetigo, as well as deeper infections, such as erysipelas and cellulitis. In more severe cases, these infections can lead to ulceration and systemic infections. This section covers topical antibacterial agents that can be used for the treatment and prevention of certain superficial skin infections. Bacitracin is mostly used for the prevention of skin infections after burns or minor scrapes. It is frequently found in combination products with neomycin and/or polymyxin (see below). This agent is often used in combination with other agents to treat skin infections caused by gram-negative organisms. It is useful in treating impetigo (a contagious skin infection caused by streptococci or staphylococci; ure 43. This agent is often formulated with other topical anti-infectives, such as bacitracin and polymyxin to treat skin infections. Common adverse effects associated with the combination agents include contact dermatitis, erythema, rash, and urticaria. As noted above, it is commonly combined with bacitracin (“double antibiotic”) and neomycin with bacitracin (“triple antibiotic”) in topical products used for the prevention of skin infections after minor skin trauma. The only available dosage form is an ointment, and the most common adverse effects are pruritus and skin irritation. Agents Used for Rosacea Rosacea is a common inflammatory disorder affecting the central portion of facial skin. Common clinical features include facial erythema (flushing) and inflammatory lesions that are similar to acne lesions. It2 is available as a gel and its major adverse effects are burning, localized warm feeling, and flushing. It is available as a capsule and tablet, and its major adverse effects include diarrhea, nausea, dyspepsia, and nasopharyngitis. It is believed to work in rosacea through anti-inflammatory or immunosuppressive effects, rather than through its antibacterial effects. It is available as a cream, gel, and lotion, and its major adverse effects are burning, erythema, skin irritation, xeroderma, and acne vulgaris. It is available as a cream, and its major adverse effects are application site dermatitis, worsening inflammatory lesions, site pruritus, site erythema, and a burning sensation. It is available as a cream, and its major adverse effects are burning, irritation, pruritus, and erythema. Agents for Pigmentation Disorders the color of skin is derived from melanin produced by melanocytes in the basal layer of the epidermis. When the melanocytes are damaged, the melanin levels are affected, which ultimately leads to pigmentation disorders. If the body does not make enough melanin, the skin gets lighter (hypopigmentation). Pigmentation disorders can be widespread and affect many areas of the skin or they can be localized. Agents used for pigmentation disorders are discussed below and summarized in ure 43. It is often used in combination with topical retinoids to treat the signs of photoaging. The mechanism of action of hydroquinone is through inhibition of the tyrosinase, an enzyme required for melanin synthesis. Hydroquinone lightens the skin temporarily and is commonly used as a 4% preparation. It should not be used in higher concentrations, or in excessive quantities for an extended duration, as it is associated with possible carcinogenicity.

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Zafirlukast may reduce the severity of attacks order 250 mcg seroflo fast delivery allergy shots not effective, but not to the same degree or consistency as fluticasone (or other corticosteroids) proven 250 mcg seroflo allergy testing youtube. Despite using salmeterol twice daily cheap 250 mcg seroflo with mastercard allergy treatment relief, he reports continued symptoms of shortness of breath with mild exertion buy generic seroflo 250mcg on-line allergy treatment at home. Roflumilast is not indicated, since the patient only has moderate airway obstruction. Her regimen for the past year has included inhaled salmeterol twice daily and inhaled tiotropium once daily. The addition of an inhaled corticosteroid may provide additional benefit since the patient has significant airway obstruction and frequent exacerbations requiring hospitalization. It is not routinely recommended to discontinue a long-acting bronchodilator unless the patient experiences an adverse effect or experiences no therapeutic benefit. In this case, the patient reports mild symptoms in between exacerbations, suggesting she may benefit from both bronchodilators. Benzonatate suppresses the cough reflex through peripheral action and has no abuse potential. Dextromethorphan, an opioid derivative, and codeine, an opioid, both have abuse potential. Inhaled corticosteroids have direct anti-inflammatory properties on the airways and require regular dosing to be effective. Salmeterol and albuterol are both bronchodilators, but do not have anti-inflammatory properties. Chlorpheniramine and diphenhydramine are first-generation antihistamines and are usually not a preferred treatment due to their increased risk of adverse effects, such as sedation, performance impairment, and other anticholinergic effects. Cetirizine is a second-generation antihistamine and is generally better tolerated, making it a preferred agent for allergic rhinitis. While zafirlukast and montelukast both inhibit the effects of leukotrienes, they do so by blocking the receptor. Use a large-volume chamber (spacer) to decrease deposition of drug in the mouth caused by improper inhaler technique. Rinse mouth in a “swish-and-spit” method with water prior to inhaler use to decrease the chance of adverse events. Rinsing the mouth may be appropriate for either type of inhaler if the medication being administered is an inhaled corticosteroid; however, this should always be done following inhaler use, not prior to use. Intranasal decongestants should be used no longer than 3 days due to the risk of rebound nasal congestion (rhinitis medicamentosa). For this reason, the α-adrenergic agents should not be used in the long-term treatment of allergic rhinitis. For example, the meperidine derivative diphenoxylate, which decreases peristaltic activity of the gut, is useful in the treatment of severe diarrhea. Antimicrobial agents Patients with peptic ulcer disease (duodenal or gastric ulcers) who are infected with H. H receptor antagonists2 Gastric acid secretion is stimulated by acetylcholine, histamine, and gastrin (ure 40. By competitively blocking the binding of histamine to H receptors, these agents reduce the2 secretion of gastric acid. However, its utility is limited by its adverse effect profile and drug–drug interactions. G and G are membrane proteins thats i mediate the stimulatory or inhibitory effect of receptor coupling to adenylyl cyclase. Actions the histamine H receptor antagonists act selectively on H receptors in the stomach, without effects on H2 2 1 receptors. Peptic ulcers All four agents are equally effective in promoting the healing of duodenal and gastric ulcers. Acute stress ulcers These drugs are given as an intravenous infusion to prevent and manage acute stress ulcers associated with high-risk patients in the intensive care setting. H receptor antagonists act by2 2 decreasing acid secretion; therefore, they may not relieve symptoms of heartburn for up to 45 minutes. Antacids more quickly and efficiently neutralize stomach acid, but their action is short lived. Pharmacokinetics After oral administration, the H receptor antagonists distribute widely throughout the body (including into breast2 milk and across the placenta) and are excreted mainly in the urine. Cimetidine, ranitidine, and famotidine are also 1544 available in intravenous formulations. The half-life of these agents may be increased in patients with renal dysfunction, and dosage adjustments are needed. However,2 cimetidine can have endocrine effects, such as gynecomastia and galactorrhea (continuous release/discharge of milk), because it acts as a nonsteroidal antiandrogen. Other central nervous system effects such as confusion and altered mentation occur primarily in elderly patients and after intravenous administration. H receptor antagonists may reduce the efficacy of drugs that2 require an acidic environment for absorption, such as ketoconazole. Cimetidine inhibits several cytochrome P450 isoenzymes and can interfere with the metabolism of many drugs, such as warfarin, phenytoin, and clopidogrel (ure 40. The membrane-bound proton pump is the final step in the secretion of gastric acid (ure 40. Actions These agents are prodrugs with an acid-resistant enteric coating to protect them from premature degradation by gastric acid. The coating is removed in the alkaline duodenum, and the prodrug, a weak base, is absorbed and transported to the parietal cell. It takes about 18 hours for the enzyme to be resynthesized, and acid secretion is inhibited+ + during this time. An oral product containing omeprazole combined with sodium bicarbonate for faster absorption is also available. Calcium citrate is an effective option for calcium supplementation in patients on acid suppressive therapy, since absorption of the citrate salt is not affected by gastric pH. Additional adverse effects may include hypomagnesemia and an increased incidence of pneumonia. Prostaglandins Prostaglandin E, produced by the gastric mucosa, inhibits secretion of acid and stimulates secretion of mucus and bicarbonate (cytoprotective effect). A deficiency of prostaglandins is thought to be involved in the pathogenesis of peptic ulcers. Misoprostol is contraindicated in pregnancy, since it can stimulate uterine contractions and cause miscarriage. Dose-related diarrhea is the most common adverse effect and limits the use of this agent. Antacids Antacids are weak bases that react with gastric acid to form water and a salt to diminish gastric acidity. Because pepsin (a proteolytic enzyme) is inactive at a pH greater than 4, antacids also reduce pepsin activity. Chemistry Antacid products vary widely in their chemical composition, acid-neutralizing capacity, sodium content, and palatability.

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It is essential to monitor urine output – Drugs and fluid intake and respiratory rate throughout fluid – Corrosives resuscitation of patients in shock and altered sensorium/ – Ménétrier’s disease coma discount 250 mcg seroflo with mastercard allergy testing reaction. Its use in children requires further evaluation though found to be Bleeding etiology Clinical clues more effective in controlling bleeding (up to 79%) than Mallory-Weiss tear Emesis before hematemesis generic 250 mcg seroflo fast delivery allergy medicine loratadine 10mg, pain + vasopressin without any adverse side effects generic seroflo 250mcg without prescription allergy treatment products. In children the dose is 1–2 µg/kg over 2–5 min purchase seroflo 250 mcg otc allergy forecast orange county ca, then 1–2 µg/kg per hour for 5 days. Oxygen is given gastric variceal than esophageal bleed) and the Minnesota to counter hypoxia due to acute blood loss. Nasogastric tube (four lumen and two balloons) are handled by only aspiration is done to know the magnitude of bleeding, to by experienced specialists as a lifesaver in active variceal clear the stomach for endoscopy and to prevent hepatic bleeding if emergency sclerotherapyor banding is unavailable encephalopathy. In patients with active bleeding, an endotracheal tube should Control of acute variceal Bleeding be inserted to protect the airway before attemptingto place It can be by the following modalities: the esophageal balloon tube. Continued bleeding during balloon tamponade indicates an incorrectly positioned Pharmacotherapy tube and bleeding from another source. After resuscitation, the most widely used agents to stop variceal bleeds are: and within 12 hours, the tube is removed and endoscopic • vasopressin:It is a potent non-selective vasoconstrictor. It lowers the portal pressure by causing splanchnic arterial vasoconstriction and reducing the splanchnic Endotherapy (Endoscopic Variceal Ligation or blood flow to the varices. It is given in a bolus of 1 Sclerotherapy) unit per 3 kg of body weight diluted with 2 ml/kg of • endoscopic variceal ligation: Using multiband ligator 5% dextrose given over a period of 15–20 minutes. Various sclerosants Bleeding from an ulcer is controlled using injection with used in esophageal varices are polydocanol, sodium adrenaline and recently hemoclips are also available for tetradecylsulfate, absolute alcohol, sodium morrhuate clipping at the site of vessel bleed at the base of the ulcer. It is effective only in portal hypertension specific management of Common Conditions of hepatic origin and contraindicated in portal vein Presenting as lGi Bleeding thrombosis, biliary block, septicemia and severe hepatic • anal fissure: Treatment of constipation, laxatives, Sitz encephalopathy. Rarely, surgery with intraoperative endoscopy scopy is very useful to detect esophagitis, Mallory-Weiss may be required (Flow chart 9. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Approximately 10–25% of all patients attending the pediatric gastroenterology clinics present with various causes defecation disorders and 1. The list is not exhaustive and a condition may are functional and often does not need extensive tests. Other rare causes of good history, physical examination including per rectal and constipation are neuronal intestinal dysplasia, Chagas checking for red flags is needed to differentiate functional disease, small left colon syndrome, neurofibromatosis, from an organic cause (5%). Significant number of children and intrinsic hollow visceral myopathy leading on to has associated urinary bladder voiding dysfunction. Normally the stool frequency reduces progressively in childhood from an average of 4/day in the It is the most common cause of constipation in children first month to 1. However, it can manifest encopresis earlier during weaning, during toilet training or at the time Encopresis is involuntary passage of stools soiling the of joining a school. The causes include a combination of underwear in the presence of functional or habitual poor diet including formula weaning, improper bowel constipation and the term fecal incontinence replaces the training/habituation to move bowels and impact of varying term encopresis. This route by digital is quick, invasive and but may increase the fear of defecation though effective. Rectal suppositories clinical Presentation are useful in infants and include glycerine suppository 1 g for pediatric size and 2–3 g for adolescents. Rectal enema In addition to constipation, many present with chronic includes glycerine, sodium biphosphate, saline or dioctyl recurrent abdominal pain and occasionally poor feeding. Enuresis and other voiding disturbances, some culminating in urinary infections, may be the presenting feature. Rectal examination reveals a dilated rectum jelly using ear bud are effective in anal cracks. Children adopt peculiar postures during defecation with many crossing their legs maintenance (Vincent’s curtsy) or attempting to defecate in the standing Maintenance therapy is aimed to avoid reimpaction and position. With a vicious cycle leading to fecal retention to ensure regular passage of stools by diet, laxatives and and impaction, there is soiling of the undergarments behavioral therapy. Diet in constipation includes fiber containing items like sprouted whole grains, pulses, beans, sorbitol rich fruits (apple Treatment with peel, guava, pomegranate, pear, and prune juice), green the main steps in the management of constipation are: leafy vegetables and water. Fiber intake is recommended • Disimpaction over 2 years of age and the dose is calculated as age in years • Maintenance therapy with diet, laxative and behavioral plus 5 g/day. Behavioral therapy includes proper toilet training, after feeds, three times daily for 5–10 minutes. One word, one disimpaction person, one year, one stool/day, one sitting posture policy Oral is ideal. Guidelines for Functional constipation Hirschsprung disease maintenance dose of commonly used drugs are given in Table 9. More common Less common Meconium history—normal Delayed passage follow-up schedule Onset beyond infancy From birth • monthly follow up till regular bowel movement is Fecal soiling Spurious diarrhea achieved: Check diary, physical and rectal examination. Stool softeners like sorbitol containing difficulty and delay in passing dry stools. Children with refractory constipation with recurrent • Management includes drugs, diet modification, toilet impaction, not responding to routine use of laxatives, training and regular follow up and behavioral therapy. Clinical Practice Guidelines: Evaluation and Treatment manometry or ileo-colonoscopy, planning work for spinal of Constipation in Children. It has an incidence of 1/4,000–7,000 live births and an overall Currently, nearly 90% is diagnosed in the neonatal period or 4:1 male preponderance. Failure to pass meconium within 48 hours of occurs sporadically in full-term births, the rest accounts for birth is a cardinal clinical feature seen in 80–90% infants with the rare genetic/familial/syndromic forms. Symptoms of abdominal distension, poor embryology, etiopathogenesis and feeding, non-bilious vomiting and progressive constipation are characteristic. Infantile constipation often manifests Pathophysiology at weaning, and the recurrent symptom complex of the ganglion cells originate in the neural crest and migrate constipation—spurious diarrhea—abdominal distension— aborally along the bowel till the proximal anal canal; further failure to thrive during childhood. These parasympathetic toxic fulminant sepsis occurring at any age, even after ganglion cells of the intrinsic enteric nervous system definitive management is completed. It presents with fever, employ nitric oxide as the neurotransmitter and modulate foul smelling diarrhea, abdominal distension and lethargy; smooth muscle excitatory/inhibitory interactions in the some progressing to perforation of the cecum or appendix, bowel to effect a relaxation during rest and a coordinated particularly in the neonate. Such long segment disease is characterized by relative female preponderance and association with familial, syndromic and genetic forms. In conclusion, the contrast enema is a good screening conditions that may mimic it in the neonatal period. Historical clues and clinical features help to biopsy is essential to confirm the diagnosis of all forms resolve the issue and direct the confirmatory investigations. A suction fecal loading of rectum and perianal soiling, poor dietary fiber, evidence of associated voiding disturbances and psychological overlay. Though it is least invasive and attractive and has 75–95% accuracy, it is not widely available and difficult in the young uncooperative child. The mixed barium-stool picture in the delayed contrast enema film at 24 hours is also reliable. In associated colitis, double contrast enemas show a saw tooth mucosal contour and irregular uncoordinated contractions of the aganglionic segment. Note the question mark microcolon of total colonic aganglionosis in both rectal biopsy is also available.

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In guttate (raindrop-like) psoriasis seroflo 250mcg mastercard allergy testing jakarta, there are smaller psoriatic papules and plaques diffusely over the body purchase seroflo 250 mcg visa allergy medicine 95a, and this is often triggered by streptococcal infections purchase seroflo 250 mcg mastercard allergy now. Sudden onset of sterile pustules that coalesce to form “lakes of pus” at the edges of psoriatic plaques associated with fever typifies the more generalized form of pustular psoriasis buy discount seroflo 250 mcg line allergy on dogs. These patients are itchy and also complain of chills from the extensive heat loss due to dilatation of cutaneous vessels. There is a recognized association of psoriasis, particularly severe disease, with increased risk of cardiovascular, cerebrovascular, and peripheral vascular disease [151,152]. Large pustules coalescing to form “lakes of pus” over an area of well- demarcated erythema of the palm. For erythrodermic psoriasis, cyclosporine and infliximab appear to be the fastest acting agents; however, their use is predicated on severity of presentation and patient comorbidities [153]. Atopic Dermatitis Atopic dermatitis is characterized by eczematous skin changes and typically involves flexor surfaces in adults, although any body area may be involved. The disease is most common among young children in whom the tendency for atopic dermatitis is to gradually improve with age; however, in a minority of patients, disease persists into or manifests in adulthood. In the most severe cases, eczematous dermatitis may evolve into erythroderma (see “Exfoliative Erythroderma” section). Other complications of this disease include secondary bacterial infection (impetigo) or herpetic infection, a condition known as eczema herpeticum. Treatment of atopic dermatitis includes topical corticosteroids, emollients, oral antihistamines, antibiotics as needed, and management of coexisting asthma and allergies. Contact Dermatitis Contact dermatitis occurs when direct contact with a substance triggers an inflammatory response in the skin. Irritant contact dermatitis, which accounts for 80% of contact cases, occurs when a chemical directly induces damage to the skin. Causes of allergic contact dermatitis in hospitalized patients include adhesives, topical medications, topical antibiotics, preservatives, fragrances, metals, and rubber components. Older adults have an impaired epidermal barrier and are more susceptible to both irritants and allergens. Patients with stasis dermatitis and lower extremity ulcerations are at increased risk of allergic contact dermatitis [154]. Acute contact dermatitis, whether irritant or allergic in nature, presents with pruritic papules and weepy vesicles on an erythematous base, initially localized to the area of contact. Chronic lesions are erythematous plaques of thickened skin with accentuated skin markings, scale, and occasionally fissuring. The differential diagnosis may vary depending on the location of the eruption, but generally includes atopic dermatitis, seborrheic dermatitis, stasis dermatitis, and tinea. Rarely, systemic contact dermatitis can occur when a sensitized individual is exposed to a cross-reacting substance. The most common allergens implicated in systemic allergic contact dermatitis are nickel, aminoglycoside antibiotics, corticosteroids, balsam of Peru, and plants [155]. A common mistake is to attribute the dermatitis to the infection rather than seeing the infection as the result of the dermatitis. For extensive and severe cases, a 2- to 3-week tapering course of oral prednisone, along with an oral antihistamine to relieve pruritus, is appropriate. It is not uncommon to treat patients with both steroids and antibiotics to treat both the cause and the secondary infection. Seborrheic Dermatitis Seborrheic dermatitis is a common, usually asymptomatic, scaly eruption of the oil gland–bearing skin of the scalp, face, and trunk. It may present in mild cases as common dandruff and in severe cases as a florid erythematous scaling eruption involving the scalp, eyebrows, eyelids, paranasal folds, chest, and axillae. Seborrheic dermatitis typically occurs in healthy individuals, but is usually most severe among immunocompromised patients and among patients with neuropsychiatric disorders. Malassezia yeasts are frequently seen in high levels on the skin of patients with seborrheic dermatitis, but their pathogenic role is unclear. The differential diagnosis includes psoriasis, tinea capitis, rosacea, and atopic or contact dermatitis. Treatment is with antidandruff shampoos containing selenium sulfide, zinc pyrithione, ketoconazole, or ciclopirox and topical antifungals (ketoconazole cream, etc. It is caused by blockage of eccrine sweat ducts that occurs in the setting of fever and excessive sweating, often in patients who are largely confined to bed. It occurs in three main forms: miliaria crystallina, which presents as tiny clear asymptomatic superficial vesicles on the trunk, head, and neck; miliaria rubra, which presents as uniform, small pruritic erythematous papules on the trunk, neck, and flexural extremities. It is important to be able to recognize miliaria to distinguish it from more medically significant entities such as disseminated herpes simplex, varicella, or candidiasis. The distribution of miliaria in areas where the skin is occluded and where excessive sweating occurs is helpful for the diagnosis. Some reports state that oral ascorbic acid and topical lanolin can be helpful, but no controlled trials have been done [158]. Tinea corporis is the common, superficial fungal infection found on any area of the skin excluding the palms, soles, scalp, and groin. Trichophyton rubrum is the most common causative organism, although any dermatophyte may be responsible. Tinea corporis presents as one or multiple annular lesions with erythematous scaly borders that exhibit centrifugal spread and leave a central clearing. Other clinical presentations include tinea profunda, which exhibits a granulomatous or verrucous appearance due to an excessive host inflammatory response, and Majocchi’s granuloma, which presents as follicular-based pustules or papules. The differential diagnosis includes nummular eczema, subacute cutaneous lupus erythematosus, and granuloma annulare. Limited disease may be treated with topical agents such as naftifine 1% cream, terbinafine 1% cream, or clotrimazole 1% cream applied twice daily for 2 to 4 weeks in combination with a topical steroid if there is significant local inflammation [159]. More extensive or recalcitrant disease may require systemic treatment such as itraconazole 100 mg daily or terbinafine 250 mg daily for 2 weeks. Prognosis is excellent with 70% to 100% cure after treatment, but recurrence is common [160], especially among the immunosuppressed. Scabies Scabies is a common, extremely pruritic dermatosis caused by infestation with the mite, Sarcoptes scabiei. It spreads from person to person through direct skin contact, although it can rarely spread through fomites such as bedding or towels. Scabies should be considered in the differential diagnosis of any patient with severe generalized itching, especially if they have had contact with residential institutions such as nursing homes, where it may be endemic. Patients with scabies present with severe generalized pruritus, sparing the head and neck, which is worse at night. Papules, pustules, vesicles, and nodules may also occur, the last being especially common in children.

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