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The Journal of Family Practice is a peer-reviewed and indexed journal that provides its 95,000 family physician readers with timely, practical, and evidence-based information that they can immediately put into practice. Research and applied evidence articles, plus patient-oriented departments like Practice Alert, PURLs, and Clinical Inquiries can be found in print and at jfponline.com. The Web site, which logs an average of 125,000 visitors every month, also offers audiocasts by physician specialists and interactive features like Instant Polls and Photo Rounds Friday—a weekly diagnostic puzzle.
gambling
compulsive behaviors
ammunition
assault rifle
black jack
Boko Haram
bondage
child abuse
cocaine
Daech
drug paraphernalia
explosion
gun
human trafficking
ISIL
ISIS
Islamic caliphate
Islamic state
mixed martial arts
MMA
molestation
national rifle association
NRA
nsfw
pedophile
pedophilia
poker
porn
pornography
psychedelic drug
recreational drug
sex slave rings
slot machine
terrorism
terrorist
Texas hold 'em
UFC
substance abuse
abuseed
abuseer
abusees
abuseing
abusely
abuses
aeolus
aeolused
aeoluser
aeoluses
aeolusing
aeolusly
aeoluss
ahole
aholeed
aholeer
aholees
aholeing
aholely
aholes
alcohol
alcoholed
alcoholer
alcoholes
alcoholing
alcoholly
alcohols
allman
allmaned
allmaner
allmanes
allmaning
allmanly
allmans
alted
altes
alting
altly
alts
analed
analer
anales
analing
anally
analprobe
analprobeed
analprobeer
analprobees
analprobeing
analprobely
analprobes
anals
anilingus
anilingused
anilinguser
anilinguses
anilingusing
anilingusly
anilinguss
anus
anused
anuser
anuses
anusing
anusly
anuss
areola
areolaed
areolaer
areolaes
areolaing
areolaly
areolas
areole
areoleed
areoleer
areolees
areoleing
areolely
areoles
arian
arianed
arianer
arianes
arianing
arianly
arians
aryan
aryaned
aryaner
aryanes
aryaning
aryanly
aryans
asiaed
asiaer
asiaes
asiaing
asialy
asias
ass
ass hole
ass lick
ass licked
ass licker
ass lickes
ass licking
ass lickly
ass licks
assbang
assbanged
assbangeded
assbangeder
assbangedes
assbangeding
assbangedly
assbangeds
assbanger
assbanges
assbanging
assbangly
assbangs
assbangsed
assbangser
assbangses
assbangsing
assbangsly
assbangss
assed
asser
asses
assesed
asseser
asseses
assesing
assesly
assess
assfuck
assfucked
assfucker
assfuckered
assfuckerer
assfuckeres
assfuckering
assfuckerly
assfuckers
assfuckes
assfucking
assfuckly
assfucks
asshat
asshated
asshater
asshates
asshating
asshatly
asshats
assholeed
assholeer
assholees
assholeing
assholely
assholes
assholesed
assholeser
assholeses
assholesing
assholesly
assholess
assing
assly
assmaster
assmastered
assmasterer
assmasteres
assmastering
assmasterly
assmasters
assmunch
assmunched
assmuncher
assmunches
assmunching
assmunchly
assmunchs
asss
asswipe
asswipeed
asswipeer
asswipees
asswipeing
asswipely
asswipes
asswipesed
asswipeser
asswipeses
asswipesing
asswipesly
asswipess
azz
azzed
azzer
azzes
azzing
azzly
azzs
babeed
babeer
babees
babeing
babely
babes
babesed
babeser
babeses
babesing
babesly
babess
ballsac
ballsaced
ballsacer
ballsaces
ballsacing
ballsack
ballsacked
ballsacker
ballsackes
ballsacking
ballsackly
ballsacks
ballsacly
ballsacs
ballsed
ballser
ballses
ballsing
ballsly
ballss
barf
barfed
barfer
barfes
barfing
barfly
barfs
bastard
bastarded
bastarder
bastardes
bastarding
bastardly
bastards
bastardsed
bastardser
bastardses
bastardsing
bastardsly
bastardss
bawdy
bawdyed
bawdyer
bawdyes
bawdying
bawdyly
bawdys
beaner
beanered
beanerer
beaneres
beanering
beanerly
beaners
beardedclam
beardedclamed
beardedclamer
beardedclames
beardedclaming
beardedclamly
beardedclams
beastiality
beastialityed
beastialityer
beastialityes
beastialitying
beastialityly
beastialitys
beatch
beatched
beatcher
beatches
beatching
beatchly
beatchs
beater
beatered
beaterer
beateres
beatering
beaterly
beaters
beered
beerer
beeres
beering
beerly
beeyotch
beeyotched
beeyotcher
beeyotches
beeyotching
beeyotchly
beeyotchs
beotch
beotched
beotcher
beotches
beotching
beotchly
beotchs
biatch
biatched
biatcher
biatches
biatching
biatchly
biatchs
big tits
big titsed
big titser
big titses
big titsing
big titsly
big titss
bigtits
bigtitsed
bigtitser
bigtitses
bigtitsing
bigtitsly
bigtitss
bimbo
bimboed
bimboer
bimboes
bimboing
bimboly
bimbos
bisexualed
bisexualer
bisexuales
bisexualing
bisexually
bisexuals
bitch
bitched
bitcheded
bitcheder
bitchedes
bitcheding
bitchedly
bitcheds
bitcher
bitches
bitchesed
bitcheser
bitcheses
bitchesing
bitchesly
bitchess
bitching
bitchly
bitchs
bitchy
bitchyed
bitchyer
bitchyes
bitchying
bitchyly
bitchys
bleached
bleacher
bleaches
bleaching
bleachly
bleachs
blow job
blow jobed
blow jober
blow jobes
blow jobing
blow jobly
blow jobs
blowed
blower
blowes
blowing
blowjob
blowjobed
blowjober
blowjobes
blowjobing
blowjobly
blowjobs
blowjobsed
blowjobser
blowjobses
blowjobsing
blowjobsly
blowjobss
blowly
blows
boink
boinked
boinker
boinkes
boinking
boinkly
boinks
bollock
bollocked
bollocker
bollockes
bollocking
bollockly
bollocks
bollocksed
bollockser
bollockses
bollocksing
bollocksly
bollockss
bollok
bolloked
bolloker
bollokes
bolloking
bollokly
bolloks
boner
bonered
bonerer
boneres
bonering
bonerly
boners
bonersed
bonerser
bonerses
bonersing
bonersly
bonerss
bong
bonged
bonger
bonges
bonging
bongly
bongs
boob
boobed
boober
boobes
boobies
boobiesed
boobieser
boobieses
boobiesing
boobiesly
boobiess
boobing
boobly
boobs
boobsed
boobser
boobses
boobsing
boobsly
boobss
booby
boobyed
boobyer
boobyes
boobying
boobyly
boobys
booger
boogered
boogerer
boogeres
boogering
boogerly
boogers
bookie
bookieed
bookieer
bookiees
bookieing
bookiely
bookies
bootee
booteeed
booteeer
booteees
booteeing
booteely
bootees
bootie
bootieed
bootieer
bootiees
bootieing
bootiely
booties
booty
bootyed
bootyer
bootyes
bootying
bootyly
bootys
boozeed
boozeer
boozees
boozeing
boozely
boozer
boozered
boozerer
boozeres
boozering
boozerly
boozers
boozes
boozy
boozyed
boozyer
boozyes
boozying
boozyly
boozys
bosomed
bosomer
bosomes
bosoming
bosomly
bosoms
bosomy
bosomyed
bosomyer
bosomyes
bosomying
bosomyly
bosomys
bugger
buggered
buggerer
buggeres
buggering
buggerly
buggers
bukkake
bukkakeed
bukkakeer
bukkakees
bukkakeing
bukkakely
bukkakes
bull shit
bull shited
bull shiter
bull shites
bull shiting
bull shitly
bull shits
bullshit
bullshited
bullshiter
bullshites
bullshiting
bullshitly
bullshits
bullshitsed
bullshitser
bullshitses
bullshitsing
bullshitsly
bullshitss
bullshitted
bullshitteded
bullshitteder
bullshittedes
bullshitteding
bullshittedly
bullshitteds
bullturds
bullturdsed
bullturdser
bullturdses
bullturdsing
bullturdsly
bullturdss
bung
bunged
bunger
bunges
bunging
bungly
bungs
busty
bustyed
bustyer
bustyes
bustying
bustyly
bustys
butt
butt fuck
butt fucked
butt fucker
butt fuckes
butt fucking
butt fuckly
butt fucks
butted
buttes
buttfuck
buttfucked
buttfucker
buttfuckered
buttfuckerer
buttfuckeres
buttfuckering
buttfuckerly
buttfuckers
buttfuckes
buttfucking
buttfuckly
buttfucks
butting
buttly
buttplug
buttpluged
buttpluger
buttpluges
buttpluging
buttplugly
buttplugs
butts
caca
cacaed
cacaer
cacaes
cacaing
cacaly
cacas
cahone
cahoneed
cahoneer
cahonees
cahoneing
cahonely
cahones
cameltoe
cameltoeed
cameltoeer
cameltoees
cameltoeing
cameltoely
cameltoes
carpetmuncher
carpetmunchered
carpetmuncherer
carpetmuncheres
carpetmunchering
carpetmuncherly
carpetmunchers
cawk
cawked
cawker
cawkes
cawking
cawkly
cawks
chinc
chinced
chincer
chinces
chincing
chincly
chincs
chincsed
chincser
chincses
chincsing
chincsly
chincss
chink
chinked
chinker
chinkes
chinking
chinkly
chinks
chode
chodeed
chodeer
chodees
chodeing
chodely
chodes
chodesed
chodeser
chodeses
chodesing
chodesly
chodess
clit
clited
cliter
clites
cliting
clitly
clitoris
clitorised
clitoriser
clitorises
clitorising
clitorisly
clitoriss
clitorus
clitorused
clitoruser
clitoruses
clitorusing
clitorusly
clitoruss
clits
clitsed
clitser
clitses
clitsing
clitsly
clitss
clitty
clittyed
clittyer
clittyes
clittying
clittyly
clittys
cocain
cocaine
cocained
cocaineed
cocaineer
cocainees
cocaineing
cocainely
cocainer
cocaines
cocaining
cocainly
cocains
cock
cock sucker
cock suckered
cock suckerer
cock suckeres
cock suckering
cock suckerly
cock suckers
cockblock
cockblocked
cockblocker
cockblockes
cockblocking
cockblockly
cockblocks
cocked
cocker
cockes
cockholster
cockholstered
cockholsterer
cockholsteres
cockholstering
cockholsterly
cockholsters
cocking
cockknocker
cockknockered
cockknockerer
cockknockeres
cockknockering
cockknockerly
cockknockers
cockly
cocks
cocksed
cockser
cockses
cocksing
cocksly
cocksmoker
cocksmokered
cocksmokerer
cocksmokeres
cocksmokering
cocksmokerly
cocksmokers
cockss
cocksucker
cocksuckered
cocksuckerer
cocksuckeres
cocksuckering
cocksuckerly
cocksuckers
coital
coitaled
coitaler
coitales
coitaling
coitally
coitals
commie
commieed
commieer
commiees
commieing
commiely
commies
condomed
condomer
condomes
condoming
condomly
condoms
coon
cooned
cooner
coones
cooning
coonly
coons
coonsed
coonser
coonses
coonsing
coonsly
coonss
corksucker
corksuckered
corksuckerer
corksuckeres
corksuckering
corksuckerly
corksuckers
cracked
crackwhore
crackwhoreed
crackwhoreer
crackwhorees
crackwhoreing
crackwhorely
crackwhores
crap
craped
craper
crapes
craping
craply
crappy
crappyed
crappyer
crappyes
crappying
crappyly
crappys
cum
cumed
cumer
cumes
cuming
cumly
cummin
cummined
cumminer
cummines
cumming
cumminged
cumminger
cumminges
cumminging
cummingly
cummings
cummining
cumminly
cummins
cums
cumshot
cumshoted
cumshoter
cumshotes
cumshoting
cumshotly
cumshots
cumshotsed
cumshotser
cumshotses
cumshotsing
cumshotsly
cumshotss
cumslut
cumsluted
cumsluter
cumslutes
cumsluting
cumslutly
cumsluts
cumstain
cumstained
cumstainer
cumstaines
cumstaining
cumstainly
cumstains
cunilingus
cunilingused
cunilinguser
cunilinguses
cunilingusing
cunilingusly
cunilinguss
cunnilingus
cunnilingused
cunnilinguser
cunnilinguses
cunnilingusing
cunnilingusly
cunnilinguss
cunny
cunnyed
cunnyer
cunnyes
cunnying
cunnyly
cunnys
cunt
cunted
cunter
cuntes
cuntface
cuntfaceed
cuntfaceer
cuntfacees
cuntfaceing
cuntfacely
cuntfaces
cunthunter
cunthuntered
cunthunterer
cunthunteres
cunthuntering
cunthunterly
cunthunters
cunting
cuntlick
cuntlicked
cuntlicker
cuntlickered
cuntlickerer
cuntlickeres
cuntlickering
cuntlickerly
cuntlickers
cuntlickes
cuntlicking
cuntlickly
cuntlicks
cuntly
cunts
cuntsed
cuntser
cuntses
cuntsing
cuntsly
cuntss
dago
dagoed
dagoer
dagoes
dagoing
dagoly
dagos
dagosed
dagoser
dagoses
dagosing
dagosly
dagoss
dammit
dammited
dammiter
dammites
dammiting
dammitly
dammits
damn
damned
damneded
damneder
damnedes
damneding
damnedly
damneds
damner
damnes
damning
damnit
damnited
damniter
damnites
damniting
damnitly
damnits
damnly
damns
dick
dickbag
dickbaged
dickbager
dickbages
dickbaging
dickbagly
dickbags
dickdipper
dickdippered
dickdipperer
dickdipperes
dickdippering
dickdipperly
dickdippers
dicked
dicker
dickes
dickface
dickfaceed
dickfaceer
dickfacees
dickfaceing
dickfacely
dickfaces
dickflipper
dickflippered
dickflipperer
dickflipperes
dickflippering
dickflipperly
dickflippers
dickhead
dickheaded
dickheader
dickheades
dickheading
dickheadly
dickheads
dickheadsed
dickheadser
dickheadses
dickheadsing
dickheadsly
dickheadss
dicking
dickish
dickished
dickisher
dickishes
dickishing
dickishly
dickishs
dickly
dickripper
dickrippered
dickripperer
dickripperes
dickrippering
dickripperly
dickrippers
dicks
dicksipper
dicksippered
dicksipperer
dicksipperes
dicksippering
dicksipperly
dicksippers
dickweed
dickweeded
dickweeder
dickweedes
dickweeding
dickweedly
dickweeds
dickwhipper
dickwhippered
dickwhipperer
dickwhipperes
dickwhippering
dickwhipperly
dickwhippers
dickzipper
dickzippered
dickzipperer
dickzipperes
dickzippering
dickzipperly
dickzippers
diddle
diddleed
diddleer
diddlees
diddleing
diddlely
diddles
dike
dikeed
dikeer
dikees
dikeing
dikely
dikes
dildo
dildoed
dildoer
dildoes
dildoing
dildoly
dildos
dildosed
dildoser
dildoses
dildosing
dildosly
dildoss
diligaf
diligafed
diligafer
diligafes
diligafing
diligafly
diligafs
dillweed
dillweeded
dillweeder
dillweedes
dillweeding
dillweedly
dillweeds
dimwit
dimwited
dimwiter
dimwites
dimwiting
dimwitly
dimwits
dingle
dingleed
dingleer
dinglees
dingleing
dinglely
dingles
dipship
dipshiped
dipshiper
dipshipes
dipshiping
dipshiply
dipships
dizzyed
dizzyer
dizzyes
dizzying
dizzyly
dizzys
doggiestyleed
doggiestyleer
doggiestylees
doggiestyleing
doggiestylely
doggiestyles
doggystyleed
doggystyleer
doggystylees
doggystyleing
doggystylely
doggystyles
dong
donged
donger
donges
donging
dongly
dongs
doofus
doofused
doofuser
doofuses
doofusing
doofusly
doofuss
doosh
dooshed
doosher
dooshes
dooshing
dooshly
dooshs
dopeyed
dopeyer
dopeyes
dopeying
dopeyly
dopeys
douchebag
douchebaged
douchebager
douchebages
douchebaging
douchebagly
douchebags
douchebagsed
douchebagser
douchebagses
douchebagsing
douchebagsly
douchebagss
doucheed
doucheer
douchees
doucheing
douchely
douches
douchey
doucheyed
doucheyer
doucheyes
doucheying
doucheyly
doucheys
drunk
drunked
drunker
drunkes
drunking
drunkly
drunks
dumass
dumassed
dumasser
dumasses
dumassing
dumassly
dumasss
dumbass
dumbassed
dumbasser
dumbasses
dumbassesed
dumbasseser
dumbasseses
dumbassesing
dumbassesly
dumbassess
dumbassing
dumbassly
dumbasss
dummy
dummyed
dummyer
dummyes
dummying
dummyly
dummys
dyke
dykeed
dykeer
dykees
dykeing
dykely
dykes
dykesed
dykeser
dykeses
dykesing
dykesly
dykess
erotic
eroticed
eroticer
erotices
eroticing
eroticly
erotics
extacy
extacyed
extacyer
extacyes
extacying
extacyly
extacys
extasy
extasyed
extasyer
extasyes
extasying
extasyly
extasys
fack
facked
facker
fackes
facking
fackly
facks
fag
faged
fager
fages
fagg
fagged
faggeded
faggeder
faggedes
faggeding
faggedly
faggeds
fagger
fagges
fagging
faggit
faggited
faggiter
faggites
faggiting
faggitly
faggits
faggly
faggot
faggoted
faggoter
faggotes
faggoting
faggotly
faggots
faggs
faging
fagly
fagot
fagoted
fagoter
fagotes
fagoting
fagotly
fagots
fags
fagsed
fagser
fagses
fagsing
fagsly
fagss
faig
faiged
faiger
faiges
faiging
faigly
faigs
faigt
faigted
faigter
faigtes
faigting
faigtly
faigts
fannybandit
fannybandited
fannybanditer
fannybandites
fannybanditing
fannybanditly
fannybandits
farted
farter
fartes
farting
fartknocker
fartknockered
fartknockerer
fartknockeres
fartknockering
fartknockerly
fartknockers
fartly
farts
felch
felched
felcher
felchered
felcherer
felcheres
felchering
felcherly
felchers
felches
felching
felchinged
felchinger
felchinges
felchinging
felchingly
felchings
felchly
felchs
fellate
fellateed
fellateer
fellatees
fellateing
fellately
fellates
fellatio
fellatioed
fellatioer
fellatioes
fellatioing
fellatioly
fellatios
feltch
feltched
feltcher
feltchered
feltcherer
feltcheres
feltchering
feltcherly
feltchers
feltches
feltching
feltchly
feltchs
feom
feomed
feomer
feomes
feoming
feomly
feoms
fisted
fisteded
fisteder
fistedes
fisteding
fistedly
fisteds
fisting
fistinged
fistinger
fistinges
fistinging
fistingly
fistings
fisty
fistyed
fistyer
fistyes
fistying
fistyly
fistys
floozy
floozyed
floozyer
floozyes
floozying
floozyly
floozys
foad
foaded
foader
foades
foading
foadly
foads
fondleed
fondleer
fondlees
fondleing
fondlely
fondles
foobar
foobared
foobarer
foobares
foobaring
foobarly
foobars
freex
freexed
freexer
freexes
freexing
freexly
freexs
frigg
frigga
friggaed
friggaer
friggaes
friggaing
friggaly
friggas
frigged
frigger
frigges
frigging
friggly
friggs
fubar
fubared
fubarer
fubares
fubaring
fubarly
fubars
fuck
fuckass
fuckassed
fuckasser
fuckasses
fuckassing
fuckassly
fuckasss
fucked
fuckeded
fuckeder
fuckedes
fuckeding
fuckedly
fuckeds
fucker
fuckered
fuckerer
fuckeres
fuckering
fuckerly
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rumper
rumpes
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How well do antivirals shorten genital herpes pain duration?
Oral and intravenous (IV) acyclovir each shorten the duration of pain for a first primary outbreak of herpes by about 50%; topical acyclovir shortens it by about 25% (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs] with some methodological flaws).
Oral valacyclovir and famciclovir are equivalent to oral acyclovir. Adding topical acyclovir to oral acyclovir doesn’t produce additional benefit (SOR: B, RCTs).
Patients with severe disease may require IV acyclovir (SOR: C, expert opinion).
General treatment measures that may improve patient comfort include keeping lesions clean and dry, avoiding tight clothing, taking analgesics, and using ice packs or taking warm baths (SOR: C, expert opinion).
Evidence for using complementary and alternative medicine to treat genital herpes is lacking or conflicting [SOR: C, narrative review of clinical trials].
EVIDENCE SUMMARY
A review of 3 double-blind, placebo-controlled RCTs compared topical, oral, and IV acyclovir in patients with a first episode of genital herpes.1 Researchers recruited a total of 138 patients and randomized them to receive either placebo or one of the following: oral acyclovir (200 mg 5 times daily for 10 days), IV acyclovir (5 mg/kg dose, 3 times daily for 5 days), or 5% topical acyclovir in polyethylene glycol (4 times daily for 6 days).
All treatments shortened duration of pain compared with placebo: oral (3 days vs 7 days, P<.01), IV (5 days vs 9 days, P<.05), and topical (5 days vs 7 days, P<.05).
A subsequent RCT with 50 patients found that adding topical acyclovir to oral acyclovir was no more effective than oral acyclovir alone.2
Oral acyclovir, valacyclovir, and famciclovir work equally well
Head-to-head trials comparing acyclovir with valacyclovir or famciclovir show no difference in decreased duration of pain caused by primary genital herpes. An RCT of 643 adults found valacyclovir (1000 mg twice daily for 10 days) to be as effective and well-tolerated as acyclovir (200 mg 5 times daily for 10 days).3 An RCT of 951 adults demonstrated that famciclovir (250 mg 3 times daily for either 5 or 10 days) worked as well as acyclovir (200 mg 5 times daily for 10 days).4
General treatment measures
Expert opinion recommends the following general treatment measures for genital herpes lesions: keeping the affected area clean and dry, wearing dry, loose-fitting clothing and cotton underwear, and not touching the lesions. Additional symptomatic treatments for local pain include ice packs, baking soda compresses, warm baths, oral analgesics, topical anesthetics, and drying the affected area with cool air.5-8
CAM approaches lack evidence of efficacy
A 2005 nonsystematic review of available scientific data on complementary and alternative medicine found a lack of evidence or conflicting evidence concerning the use of aloe vera, echinacea, L-lysine, bee products (honey pollen), zinc, and eleuthero for the treatment of pain in genital herpes.9
RECOMMENDATIONS
Clinical practice guidelines recommend prescribing oral antiviral therapy for patients with a first episode of genital herpes because patients with mild clinical findings at onset may develop severe or prolonged symptoms. Choices include a 7- to 10-day course of valacyclovir 1 g twice a day, famciclovir 250 mg 3 times a day, acyclovir 400 mg 3 times a day, or acyclovir 400 mg 5 times a day.5,10
The guidelines recommend treating patients with severe disease (such as disseminated infection, pneumonitis, hepatitis, or meningoencephalitis) with IV acyclovir (5-10 mg/kg every 8 hours for 2-7 days or until clinical improvement), followed by oral acyclovir for at least 10 days.
1. Corey L, Benedetti J, Critchlow C, et al. Treatment of primary first-episode genital herpes simplex virus infections with acyclovir: results of topical, intravenous and oral therapy. J Antimicrob Chemother. 1983;12(suppl B):79-88.
2. Kinghorn GR, Abeywickreme I, Jeavons M, et al. Efficacy of combined treatment with oral and topical acyclovir in first episode genital herpes. Genitourin Med. 1986;62:186-188.
3. Fife KH, Barabarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinic trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis. 1997;24:481-486.
4. Loveless M, Sacks SL, Harris JRW. Famciclovir in the management of first-episode genital herpes. Infect Dis Clin Prac. 1997;6(suppl 1):S12-S16.
5. ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists, number 57, November 2004. Gynecologic herpes simplex virus infections. Obstet Gynecol. 2004;104(5 pt 1):1111-1118.
6. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72:1527-1534.
7. Patel R. Progress in meeting today’s demands in genital herpes: an overview of current management. J Infect Dis. 2002;186(suppl 1):S847-S856.
8. Stanberry LR, Rosenthal SL. Genital herpes simplex virus infection in the adolescent: special considerations for management. Pediatr Drugs. 2002;4:291-297.
9. Perfect MM, Bourne N, Ebel C, et al. Use of complementary and alternative medicine for the treatment of genital herpes. Herpes. 2005;12:38-41.
10. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1-110.
Oral and intravenous (IV) acyclovir each shorten the duration of pain for a first primary outbreak of herpes by about 50%; topical acyclovir shortens it by about 25% (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs] with some methodological flaws).
Oral valacyclovir and famciclovir are equivalent to oral acyclovir. Adding topical acyclovir to oral acyclovir doesn’t produce additional benefit (SOR: B, RCTs).
Patients with severe disease may require IV acyclovir (SOR: C, expert opinion).
General treatment measures that may improve patient comfort include keeping lesions clean and dry, avoiding tight clothing, taking analgesics, and using ice packs or taking warm baths (SOR: C, expert opinion).
Evidence for using complementary and alternative medicine to treat genital herpes is lacking or conflicting [SOR: C, narrative review of clinical trials].
EVIDENCE SUMMARY
A review of 3 double-blind, placebo-controlled RCTs compared topical, oral, and IV acyclovir in patients with a first episode of genital herpes.1 Researchers recruited a total of 138 patients and randomized them to receive either placebo or one of the following: oral acyclovir (200 mg 5 times daily for 10 days), IV acyclovir (5 mg/kg dose, 3 times daily for 5 days), or 5% topical acyclovir in polyethylene glycol (4 times daily for 6 days).
All treatments shortened duration of pain compared with placebo: oral (3 days vs 7 days, P<.01), IV (5 days vs 9 days, P<.05), and topical (5 days vs 7 days, P<.05).
A subsequent RCT with 50 patients found that adding topical acyclovir to oral acyclovir was no more effective than oral acyclovir alone.2
Oral acyclovir, valacyclovir, and famciclovir work equally well
Head-to-head trials comparing acyclovir with valacyclovir or famciclovir show no difference in decreased duration of pain caused by primary genital herpes. An RCT of 643 adults found valacyclovir (1000 mg twice daily for 10 days) to be as effective and well-tolerated as acyclovir (200 mg 5 times daily for 10 days).3 An RCT of 951 adults demonstrated that famciclovir (250 mg 3 times daily for either 5 or 10 days) worked as well as acyclovir (200 mg 5 times daily for 10 days).4
General treatment measures
Expert opinion recommends the following general treatment measures for genital herpes lesions: keeping the affected area clean and dry, wearing dry, loose-fitting clothing and cotton underwear, and not touching the lesions. Additional symptomatic treatments for local pain include ice packs, baking soda compresses, warm baths, oral analgesics, topical anesthetics, and drying the affected area with cool air.5-8
CAM approaches lack evidence of efficacy
A 2005 nonsystematic review of available scientific data on complementary and alternative medicine found a lack of evidence or conflicting evidence concerning the use of aloe vera, echinacea, L-lysine, bee products (honey pollen), zinc, and eleuthero for the treatment of pain in genital herpes.9
RECOMMENDATIONS
Clinical practice guidelines recommend prescribing oral antiviral therapy for patients with a first episode of genital herpes because patients with mild clinical findings at onset may develop severe or prolonged symptoms. Choices include a 7- to 10-day course of valacyclovir 1 g twice a day, famciclovir 250 mg 3 times a day, acyclovir 400 mg 3 times a day, or acyclovir 400 mg 5 times a day.5,10
The guidelines recommend treating patients with severe disease (such as disseminated infection, pneumonitis, hepatitis, or meningoencephalitis) with IV acyclovir (5-10 mg/kg every 8 hours for 2-7 days or until clinical improvement), followed by oral acyclovir for at least 10 days.
Oral and intravenous (IV) acyclovir each shorten the duration of pain for a first primary outbreak of herpes by about 50%; topical acyclovir shortens it by about 25% (strength of recommendation [SOR]: B, small randomized controlled trials [RCTs] with some methodological flaws).
Oral valacyclovir and famciclovir are equivalent to oral acyclovir. Adding topical acyclovir to oral acyclovir doesn’t produce additional benefit (SOR: B, RCTs).
Patients with severe disease may require IV acyclovir (SOR: C, expert opinion).
General treatment measures that may improve patient comfort include keeping lesions clean and dry, avoiding tight clothing, taking analgesics, and using ice packs or taking warm baths (SOR: C, expert opinion).
Evidence for using complementary and alternative medicine to treat genital herpes is lacking or conflicting [SOR: C, narrative review of clinical trials].
EVIDENCE SUMMARY
A review of 3 double-blind, placebo-controlled RCTs compared topical, oral, and IV acyclovir in patients with a first episode of genital herpes.1 Researchers recruited a total of 138 patients and randomized them to receive either placebo or one of the following: oral acyclovir (200 mg 5 times daily for 10 days), IV acyclovir (5 mg/kg dose, 3 times daily for 5 days), or 5% topical acyclovir in polyethylene glycol (4 times daily for 6 days).
All treatments shortened duration of pain compared with placebo: oral (3 days vs 7 days, P<.01), IV (5 days vs 9 days, P<.05), and topical (5 days vs 7 days, P<.05).
A subsequent RCT with 50 patients found that adding topical acyclovir to oral acyclovir was no more effective than oral acyclovir alone.2
Oral acyclovir, valacyclovir, and famciclovir work equally well
Head-to-head trials comparing acyclovir with valacyclovir or famciclovir show no difference in decreased duration of pain caused by primary genital herpes. An RCT of 643 adults found valacyclovir (1000 mg twice daily for 10 days) to be as effective and well-tolerated as acyclovir (200 mg 5 times daily for 10 days).3 An RCT of 951 adults demonstrated that famciclovir (250 mg 3 times daily for either 5 or 10 days) worked as well as acyclovir (200 mg 5 times daily for 10 days).4
General treatment measures
Expert opinion recommends the following general treatment measures for genital herpes lesions: keeping the affected area clean and dry, wearing dry, loose-fitting clothing and cotton underwear, and not touching the lesions. Additional symptomatic treatments for local pain include ice packs, baking soda compresses, warm baths, oral analgesics, topical anesthetics, and drying the affected area with cool air.5-8
CAM approaches lack evidence of efficacy
A 2005 nonsystematic review of available scientific data on complementary and alternative medicine found a lack of evidence or conflicting evidence concerning the use of aloe vera, echinacea, L-lysine, bee products (honey pollen), zinc, and eleuthero for the treatment of pain in genital herpes.9
RECOMMENDATIONS
Clinical practice guidelines recommend prescribing oral antiviral therapy for patients with a first episode of genital herpes because patients with mild clinical findings at onset may develop severe or prolonged symptoms. Choices include a 7- to 10-day course of valacyclovir 1 g twice a day, famciclovir 250 mg 3 times a day, acyclovir 400 mg 3 times a day, or acyclovir 400 mg 5 times a day.5,10
The guidelines recommend treating patients with severe disease (such as disseminated infection, pneumonitis, hepatitis, or meningoencephalitis) with IV acyclovir (5-10 mg/kg every 8 hours for 2-7 days or until clinical improvement), followed by oral acyclovir for at least 10 days.
1. Corey L, Benedetti J, Critchlow C, et al. Treatment of primary first-episode genital herpes simplex virus infections with acyclovir: results of topical, intravenous and oral therapy. J Antimicrob Chemother. 1983;12(suppl B):79-88.
2. Kinghorn GR, Abeywickreme I, Jeavons M, et al. Efficacy of combined treatment with oral and topical acyclovir in first episode genital herpes. Genitourin Med. 1986;62:186-188.
3. Fife KH, Barabarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinic trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis. 1997;24:481-486.
4. Loveless M, Sacks SL, Harris JRW. Famciclovir in the management of first-episode genital herpes. Infect Dis Clin Prac. 1997;6(suppl 1):S12-S16.
5. ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists, number 57, November 2004. Gynecologic herpes simplex virus infections. Obstet Gynecol. 2004;104(5 pt 1):1111-1118.
6. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72:1527-1534.
7. Patel R. Progress in meeting today’s demands in genital herpes: an overview of current management. J Infect Dis. 2002;186(suppl 1):S847-S856.
8. Stanberry LR, Rosenthal SL. Genital herpes simplex virus infection in the adolescent: special considerations for management. Pediatr Drugs. 2002;4:291-297.
9. Perfect MM, Bourne N, Ebel C, et al. Use of complementary and alternative medicine for the treatment of genital herpes. Herpes. 2005;12:38-41.
10. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1-110.
1. Corey L, Benedetti J, Critchlow C, et al. Treatment of primary first-episode genital herpes simplex virus infections with acyclovir: results of topical, intravenous and oral therapy. J Antimicrob Chemother. 1983;12(suppl B):79-88.
2. Kinghorn GR, Abeywickreme I, Jeavons M, et al. Efficacy of combined treatment with oral and topical acyclovir in first episode genital herpes. Genitourin Med. 1986;62:186-188.
3. Fife KH, Barabarash RA, Rudolph T, et al. Valaciclovir versus acyclovir in the treatment of first-episode genital herpes infection. Results of an international, multicenter, double-blind, randomized clinic trial. The Valaciclovir International Herpes Simplex Virus Study Group. Sex Transm Dis. 1997;24:481-486.
4. Loveless M, Sacks SL, Harris JRW. Famciclovir in the management of first-episode genital herpes. Infect Dis Clin Prac. 1997;6(suppl 1):S12-S16.
5. ACOG Committee on Practice Bulletins—Gynecology. ACOG practice bulletin: Clinical management guidelines for obstetrician-gynecologists, number 57, November 2004. Gynecologic herpes simplex virus infections. Obstet Gynecol. 2004;104(5 pt 1):1111-1118.
6. Beauman JG. Genital herpes: a review. Am Fam Physician. 2005;72:1527-1534.
7. Patel R. Progress in meeting today’s demands in genital herpes: an overview of current management. J Infect Dis. 2002;186(suppl 1):S847-S856.
8. Stanberry LR, Rosenthal SL. Genital herpes simplex virus infection in the adolescent: special considerations for management. Pediatr Drugs. 2002;4:291-297.
9. Perfect MM, Bourne N, Ebel C, et al. Use of complementary and alternative medicine for the treatment of genital herpes. Herpes. 2005;12:38-41.
10. Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. 2010;59:1-110.
Evidence-based answers from the Family Physicians Inquiries Network
Does the presence of a trained support person during labor decrease C-section rates?
Sometimes. The continuous presence of a support person during labor slightly decreases (by about 2%) the likelihood of a cesarean section (C-section) but only when companions can’t be present and epidurals aren’t routine (strength of recommendation [SOR]: A, a well-done systematic review of randomized controlled trials [RCTs]). When the support person was neither hospital staff nor a member of the woman’s social network, C-section was significantly less likely (SOR A, a well-done systematic review of RCTs).
EVIDENCE SUMMARY
A 2012 Cochrane review of 22 multinational RCTs with a total of 15,288 patients investigated the effect of continuous support in labor on several outcomes, including C-section.1 All trials included pregnant women in labor. The study populations were heterogenous in terms of parity; most included only nulliparous women, but some included multiparous women. At least one study incorporated higher-risk groups such as mothers of twins, but several trials limited the study group to low-risk pregnancies.
The review found a small but significant decrease in risk of C-section in women receiving continuous support (absolute risk reduction [ARR]=2%; number needed to treat [NNT]=50; P=.0017).1 The average cost of trained childbirth support in 3 US metropolitan areas in October 2014 was about $875, according to a Web search of established businesses.
The effect only works in the absence of companions and epidurals…
A subgroup analysis of 22 studies investigated several variables to determine circumstances under which a support person decreased the risk of C-section.1 The support person’s presence was significant only when hospital policy prevented companions (such as the woman’s spouse) in the labor room and when epidurals were not routinely available. Eleven of the 22 studies (11,326 patients) permitted a companion; 11 studies (3849 patients) didn’t.
When policy allowed companions, the presence of a support person didn’t decrease C-section rates significantly (12.7% without support compared with 11.9% with support; P=.20).1 When the woman wasn’t permitted to have a companion, however, the presence of a support person significantly decreased C-section (ARR=5.4%; NNT=19; P<.01).
In 14 studies, with a total of 13,064 patients, epidurals were routinely available. In the other 8, with 2077 patients, epidurals weren’t available.1 These were older studies or studies conducted in developing countries. When epidurals were routinely available, the presence of a support person didn’t affect the C-section rate (13.8% rate without support, 12.9% with support; P=.12). But if epidural anesthesia wasn’t available, a support person decreased C-section (ARR=8.6%; NNT=12; P<.00001).
…And when the support person isn’t a hospital staffer or known to the patient
The Cochrane Review also evaluated different types of labor supporters: companions of the patient’s choice from her social network, hospital employees, and people who were neither. The support person conferred significant benefit only when that person was neither hospital staff nor a member of the woman’s social network.
Hospital staff members who provided support didn’t effectively decrease the C-section rate (12% rate in control group vs 11.3% in supported group; P=.28). Support people chosen by the patient likewise didn’t successfully reduce C-sections (19.4% control rate vs 15.5% supported rate; P=.062). When the support person was neither hospital staff nor someone well-known to the patient, the risk of C-section was significantly lower (ARR=6%; NNT=17; P=.0003).
RECOMMENDATIONS
In a Comparative Effectiveness Review published in October 2012, the Agency for Healthcare Research and Quality investigated 18 strategies to reduce C-section, one of which was psychosocial support from doulas and other providers. A trained support person was the only intervention that showed evidence of benefit in decreasing C-section, but the strength of evidence was low.2
An American College of Obstetricians and Gynecologists Practice Bulletin recommends continuous labor support, noting “the continuous presence of a support person may reduce the likelihood of…operative delivery” with no apparent harmful effects.3
1. Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2012;(10):CD003766.
2. Agency for Healthcare Research and Quality. Strategies to reduce cesarean birth in low-risk women. Agency for Healthcare Research and Quality Web site. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/263/1291/CER80_C-Section_ExecutiveSummary_20121018.pdf. Accessed February 22, 2015.
3. American College of Obstetrics and Gynecology Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol. 2003;102:1445-1454.
Sometimes. The continuous presence of a support person during labor slightly decreases (by about 2%) the likelihood of a cesarean section (C-section) but only when companions can’t be present and epidurals aren’t routine (strength of recommendation [SOR]: A, a well-done systematic review of randomized controlled trials [RCTs]). When the support person was neither hospital staff nor a member of the woman’s social network, C-section was significantly less likely (SOR A, a well-done systematic review of RCTs).
EVIDENCE SUMMARY
A 2012 Cochrane review of 22 multinational RCTs with a total of 15,288 patients investigated the effect of continuous support in labor on several outcomes, including C-section.1 All trials included pregnant women in labor. The study populations were heterogenous in terms of parity; most included only nulliparous women, but some included multiparous women. At least one study incorporated higher-risk groups such as mothers of twins, but several trials limited the study group to low-risk pregnancies.
The review found a small but significant decrease in risk of C-section in women receiving continuous support (absolute risk reduction [ARR]=2%; number needed to treat [NNT]=50; P=.0017).1 The average cost of trained childbirth support in 3 US metropolitan areas in October 2014 was about $875, according to a Web search of established businesses.
The effect only works in the absence of companions and epidurals…
A subgroup analysis of 22 studies investigated several variables to determine circumstances under which a support person decreased the risk of C-section.1 The support person’s presence was significant only when hospital policy prevented companions (such as the woman’s spouse) in the labor room and when epidurals were not routinely available. Eleven of the 22 studies (11,326 patients) permitted a companion; 11 studies (3849 patients) didn’t.
When policy allowed companions, the presence of a support person didn’t decrease C-section rates significantly (12.7% without support compared with 11.9% with support; P=.20).1 When the woman wasn’t permitted to have a companion, however, the presence of a support person significantly decreased C-section (ARR=5.4%; NNT=19; P<.01).
In 14 studies, with a total of 13,064 patients, epidurals were routinely available. In the other 8, with 2077 patients, epidurals weren’t available.1 These were older studies or studies conducted in developing countries. When epidurals were routinely available, the presence of a support person didn’t affect the C-section rate (13.8% rate without support, 12.9% with support; P=.12). But if epidural anesthesia wasn’t available, a support person decreased C-section (ARR=8.6%; NNT=12; P<.00001).
…And when the support person isn’t a hospital staffer or known to the patient
The Cochrane Review also evaluated different types of labor supporters: companions of the patient’s choice from her social network, hospital employees, and people who were neither. The support person conferred significant benefit only when that person was neither hospital staff nor a member of the woman’s social network.
Hospital staff members who provided support didn’t effectively decrease the C-section rate (12% rate in control group vs 11.3% in supported group; P=.28). Support people chosen by the patient likewise didn’t successfully reduce C-sections (19.4% control rate vs 15.5% supported rate; P=.062). When the support person was neither hospital staff nor someone well-known to the patient, the risk of C-section was significantly lower (ARR=6%; NNT=17; P=.0003).
RECOMMENDATIONS
In a Comparative Effectiveness Review published in October 2012, the Agency for Healthcare Research and Quality investigated 18 strategies to reduce C-section, one of which was psychosocial support from doulas and other providers. A trained support person was the only intervention that showed evidence of benefit in decreasing C-section, but the strength of evidence was low.2
An American College of Obstetricians and Gynecologists Practice Bulletin recommends continuous labor support, noting “the continuous presence of a support person may reduce the likelihood of…operative delivery” with no apparent harmful effects.3
Sometimes. The continuous presence of a support person during labor slightly decreases (by about 2%) the likelihood of a cesarean section (C-section) but only when companions can’t be present and epidurals aren’t routine (strength of recommendation [SOR]: A, a well-done systematic review of randomized controlled trials [RCTs]). When the support person was neither hospital staff nor a member of the woman’s social network, C-section was significantly less likely (SOR A, a well-done systematic review of RCTs).
EVIDENCE SUMMARY
A 2012 Cochrane review of 22 multinational RCTs with a total of 15,288 patients investigated the effect of continuous support in labor on several outcomes, including C-section.1 All trials included pregnant women in labor. The study populations were heterogenous in terms of parity; most included only nulliparous women, but some included multiparous women. At least one study incorporated higher-risk groups such as mothers of twins, but several trials limited the study group to low-risk pregnancies.
The review found a small but significant decrease in risk of C-section in women receiving continuous support (absolute risk reduction [ARR]=2%; number needed to treat [NNT]=50; P=.0017).1 The average cost of trained childbirth support in 3 US metropolitan areas in October 2014 was about $875, according to a Web search of established businesses.
The effect only works in the absence of companions and epidurals…
A subgroup analysis of 22 studies investigated several variables to determine circumstances under which a support person decreased the risk of C-section.1 The support person’s presence was significant only when hospital policy prevented companions (such as the woman’s spouse) in the labor room and when epidurals were not routinely available. Eleven of the 22 studies (11,326 patients) permitted a companion; 11 studies (3849 patients) didn’t.
When policy allowed companions, the presence of a support person didn’t decrease C-section rates significantly (12.7% without support compared with 11.9% with support; P=.20).1 When the woman wasn’t permitted to have a companion, however, the presence of a support person significantly decreased C-section (ARR=5.4%; NNT=19; P<.01).
In 14 studies, with a total of 13,064 patients, epidurals were routinely available. In the other 8, with 2077 patients, epidurals weren’t available.1 These were older studies or studies conducted in developing countries. When epidurals were routinely available, the presence of a support person didn’t affect the C-section rate (13.8% rate without support, 12.9% with support; P=.12). But if epidural anesthesia wasn’t available, a support person decreased C-section (ARR=8.6%; NNT=12; P<.00001).
…And when the support person isn’t a hospital staffer or known to the patient
The Cochrane Review also evaluated different types of labor supporters: companions of the patient’s choice from her social network, hospital employees, and people who were neither. The support person conferred significant benefit only when that person was neither hospital staff nor a member of the woman’s social network.
Hospital staff members who provided support didn’t effectively decrease the C-section rate (12% rate in control group vs 11.3% in supported group; P=.28). Support people chosen by the patient likewise didn’t successfully reduce C-sections (19.4% control rate vs 15.5% supported rate; P=.062). When the support person was neither hospital staff nor someone well-known to the patient, the risk of C-section was significantly lower (ARR=6%; NNT=17; P=.0003).
RECOMMENDATIONS
In a Comparative Effectiveness Review published in October 2012, the Agency for Healthcare Research and Quality investigated 18 strategies to reduce C-section, one of which was psychosocial support from doulas and other providers. A trained support person was the only intervention that showed evidence of benefit in decreasing C-section, but the strength of evidence was low.2
An American College of Obstetricians and Gynecologists Practice Bulletin recommends continuous labor support, noting “the continuous presence of a support person may reduce the likelihood of…operative delivery” with no apparent harmful effects.3
1. Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2012;(10):CD003766.
2. Agency for Healthcare Research and Quality. Strategies to reduce cesarean birth in low-risk women. Agency for Healthcare Research and Quality Web site. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/263/1291/CER80_C-Section_ExecutiveSummary_20121018.pdf. Accessed February 22, 2015.
3. American College of Obstetrics and Gynecology Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol. 2003;102:1445-1454.
1. Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2012;(10):CD003766.
2. Agency for Healthcare Research and Quality. Strategies to reduce cesarean birth in low-risk women. Agency for Healthcare Research and Quality Web site. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/263/1291/CER80_C-Section_ExecutiveSummary_20121018.pdf. Accessed February 22, 2015.
3. American College of Obstetrics and Gynecology Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol. 2003;102:1445-1454.
Evidence-based answers from the Family Physicians Inquiries Network
Plaques on dorsal hands & arms
A 45-year-old woman sought treatment for plaques that she’d had on the top of her hands for 6 months (FIGURE 1). These plaques had been getting larger, and new papules and plaques were now developing on the dorsal arms. She’d first noticed the lesions after unpacking some crates from overseas while working at a hardware store. She’d applied unspecified types and dosages of topical steroids and antifungals, but her condition hadn’t improved. We performed a punch biopsy of a lesion on her arm.
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Chromoblastomycosis
The punch biopsy revealed pseudoepitheliomatous hyperplasia with intraepidermal microabscesses (FIGURE 2), which was consistent with chromoblastomycosis. Two additional biopsies taken from plaques on the patient’s arm grew Phialophora verrucosa, confirming the diagnosis. We assumed she contracted chromoblastomycosis from her exposure to the overseas crates at her job, but we could not confirm this. However, there were no other likely sources of infection.
Differential Dx includes BCC and sarcoidosis
Superficial basal cell carcinoma (BCC).3 Like chromoblastomycosis, BCC has a similar history of slow-growing scaly plaques. With BCC, there is usually a solitary plaque, although it may be large. Biopsy would distinguish BCC from chromoblastomycosis.
Sarcoidosis.3,4 The plaques of sarcoidosis are less scaly than those of chromoblastomycosis and biopsy would show granulomatous process. Sarcoidosis may also be associated with respiratory symptoms, elevated angiotensin converting enzyme, or hilar nodules on chest x-ray.
Plaque-type porokeratosis.4 Porokera-tosis is an inherited or acquired solitary lesion that is annular, round, and thin with raised edges; it often develops on the lower legs. What triggers its appearance is unknown, though trauma and photodamage have been suggested. In some variants, it may appear similar to chromoblastomycosis.
Cellulitis. In cellulitis, the advancing edge of erythema changes over days instead of months to years (as chromoblastomycosis does). Possible systemic symptoms of cellulitis include pain, fever, swelling, or malaise.
Cutaneous tuberculosis.3 Although rare, cutaneous tuberculosis, which often presents as firm, shallow ulcers with a granular base, may be associated with significant discomfort. It can persist for up to a year, is more likely to form an abscess and drain, and is associated with lymphadenopathy after several weeks.
Sporotrichosis.3 The appearance of sporotrichosis is similar to that of chromoblastomycosis, with hematogenous spread that may mimic autoinoculation. Biopsy and tissue culture would differentiate sporotrichosis from chromoblastomycosis.
Tissue culture clinches the Dx
Diagnosis of chromoblastomycosis is often delayed because of the slow-growing nature of the plaques, its few initial symptoms, and the rarity of the condition in nonendemic regions.1,2 A skin scraping may demonstrate hyphae or spores. On histology, clusters of brown spores (“copper pennies”) are pathognomonic.5 A biopsy and tissue culture establish the diagnosis. The most frequent organisms identified include Phialophora, Fonsecaea, and Cladosporium.1
More than one type of treatment may be necessary
Chromoblastomycosis is often extremely difficult to treat; frequent recurrences may require multimodal therapy.6,7 Treatment options include pharmacotherapy, surgery, and destructive therapy.
Systemic antifungals are the mainstay of therapy because topical antifungals do not penetrate deep enough in the skin. Several regimens have been presented in the literature. A common starting point is oral terbinafine8 250 to 500 mg/d and itraconazole9 200 mg to 400 mg/d for 6 to 12 months. Another medication used to treat chromoblastomycosis is intralesional or intravenous amphotericin B dosed variably with or without 5-flucytosine until the plaques clear.10 Based on small trials, treatment efficacy with antifungals ranges from 70% to 90%.6,7 Treatment often is limited by medication interactions and adverse effects.
Surgical therapy. A solitary plaque or smaller plaques may be removed with good outcomes. However, plaques may be so large that surgical removal is impractical or disfiguring.5,11
Destructive therapy. Cryotherapy with liquid nitrogen or electrocautery may be used to destroy plaques. This approach may be used with or without pharmacotherapy.11
Our patient. Because chromoblastomycosis is rare in North America, we consulted with a dermatologist who worked in an endemic area. Our patient was also seen by an infectious disease specialist. For 9 months, she took oral terbinafine 500 mg/d and itraconazole 200 mg/d. Initially, the patient experienced modest improvement in the largest plaques, but they didn’t clear completely. Smaller lesions cleared with cryotherapy but new lesions developed on her ears. The patient’s lesions finally cleared after 12 months of therapy; 2 repeated cultures were also negative.
CORRESPONDENCE
Jonathan Karnes, MD, Maine-Dartmouth Family Medicine Residency, 15 East Chestnut Street, Augusta, ME 04330; jonathan.karnes@mainegeneral.org
1. Correia RT, Valente NY, Criado PR, et al. Chromoblastomycosis: study of 27 cases and review of medical literature. An Bras Dermatol. 2010;85:448-454.
2. Minotto R, Bernardi CD, Mallmann LF, et al. Chromoblastomycosis: a review of 100 cases in the state of Rio Grande do Sul, Brazil. J Am Acad Dermatol. 2001;44:585-592.
3. Krzyściak PM, Pindycka-Piaszczyńska M, Piaszczyński M. Chromoblastomycosis. Postep Derm Alergol. 2014;31:310-321.
4. Long H, Zhang G, Lu Q. A persistent red crusted plaque on the back. JAMA. 2013;310:1730-1731.
5. Ameen M. Managing chromoblastomycosis. Trop Doct. 2010;40:65-67.
6. Torres-Guerrero E, Isa-Isa R, Isa M, et al. Chromoblastomycosis. Clin Dermatol. 2012;30:403-408.
7. Tuffanelli L, Millburn PB. Treatment of chromoblastomycosis. J Am Acad Dermatol. 1990;23(4 pt 1):728-732.
8. Lamisil [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2001.
9. Schwartz RA. Chromoblastomycosis treatment & management. Medscape Web site. Available at: http://emedicine.medscape.com/article/1092695-treatment. Accessed February 19, 2015.
10. Poirriez J, Breuillard F, Francois N, et al. A case of chromomycosis treated by a combination of cryotherapy, shaving, oral 5-fluorocystosine and oral amphotericin B. Am J Trop Med Hyg. 2000;63:61-63.
11. Ameen M. Chromoblastomycosis: clinical presentation and management. Clin Exp Dermatol. 2009;34:849-854.
A 45-year-old woman sought treatment for plaques that she’d had on the top of her hands for 6 months (FIGURE 1). These plaques had been getting larger, and new papules and plaques were now developing on the dorsal arms. She’d first noticed the lesions after unpacking some crates from overseas while working at a hardware store. She’d applied unspecified types and dosages of topical steroids and antifungals, but her condition hadn’t improved. We performed a punch biopsy of a lesion on her arm.
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Chromoblastomycosis
The punch biopsy revealed pseudoepitheliomatous hyperplasia with intraepidermal microabscesses (FIGURE 2), which was consistent with chromoblastomycosis. Two additional biopsies taken from plaques on the patient’s arm grew Phialophora verrucosa, confirming the diagnosis. We assumed she contracted chromoblastomycosis from her exposure to the overseas crates at her job, but we could not confirm this. However, there were no other likely sources of infection.
Differential Dx includes BCC and sarcoidosis
Superficial basal cell carcinoma (BCC).3 Like chromoblastomycosis, BCC has a similar history of slow-growing scaly plaques. With BCC, there is usually a solitary plaque, although it may be large. Biopsy would distinguish BCC from chromoblastomycosis.
Sarcoidosis.3,4 The plaques of sarcoidosis are less scaly than those of chromoblastomycosis and biopsy would show granulomatous process. Sarcoidosis may also be associated with respiratory symptoms, elevated angiotensin converting enzyme, or hilar nodules on chest x-ray.
Plaque-type porokeratosis.4 Porokera-tosis is an inherited or acquired solitary lesion that is annular, round, and thin with raised edges; it often develops on the lower legs. What triggers its appearance is unknown, though trauma and photodamage have been suggested. In some variants, it may appear similar to chromoblastomycosis.
Cellulitis. In cellulitis, the advancing edge of erythema changes over days instead of months to years (as chromoblastomycosis does). Possible systemic symptoms of cellulitis include pain, fever, swelling, or malaise.
Cutaneous tuberculosis.3 Although rare, cutaneous tuberculosis, which often presents as firm, shallow ulcers with a granular base, may be associated with significant discomfort. It can persist for up to a year, is more likely to form an abscess and drain, and is associated with lymphadenopathy after several weeks.
Sporotrichosis.3 The appearance of sporotrichosis is similar to that of chromoblastomycosis, with hematogenous spread that may mimic autoinoculation. Biopsy and tissue culture would differentiate sporotrichosis from chromoblastomycosis.
Tissue culture clinches the Dx
Diagnosis of chromoblastomycosis is often delayed because of the slow-growing nature of the plaques, its few initial symptoms, and the rarity of the condition in nonendemic regions.1,2 A skin scraping may demonstrate hyphae or spores. On histology, clusters of brown spores (“copper pennies”) are pathognomonic.5 A biopsy and tissue culture establish the diagnosis. The most frequent organisms identified include Phialophora, Fonsecaea, and Cladosporium.1
More than one type of treatment may be necessary
Chromoblastomycosis is often extremely difficult to treat; frequent recurrences may require multimodal therapy.6,7 Treatment options include pharmacotherapy, surgery, and destructive therapy.
Systemic antifungals are the mainstay of therapy because topical antifungals do not penetrate deep enough in the skin. Several regimens have been presented in the literature. A common starting point is oral terbinafine8 250 to 500 mg/d and itraconazole9 200 mg to 400 mg/d for 6 to 12 months. Another medication used to treat chromoblastomycosis is intralesional or intravenous amphotericin B dosed variably with or without 5-flucytosine until the plaques clear.10 Based on small trials, treatment efficacy with antifungals ranges from 70% to 90%.6,7 Treatment often is limited by medication interactions and adverse effects.
Surgical therapy. A solitary plaque or smaller plaques may be removed with good outcomes. However, plaques may be so large that surgical removal is impractical or disfiguring.5,11
Destructive therapy. Cryotherapy with liquid nitrogen or electrocautery may be used to destroy plaques. This approach may be used with or without pharmacotherapy.11
Our patient. Because chromoblastomycosis is rare in North America, we consulted with a dermatologist who worked in an endemic area. Our patient was also seen by an infectious disease specialist. For 9 months, she took oral terbinafine 500 mg/d and itraconazole 200 mg/d. Initially, the patient experienced modest improvement in the largest plaques, but they didn’t clear completely. Smaller lesions cleared with cryotherapy but new lesions developed on her ears. The patient’s lesions finally cleared after 12 months of therapy; 2 repeated cultures were also negative.
CORRESPONDENCE
Jonathan Karnes, MD, Maine-Dartmouth Family Medicine Residency, 15 East Chestnut Street, Augusta, ME 04330; jonathan.karnes@mainegeneral.org
A 45-year-old woman sought treatment for plaques that she’d had on the top of her hands for 6 months (FIGURE 1). These plaques had been getting larger, and new papules and plaques were now developing on the dorsal arms. She’d first noticed the lesions after unpacking some crates from overseas while working at a hardware store. She’d applied unspecified types and dosages of topical steroids and antifungals, but her condition hadn’t improved. We performed a punch biopsy of a lesion on her arm.
HOW WOULD YOU TREAT THIS PATIENT?
Diagnosis: Chromoblastomycosis
The punch biopsy revealed pseudoepitheliomatous hyperplasia with intraepidermal microabscesses (FIGURE 2), which was consistent with chromoblastomycosis. Two additional biopsies taken from plaques on the patient’s arm grew Phialophora verrucosa, confirming the diagnosis. We assumed she contracted chromoblastomycosis from her exposure to the overseas crates at her job, but we could not confirm this. However, there were no other likely sources of infection.
Differential Dx includes BCC and sarcoidosis
Superficial basal cell carcinoma (BCC).3 Like chromoblastomycosis, BCC has a similar history of slow-growing scaly plaques. With BCC, there is usually a solitary plaque, although it may be large. Biopsy would distinguish BCC from chromoblastomycosis.
Sarcoidosis.3,4 The plaques of sarcoidosis are less scaly than those of chromoblastomycosis and biopsy would show granulomatous process. Sarcoidosis may also be associated with respiratory symptoms, elevated angiotensin converting enzyme, or hilar nodules on chest x-ray.
Plaque-type porokeratosis.4 Porokera-tosis is an inherited or acquired solitary lesion that is annular, round, and thin with raised edges; it often develops on the lower legs. What triggers its appearance is unknown, though trauma and photodamage have been suggested. In some variants, it may appear similar to chromoblastomycosis.
Cellulitis. In cellulitis, the advancing edge of erythema changes over days instead of months to years (as chromoblastomycosis does). Possible systemic symptoms of cellulitis include pain, fever, swelling, or malaise.
Cutaneous tuberculosis.3 Although rare, cutaneous tuberculosis, which often presents as firm, shallow ulcers with a granular base, may be associated with significant discomfort. It can persist for up to a year, is more likely to form an abscess and drain, and is associated with lymphadenopathy after several weeks.
Sporotrichosis.3 The appearance of sporotrichosis is similar to that of chromoblastomycosis, with hematogenous spread that may mimic autoinoculation. Biopsy and tissue culture would differentiate sporotrichosis from chromoblastomycosis.
Tissue culture clinches the Dx
Diagnosis of chromoblastomycosis is often delayed because of the slow-growing nature of the plaques, its few initial symptoms, and the rarity of the condition in nonendemic regions.1,2 A skin scraping may demonstrate hyphae or spores. On histology, clusters of brown spores (“copper pennies”) are pathognomonic.5 A biopsy and tissue culture establish the diagnosis. The most frequent organisms identified include Phialophora, Fonsecaea, and Cladosporium.1
More than one type of treatment may be necessary
Chromoblastomycosis is often extremely difficult to treat; frequent recurrences may require multimodal therapy.6,7 Treatment options include pharmacotherapy, surgery, and destructive therapy.
Systemic antifungals are the mainstay of therapy because topical antifungals do not penetrate deep enough in the skin. Several regimens have been presented in the literature. A common starting point is oral terbinafine8 250 to 500 mg/d and itraconazole9 200 mg to 400 mg/d for 6 to 12 months. Another medication used to treat chromoblastomycosis is intralesional or intravenous amphotericin B dosed variably with or without 5-flucytosine until the plaques clear.10 Based on small trials, treatment efficacy with antifungals ranges from 70% to 90%.6,7 Treatment often is limited by medication interactions and adverse effects.
Surgical therapy. A solitary plaque or smaller plaques may be removed with good outcomes. However, plaques may be so large that surgical removal is impractical or disfiguring.5,11
Destructive therapy. Cryotherapy with liquid nitrogen or electrocautery may be used to destroy plaques. This approach may be used with or without pharmacotherapy.11
Our patient. Because chromoblastomycosis is rare in North America, we consulted with a dermatologist who worked in an endemic area. Our patient was also seen by an infectious disease specialist. For 9 months, she took oral terbinafine 500 mg/d and itraconazole 200 mg/d. Initially, the patient experienced modest improvement in the largest plaques, but they didn’t clear completely. Smaller lesions cleared with cryotherapy but new lesions developed on her ears. The patient’s lesions finally cleared after 12 months of therapy; 2 repeated cultures were also negative.
CORRESPONDENCE
Jonathan Karnes, MD, Maine-Dartmouth Family Medicine Residency, 15 East Chestnut Street, Augusta, ME 04330; jonathan.karnes@mainegeneral.org
1. Correia RT, Valente NY, Criado PR, et al. Chromoblastomycosis: study of 27 cases and review of medical literature. An Bras Dermatol. 2010;85:448-454.
2. Minotto R, Bernardi CD, Mallmann LF, et al. Chromoblastomycosis: a review of 100 cases in the state of Rio Grande do Sul, Brazil. J Am Acad Dermatol. 2001;44:585-592.
3. Krzyściak PM, Pindycka-Piaszczyńska M, Piaszczyński M. Chromoblastomycosis. Postep Derm Alergol. 2014;31:310-321.
4. Long H, Zhang G, Lu Q. A persistent red crusted plaque on the back. JAMA. 2013;310:1730-1731.
5. Ameen M. Managing chromoblastomycosis. Trop Doct. 2010;40:65-67.
6. Torres-Guerrero E, Isa-Isa R, Isa M, et al. Chromoblastomycosis. Clin Dermatol. 2012;30:403-408.
7. Tuffanelli L, Millburn PB. Treatment of chromoblastomycosis. J Am Acad Dermatol. 1990;23(4 pt 1):728-732.
8. Lamisil [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2001.
9. Schwartz RA. Chromoblastomycosis treatment & management. Medscape Web site. Available at: http://emedicine.medscape.com/article/1092695-treatment. Accessed February 19, 2015.
10. Poirriez J, Breuillard F, Francois N, et al. A case of chromomycosis treated by a combination of cryotherapy, shaving, oral 5-fluorocystosine and oral amphotericin B. Am J Trop Med Hyg. 2000;63:61-63.
11. Ameen M. Chromoblastomycosis: clinical presentation and management. Clin Exp Dermatol. 2009;34:849-854.
1. Correia RT, Valente NY, Criado PR, et al. Chromoblastomycosis: study of 27 cases and review of medical literature. An Bras Dermatol. 2010;85:448-454.
2. Minotto R, Bernardi CD, Mallmann LF, et al. Chromoblastomycosis: a review of 100 cases in the state of Rio Grande do Sul, Brazil. J Am Acad Dermatol. 2001;44:585-592.
3. Krzyściak PM, Pindycka-Piaszczyńska M, Piaszczyński M. Chromoblastomycosis. Postep Derm Alergol. 2014;31:310-321.
4. Long H, Zhang G, Lu Q. A persistent red crusted plaque on the back. JAMA. 2013;310:1730-1731.
5. Ameen M. Managing chromoblastomycosis. Trop Doct. 2010;40:65-67.
6. Torres-Guerrero E, Isa-Isa R, Isa M, et al. Chromoblastomycosis. Clin Dermatol. 2012;30:403-408.
7. Tuffanelli L, Millburn PB. Treatment of chromoblastomycosis. J Am Acad Dermatol. 1990;23(4 pt 1):728-732.
8. Lamisil [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2001.
9. Schwartz RA. Chromoblastomycosis treatment & management. Medscape Web site. Available at: http://emedicine.medscape.com/article/1092695-treatment. Accessed February 19, 2015.
10. Poirriez J, Breuillard F, Francois N, et al. A case of chromomycosis treated by a combination of cryotherapy, shaving, oral 5-fluorocystosine and oral amphotericin B. Am J Trop Med Hyg. 2000;63:61-63.
11. Ameen M. Chromoblastomycosis: clinical presentation and management. Clin Exp Dermatol. 2009;34:849-854.
Consider this Tx option for insomnia: Sedating antidepressants
Breast rash
The FP was concerned about Paget disease of the breast and performed a 4 mm punch biopsy of the affected area, including a portion of the nipple. The pathology confirmed the diagnosis.
Paget disease of the breast is a low-grade malignancy that is often associated with other malignancies. It presents clinically in the nipple-areolar complex as a dermatitis that may be erythematous, eczematous, scaly, raw, vesicular, or ulcerated. The nipple is usually initially involved, and the lesion then spreads to the areola.
Most patients delay presentation (median 6-8 months), assuming the abnormality is benign. Presenting symptoms are sometimes limited to persistent pain, burning, and/or pruritus of the nipple. A palpable breast mass is present in half of all cases, but is often located more than 2 cm from the nipple-areolar complex. Twenty percent of cases will have a mammographic abnormality without a palpable mass, and 25% of cases will have neither a mass nor abnormal mammogram, but will have an occult ductal carcinoma.
The treatment and prognosis of Paget disease of the breast is first based on the stage of any underlying breast cancer. Simple mastectomy has traditionally been the standard treatment for isolated Paget disease of the breast. Breast-conserving surgery combined with breast irradiation is gaining wider acceptance.
In this case our patient chose to have a simple mastectomy with a transverse rectus abdominis muscle (TRAM) flap reconstruction.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Paget disease of the breast. In: Usatine R, Smith M, Mayeaux EJ, et al,eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:557-560.
To learn more about the Color Atlas of Family Medicine, see: http://www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: http://usatinemedia.com/
The FP was concerned about Paget disease of the breast and performed a 4 mm punch biopsy of the affected area, including a portion of the nipple. The pathology confirmed the diagnosis.
Paget disease of the breast is a low-grade malignancy that is often associated with other malignancies. It presents clinically in the nipple-areolar complex as a dermatitis that may be erythematous, eczematous, scaly, raw, vesicular, or ulcerated. The nipple is usually initially involved, and the lesion then spreads to the areola.
Most patients delay presentation (median 6-8 months), assuming the abnormality is benign. Presenting symptoms are sometimes limited to persistent pain, burning, and/or pruritus of the nipple. A palpable breast mass is present in half of all cases, but is often located more than 2 cm from the nipple-areolar complex. Twenty percent of cases will have a mammographic abnormality without a palpable mass, and 25% of cases will have neither a mass nor abnormal mammogram, but will have an occult ductal carcinoma.
The treatment and prognosis of Paget disease of the breast is first based on the stage of any underlying breast cancer. Simple mastectomy has traditionally been the standard treatment for isolated Paget disease of the breast. Breast-conserving surgery combined with breast irradiation is gaining wider acceptance.
In this case our patient chose to have a simple mastectomy with a transverse rectus abdominis muscle (TRAM) flap reconstruction.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Paget disease of the breast. In: Usatine R, Smith M, Mayeaux EJ, et al,eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:557-560.
To learn more about the Color Atlas of Family Medicine, see: http://www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: http://usatinemedia.com/
The FP was concerned about Paget disease of the breast and performed a 4 mm punch biopsy of the affected area, including a portion of the nipple. The pathology confirmed the diagnosis.
Paget disease of the breast is a low-grade malignancy that is often associated with other malignancies. It presents clinically in the nipple-areolar complex as a dermatitis that may be erythematous, eczematous, scaly, raw, vesicular, or ulcerated. The nipple is usually initially involved, and the lesion then spreads to the areola.
Most patients delay presentation (median 6-8 months), assuming the abnormality is benign. Presenting symptoms are sometimes limited to persistent pain, burning, and/or pruritus of the nipple. A palpable breast mass is present in half of all cases, but is often located more than 2 cm from the nipple-areolar complex. Twenty percent of cases will have a mammographic abnormality without a palpable mass, and 25% of cases will have neither a mass nor abnormal mammogram, but will have an occult ductal carcinoma.
The treatment and prognosis of Paget disease of the breast is first based on the stage of any underlying breast cancer. Simple mastectomy has traditionally been the standard treatment for isolated Paget disease of the breast. Breast-conserving surgery combined with breast irradiation is gaining wider acceptance.
In this case our patient chose to have a simple mastectomy with a transverse rectus abdominis muscle (TRAM) flap reconstruction.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ. Paget disease of the breast. In: Usatine R, Smith M, Mayeaux EJ, et al,eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:557-560.
To learn more about the Color Atlas of Family Medicine, see: http://www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/
You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: http://usatinemedia.com/
Genetics and hepatitis C: It’s good to be CC
In hepatitis C, people born with the IL28B CC genotype can count themselves luckier than those born with CT or TT.
To read the full article, go to the Cleveland Clinic Journal of Medicine: http://www.ccjm.org/home/article/genetics-and-hepatitis-c-its-good-to-be-cc/0afbe8ada94cdbab08fd0663c76e460e.html.
In hepatitis C, people born with the IL28B CC genotype can count themselves luckier than those born with CT or TT.
To read the full article, go to the Cleveland Clinic Journal of Medicine: http://www.ccjm.org/home/article/genetics-and-hepatitis-c-its-good-to-be-cc/0afbe8ada94cdbab08fd0663c76e460e.html.
In hepatitis C, people born with the IL28B CC genotype can count themselves luckier than those born with CT or TT.
To read the full article, go to the Cleveland Clinic Journal of Medicine: http://www.ccjm.org/home/article/genetics-and-hepatitis-c-its-good-to-be-cc/0afbe8ada94cdbab08fd0663c76e460e.html.
Help patients manage their arthritis
The Arthritis Foundation offers a free e-brochure designed to help patients manage the challenges of daily life. Available at http://www.afstore.org/Products-By-Type/Pain_6, the “Coping with Arthritis” brochure provides tips, like the following, for managing things such as cooking, driving, and shopping:
- Cooking: Stock up on arthritis-friendly tools such as a food processor, a standing mixer, an electric jar opener, and rubber bottom mixing bowls (for stability).
- Driving: Wrap the upper part of your car keys with electric tape to make it easier to turn on the ignition.
- Shopping: Unpack only perishables right away. Take a break before putting away the rest.
The brochure also offers tips for dealing with fatigue and coping with stress and depression.
The Arthritis Foundation offers a free e-brochure designed to help patients manage the challenges of daily life. Available at http://www.afstore.org/Products-By-Type/Pain_6, the “Coping with Arthritis” brochure provides tips, like the following, for managing things such as cooking, driving, and shopping:
- Cooking: Stock up on arthritis-friendly tools such as a food processor, a standing mixer, an electric jar opener, and rubber bottom mixing bowls (for stability).
- Driving: Wrap the upper part of your car keys with electric tape to make it easier to turn on the ignition.
- Shopping: Unpack only perishables right away. Take a break before putting away the rest.
The brochure also offers tips for dealing with fatigue and coping with stress and depression.
The Arthritis Foundation offers a free e-brochure designed to help patients manage the challenges of daily life. Available at http://www.afstore.org/Products-By-Type/Pain_6, the “Coping with Arthritis” brochure provides tips, like the following, for managing things such as cooking, driving, and shopping:
- Cooking: Stock up on arthritis-friendly tools such as a food processor, a standing mixer, an electric jar opener, and rubber bottom mixing bowls (for stability).
- Driving: Wrap the upper part of your car keys with electric tape to make it easier to turn on the ignition.
- Shopping: Unpack only perishables right away. Take a break before putting away the rest.
The brochure also offers tips for dealing with fatigue and coping with stress and depression.
Are your patients getting enough sleep?
The Centers for Disease Control and Prevention offers information to teach patients about the importance of getting sufficient sleep. “Are you getting enough sleep?” is available at http://www.cdc.gov/Features/Sleep/. It explains how many hours of sleep people need each night and describes common sleep disorders, including insomnia, narcolepsy, restless leg syndrome, and sleep apnea. The online resource also offers tools to improve the quality of sleep and tips on how to sleep through the night.
The Centers for Disease Control and Prevention offers information to teach patients about the importance of getting sufficient sleep. “Are you getting enough sleep?” is available at http://www.cdc.gov/Features/Sleep/. It explains how many hours of sleep people need each night and describes common sleep disorders, including insomnia, narcolepsy, restless leg syndrome, and sleep apnea. The online resource also offers tools to improve the quality of sleep and tips on how to sleep through the night.
The Centers for Disease Control and Prevention offers information to teach patients about the importance of getting sufficient sleep. “Are you getting enough sleep?” is available at http://www.cdc.gov/Features/Sleep/. It explains how many hours of sleep people need each night and describes common sleep disorders, including insomnia, narcolepsy, restless leg syndrome, and sleep apnea. The online resource also offers tools to improve the quality of sleep and tips on how to sleep through the night.
Help for patients who struggle with depression
In the online pamphlet “SpeakUP: What you should know about adult depression” available at http://www.jointcommission.org/assets/1/6/speakup_depression.pdf, The Joint Commission and several mental health organizations explain what depression is and how to get help. This pamphlet describes the warning signs of depression, what patients need to know about psychotherapy and medications for depression, and steps to take to stay on track with the treatment plan.
In the online pamphlet “SpeakUP: What you should know about adult depression” available at http://www.jointcommission.org/assets/1/6/speakup_depression.pdf, The Joint Commission and several mental health organizations explain what depression is and how to get help. This pamphlet describes the warning signs of depression, what patients need to know about psychotherapy and medications for depression, and steps to take to stay on track with the treatment plan.
In the online pamphlet “SpeakUP: What you should know about adult depression” available at http://www.jointcommission.org/assets/1/6/speakup_depression.pdf, The Joint Commission and several mental health organizations explain what depression is and how to get help. This pamphlet describes the warning signs of depression, what patients need to know about psychotherapy and medications for depression, and steps to take to stay on track with the treatment plan.
Coping with COPD
Patients with COPD can learn how to best manage their condition from this guide from the American College of Chest Physicians and the Chest Foundation. To download a copy of “Living Well with COPD: Chronic Bronchitis and Emphysema,” patients can go to http://www.chestnet.org/Foundation/Patient-Education-Resources/COPD and click on the patient guide icon in the bottom right of that page. Patients can learn about COPD medications, reducing stress, and improving their diet.
Patients with COPD can learn how to best manage their condition from this guide from the American College of Chest Physicians and the Chest Foundation. To download a copy of “Living Well with COPD: Chronic Bronchitis and Emphysema,” patients can go to http://www.chestnet.org/Foundation/Patient-Education-Resources/COPD and click on the patient guide icon in the bottom right of that page. Patients can learn about COPD medications, reducing stress, and improving their diet.
Patients with COPD can learn how to best manage their condition from this guide from the American College of Chest Physicians and the Chest Foundation. To download a copy of “Living Well with COPD: Chronic Bronchitis and Emphysema,” patients can go to http://www.chestnet.org/Foundation/Patient-Education-Resources/COPD and click on the patient guide icon in the bottom right of that page. Patients can learn about COPD medications, reducing stress, and improving their diet.