skin

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=210 BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="112f2f02egerdp.jpg"> <div> <A HREF="index.htm" TARGET="_top" TITLE="_"><U><B>RETURN TO HOMEPAGE</B></U></A></div> <div> <TABLE BORDER="0" CELLPADDING="0" CELLSPACING="0" WIDTH="195" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" ALIGN="LEFT" HSPACE="0" VSPACE="0" BGCOLOR=#FFFFFF > <tR> <tD VALIGN=TOP BGCOLOR=#66FFFF HEIGHT= 23 WIDTH="195"><div> <B> </B><A HREF="id91.htm" TARGET="_top" TITLE="BRUCE ROSEMAN, M.D. 330 West 58th Stree"><U><B>CONTACT ME</B></U></A></div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFCC99 HEIGHT= 23 WIDTH="195"><div> <B> </B><A HREF="id17.htm" TARGET="_top" TITLE="office info"><U><B>OFFICE INFO</B></U></A></div> </tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFF99 HEIGHT= 23 WIDTH="195"><div> <B> </B><A HREF="id116.htm" 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ALIGN="bottom" WIDTH="195" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <DIV ALIGN="LEFT"></DIV> <div> <A HREF="id102_m.htm#cellulitits" TARGET="TRLX_Middle" TITLE="skin"><U><B>GO TO </B></U></A></div> <div> <A HREF="id102_m.htm#cellulitits" TARGET="TRLX_Middle" TITLE="skin"><U><B>TOP OF PAGE</B></U></A></div> <bR> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000" bgproperties="fixed" background="115f0f03.jpg"> <div> <I>skin</I></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"><A NAME="cellulitits"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><A HREF="http://www.emedicine.com/med/topic310.htm" TARGET="_top" TITLE="http://www.emedicine.com/med/topic310.ht"><U>CELLULITITS</U></A></div> <div> <A HREF="http://www.intelihealth.com/IH/ihtIH/WSIHW000/8297/8297.html" TARGET="_top" TITLE="http://www.intelihealth.com/IH/ihtIH/WSI"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">SKIN CANCER</U></A></div> <div> <U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> </U><A HREF="#abcd_s_of_skin_cancer" TITLE="skin"><U>abcd's of skin cancer</U></A></div> <div> <A HREF="#lice_" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">LICE</U></A></div> <div> <A HREF="http://www.nlm.nih.gov/medlineplus/headlice.html" TARGET="_top" TITLE="http://www.nlm.nih.gov/medlineplus/headl"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">MEDLINE HEAD LICE SITE</U></A></div> <div> <A HREF="#using_lindane" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">directions for using lindane</U></A></div> <div> <A HREF="www.headlice.org" TARGET="_top" TITLE="www.headlice.org"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Terrific head lice site</U></A></div> <div> <A HREF="#first_non_toxic_treatment_for_head_lice" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700dc99006600.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">FIRST NON TOXIC TREATMENT FOR HEAD LICE</U></A></div> <div> <A HREF="http://www.skincheck.com" TARGET="_top" TITLE="http://www.skincheck.com"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">MELANOMA</U></A></div> <div> <A HREF="#people_at_highest_risk_are_those_who_" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Risk factors for melanoma</U></A></div> <div> <A HREF="#melanoma_gene" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Melanoma Gene</U></A></div> <div> <A HREF="http://www.cancer.org/eprise/main/docroot/cri/cri_2_3x?dt=39" TARGET="_top" TITLE="http://www.cancer.org/eprise/main/docroo"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">American Cancer society information on Melanoma</U></A></div> <div> <A HREF="#afp_article" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">American Family Physician article on Melanoma with pictures</U></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ACNE</div> <div> <A HREF="id48_new_12_month_data_show_elidel.htm" TARGET="_top" TITLE="ASTHMA AND ALLERGY"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Elidel (Pimecrolimus) non steroid Cream-Eczema Control</U></A></div> <div> <A HREF="id18_new_acne_drug_has_fewer_adverse_effects_.htm" TARGET="_top" TITLE=" MEDICAL NEW"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Acne Drug-new and better</U></A></div> <div> <A HREF="#benzamycin" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Benzamycin</U></A></div> <div> <A HREF="#accutane" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Accutane</U></A> </div> <div> <A HREF="#accutane_may_trigger_bowel_disease_" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ACCUTANE may trigger bowel disease </U></A></div> <div> <A HREF="id94.htm" TARGET="_top" TITLE="RETINA"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Retin-A-Isotretinoin: Improving Patient Education and Reducing Risk </U></A></div> <div> <A HREF="http://www.lightmask.com/Acne.htm" TARGET="_top" TITLE="http://www.lightmask.com/Acne.htm"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">light therapy for acne</U></A></div> <div> <A HREF="#recommended_laboratory_monitoring_for" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700dc99006600.png" HEIGHT="15" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Recommended Laboratory Monitoring for Patients Using Isotretinoin</U></A><A HREF="#recommended_laboratory_monitoring_for" TITLE="skin"><U> </U></A></div> <div> <A HREF="#subantimicrobial" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Subantimicrobial Doxycycline Tablets Effective Against Moderate Acne</U></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">WARTS</div> <div> <A HREF="#duofilm_patch__" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">DuoFilm Patch </U></A><A HREF="#duofilm_patch__" TITLE="skin"><U> </U></A></div> <div> <A HREF="#duct_tape_can_get_rid_of_warts_study_" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Duct Tape Can Get Rid of Warts: Study </U></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">FUNGUS</div> <div> <A HREF="#thrush" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">THRUSH</U></A></div> <div> <A HREF="#fluconazole_oral___floo_kon__na_zole__" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fluconazole Oral  (floo kon' na zole) </U></A>FLUCONOZOLE</div> <div> <A HREF="#ringworm_" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">RINGWORM</U></A></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">NAILS</div> <div> <A HREF="#sporanox__itraconazole" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">SPORANOX</U></A></div> <div> <A HREF="http://www.fda.gov/cder/drug/advisory/sporanox-lamisil/default.htm" TARGET="_top" TITLE="http://www.fda.gov/cder/drug/advisory/sp"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Sporanox and Lamisil Public Health Advisory </U></A></div> <div> <A HREF="#following_are_the_top_10_causes_of" TITLE="skin"><U><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">CONTACT DERMATITIS</U></A>==<A HREF="#following_are_the_top_10_causes_of" TITLE="skin"><U>THE TOP 10 causes </U></A></div> <bR> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vitamin E(400 IU per day) could be an excellent tool in treating atopic dermatitis.</div> <bR> <bR> <div> <B> <A NAME="first_non_toxic_treatment_for_head_lice"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></div> <div> <B>FIRST NON TOXIC TREATMENT FOR HEAD LICE</B></div> <div> <B>Benzyl Alcohol 5% Lotion Approved for the Treatment of Head Lice</B> </div> <div> On April 9, the FDA approved benzyl alcohol 5% lotion (Sciele Pharma, Inc [a Shionogi company) for the treatment of head lice (<I>Pediculosis capitis</I>) infestation in patients 6 months and older.</div> <div> The lotion is the first and only prescription medication that kills head lice by asphyxiation without the risk for neurotoxic adverse events.</div> <div> "Head lice are a problem that impacts more than 1 million children each year and is easily transmitted to others," said Janet Woodcock, MD, director, FDA's Center for Drug Evaluation and Research, in an agency news release. "This drug is an effective first line treatment to eliminate lice infestation, and minimize disruption in the daily routines of families."</div> <div> Head lice survive by breathing through spiracles that close on contact with most liquids, enabling a state of suspended animation that allows them to survive for hours without respiration. Benzyl alcohol prevents lice from closing their spiracles, thereby asphyxiating them within 10 minutes.</div> <div> FDA approval was based on data from 2 clinical studies of 628 individuals 6 months and older, showing that 2 ten-minute treatments with benzyl alcohol lotion given 1 week apart were significantly more effective than placebo for eradicating head lice. Two weeks after the final treatment, more than 75% of patients treated with benzyl alcohol lotion remained lice-free.</div> <div> "Head lice are an all-too-common and challenging medical problem that causes anxiety in families, schools and summer camps," said Ira A. Pion, MD, clinical assistant professor of the Department of Dermatology at New York University Medical Center, in a company news release. "Sciele's new product should be welcomed by health professionals and parents as a safe and effective treatment option that treats children with head lice without the use of harsh chemicals and addresses concerns about the increased resistance of lice to therapies that contain neurotoxic chemicals."</div> <div> Adverse events most commonly reported with use of benzyl alcohol lotion include application-site numbness and irritation of the skin, scalp, and eyes.</div> <div> The FDA notes that benzyl alcohol lotion should be used as directed and applied only to the scalp or hair attached to the scalp. The product is not approved for use in children younger than 6 months; use in premature infants can lead to serious respiratory, heart, or brain-related adverse events such as seizure, coma, or death.</div> <div> <U>FDA New Drug Information</U><FONT SIZE="3" COLOR="#660099" FACE="Arial" > </FONT></div> <bR> <div>  <A NAME="accutane_may_trigger_bowel_disease_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> ACCUTANE may trigger bowel disease </div> <div> Tue Aug 15, 2:42 PM ET </div> <div> While suspected for some time, a study now confirms that people taking the acne drug isotretinoin appear to run an increased risk of developing inflammatory bowel disease, US researchers report.</div> <div> Inflammatory bowel disease, or IBD, includes Crohn's disease and a similar condition called ulcerative colitis. Isotretinoin, more familiarly known by the brand name Accutane, was first approved for acne in the US in 1982, and numerous cases have surfaced linking the drug to IBD. Until now, a systematic review of the association had not been conducted.</div> <div> Dr. Corey A. Siegel, from Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, and colleagues reviewed all reports of isotretinoin-associated IBD that were filed with the US Food and Drug Administration via the MedWatch system, which began in 1996.</div> <div> The authors explain in the American Journal of Gastroenterology that they used a standard adverse drug reaction probability scale to grade the likelihood that a particular IBD case was, in fact, caused by isotretinoin use.</div> <div> Between 1997 and 2002, a total of 85 isotretinoin-related cases of IBD were reported. In just four cases, isotretinoin was graded as a "highly probable" cause of the IBD, while in 58 cases it was deemed a "probable" cause, and in 23 cases it was seen as a "possible" cause. The link between isotretinoin use and IBD was never graded as "doubtful."</div> <div> "Physicians and patients should be made aware of this possible association and it should be included in the already extensive consent process required before isotretinoin is prescribed," the investigators write.</div> <div> The consent process covers the high risk of birth defects if a woman becomes pregnant while taking isotretinoin.</div> <div> Should someone with severe acne take isotretinoin? "We do not think that this should prohibit the use of isotretinoin," Siegel and colleagues advise. However, "careful consideration should be made" for people with a prior personal history or family history of inflammatory bowel disease, or who have symptoms suggesting the possibility of IBD. </div> <bR> <bR> <bR> <div>  <A NAME="following_are_the_top_10_causes_of"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Following are the top 10 causes of contact dermatitis recently identified by Mayo Clinic physicians:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nickel, commonly found on jewelry clasps or buttons. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Gold, usually worn as jewelry. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Balsam of Peru, a fragrance used in skin care products and perfume. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thimerosal, a preservative used in vaccines. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Neomycin sulfate, a topical antibiotic. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fragrance mix, which is comprised of eight of the most common flavorings found in various products. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Formaldehyde, a preservative that can be found in paper products, paints, building materials, medications, household cleaners and fabric finishes. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Cobalt chloride, a metal found in medical products, hair dye, antiperspirants, and in snaps, buttons and tools. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bacitracin, a topical antibiotic. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Quaternium-15, a preservative found in skin care products and in industrial products such as pains, polishes and waxes. </div> <bR> <bR> <div> <B><U> <A NAME="abcd_s_of_skin_cancer"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>abcd's of skin cancer</U></B></div> <div>  The Harvard Health Letter offers this alphabetical memory tool:</div> <bR> <div>     * Assymetry: One half of a mole doesn't match the other half.</div> <div>     * Border irregularity: Mole edges are ragged, notched or indistinct.</div> <div>     * Color: Mole pigmentation is uneven.</div> <div>     * Diameter: Mole is larger than a pencil eraser or shows a sudden or progressive increase in size.</div> <bR> <div>  <A NAME="subantimicrobial"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Subantimicrobial Doxycycline Tablets Effective Against Moderate Acne</div> <div> <B>A DGReview of :</B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B><U>"Effects of Subantimicrobial-Dose Doxycycline in the Treatment of Moderate Acne"</U></B></FONT></div> <div> <B>Archives of Dermatology</B></div> <bR> <div> 05/02/2003</div> <div> By David Loshak</div> <bR> <div> Oral subantimicrobial doxycycline, twice daily, significantly reduces the number of both inflammatory and non-inflammatory lesions in patients with moderate facial acne.</div> <bR> <div> The treatment is well tolerated, report specialists from the University of Florida, Gainesville; West Virginia University, Morgantown; Princeton University, New Jersey; University of Pennsylvania, Philadelphia and CollaGenex Pharmaceuticals Inc., Newtown, Pennsylvania. Their research disclosed no detectable anti-microbial effect on the skin flora, nor was there any rise in the number or severity of resistant organisms.</div> <bR> <div> The researchers studied 40 adults with moderate facial acne over 6 months in a double-blind, parallel-group trial at 2 university-based clinics. The patients were randomised to receive either sub-antimicrobial doses of doxycycline or placebo twice daily.</div> <bR> <div> The aim of the study was to see if the doxycycline, compared to placebo, had any detectable effect on skin flora, led to overgrowth or colonisation of skin by opportunistic pathogens, or resulted in an increase in antibiotic resistance by the surface skin microflora.</div> <bR> <div> At 6 months, the doxycycline recipients had a significantly greater percentage reduction in the number of comedones, inflammatory and non-inflammatory lesions combined and total inflammatory lesions. They also had significantly greater improvement according to the clinician's global assessment.</div> <bR> <div> There were no significant differences in microbial counts between the two groups. Nor was there any evidence of change in antibiotic susceptibility or colonisation by potential pathogens. </div> <div> Archives of Dermatology 2003;139:4:459-464. <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><I><U>"Effects of Subantimicrobial-Dose Doxycycline in the Treatment of Moderate Acne"</U></I></FONT></div> <bR> <bR> <div> <B><U> <A NAME="recommended_laboratory_monitoring_for"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Recommended Laboratory Monitoring for Patients Using Isotretinoin</U></B><FONT SIZE="3" COLOR="#660099" FACE="Arial" ><B><U> </U></B></FONT></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=BOTTOM HEIGHT= 38 WIDTH="147"><div> <B>Test</B> </div> <bR> </tD> <tD VALIGN=BOTTOM WIDTH="197"><div> <B>Frequency</B> </div> <bR> </tD> <tD VALIGN=BOTTOM WIDTH="274"><div> <B>Comments</B> </div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 153 WIDTH="147"><div> Qualitative hCG (urine pregnancy tests are adequate if they meet the required sensitivity of 50 IU per L)*</div> </tD> <tD VALIGN=TOP WIDTH="197"><div> One week before starting treatment, then monthly*</div> <div> Monthly pregnancy tests may be replaced by detailed questioning about contraceptive use, menses, etc., at monthly visits</div> </tD> <tD VALIGN=TOP WIDTH="274"><div> Two forms of birth control (e.g., oral contraceptive plus barrier method) required; isotretinoin treatment should begin on the second or third day after the onset of a normal menstrual period; pregnancy should not be attempted until one month after discontinuation of therapy.*</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 115 WIDTH="147"><div> Lipid levels*</div> </tD> <tD VALIGN=TOP WIDTH="197"><div> Before starting treatment, then at weekly or biweekly intervals until the lipid response to isotretinoin is established, usually by four weeks* </div> </tD> <tD VALIGN=TOP WIDTH="274"><div> Measure fasting triglyceride levels; if level rises to 350 mg per dL (3.95 mmol per L), repeat in two weeks. Isotretinoin therapy should be discontinued if levels exceed 700 mg per dL (7.9 mmol per L).</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 96 ><NOBR><div> Liver function tests*</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="197"><div> Before starting treatment, then at weekly or biweekly intervals until weekly or biweekly isotretinoin is established*</div> </tD> <tD VALIGN=TOP WIDTH="274"><div> If elevations appear, reduce the dosage by 50 percent or interrupt treatment.</div> </tD> </tR> </TABLE></div> <bR> <div> hCG = human chorionic gonadotropin.</div> <div> *--Official U.S. Food and Drug Administration labeling requirements.</div> <bR> <bR> <bR> <bR> <bR> <div> <B><U> <A NAME="lice_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Lice</U></B><FONT SIZE="5" COLOR="#660099" FACE="Arial" ><B><U> </U></B></FONT></div> <DIV ALIGN="LEFT"></DIV> <div> There are three varieties of lice; head, body and pubic lice. In order for lice to survive, they must feed on blood within 24 hours. The adult female lays eggs (nits) which are attached to individuals hairs. The young emerge seven to ten days later. Under favorable conditions, the louse will reach maturity in aproximately two weeks. The adult female lives 20 to 30 days and is capable of laying 50 eggs during that time. </div> <div> <B>Pubic Lice (Crabs)</B> </div> <div> Although more commonly found in the pubic hair, these crabs may also be located in the underarm area, on the chest, eyelashes and even mustaches. </div> <div> Pubic lice are often the size and color of small freckles. When severe itching occurs in the genital area, investigate the possibility of crabs. </div> <div> The diagnosis can be made by finding lice or nits on the hairs. </div> <div> <B>Body and Head Lice</B> </div> <div> These two species of lice live on hairs located on the body and head. The nits, or eggs, are deposited by the female at the base of the hairs. </div> <div> <B>Transmission</B> </div> <div> Crab lice are most frequently spread by sexual contact, however, transmission through infested clothing and contaminated toilet seats is possible yet infrequent. </div> <div> Body and head lice are spread by: </div> <div> Direct contact with an infested person or stray hairs that have nits. </div> <div> Personal items-combs, brushes and hair care items as well as towels and pillow cases. </div> <div> Clothing may also spread body and head lice (hats, ribbons and other head coverings included.)</div> <div> <B>Treatment</B> </div> <div> Treatment for pubic, body and head lice includes topical application of Nix (permethrin), A200 Pyrinate (pyrethrins), or Kwell (lindane 1%). Nix and A200 are available without a prescription. Simultaneous treatment of sexual partner(s), household members, clothing and living quarters is recommended. </div> <div> Clean all articles that have been worn in the last two weeks. Adult lice will die after 24 hours without human contact and any eggs left by the female lice will hatch within two weeks. It is important to watch for later infestation. </div> <div> Disinfect combs, brushes and similar items by washing with the medicated shampoo. </div> <div> Items which cannot be washed or dry cleaned, i.e. furniture, can be isolated for two weeks or sealed in an airtight plastic bag.</div> <div> <B>Scabies</B> </div> <div> Commonly called the "itch mite," scabies is caused by a tiny organism named Scaroptes scabies. The pregnant female mite burrows under the skin and deposits her eggs. The intense itching is believed to be caused by the development of an allergic reaction to the waste material of the burrowing, feeding and egg-laying female mites. </div> <div> The most common symptoms of scabies is severe itching, especially at night. The usual sites of the lesions which result from the burrows are the spaces between the fingers, back of hands, elbows, armpits, groin, breasts, penis, small of back and the buttocks. Diagnosis includes skin scrapings and microscopic identification. </div> <div> <B>Transmission</B> </div> <div> Scabies is not an indication of bad hygiene, nor nutritional deficiency. It is usually transmitted through close contact with another person who is infested or with clothing, bed linens or towels contaminated with itch mites. Family members, schoolmates, teammates, roommates and sexual partner(s) are likely candidates for infection and simultaneous treatment. </div> <div> <B>Treatment</B> </div> <div> Currently the most effective treatments are Elimite (permethrin) or Kwell (lindane, 1%). Itching may take several days or even weeks to resolve completely after effective treatment. Any soothing lotion may also be used. Additionally, clothing or bed linens used in the past two weeks should be washed and/or dried using a hot cycle, or dry cleaned. Simultaneous treatment of household members, sexual partner(s) and clothing is recommended. </div> <div>  <A NAME="using_lindane"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> <B><U>directions for using lindane:</U></B></div> <div> <B>: </B></div> <div> <B><U>WARNING </U></B><B>: </B></div> <div> <B>THIS |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>PRODUCT</U></B></FONT><B> CAN BE |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>POISONOUS</U></B></FONT><B> IF MISUSED. CHILDREN |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>MUST</U></B></FONT><B> NOT BE ALLOWED TO APPLY THIS |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>DRUG</U></B></FONT><B> WITHOUT DIRECT |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>ADULT</U></B></FONT><B> SUPERVISION. USE SHAMPOO FOR |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>HEAD</U></B></FONT><B> AND |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>PUBIC</U></B></FONT><B> |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>LICE</U></B></FONT><B> ONLY. DO NOT USE FOR |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>SCABIES</U></B></FONT><B>. USE ONLY IN AMOUNTS DIRECTED BELOW. IN NO |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>CASE</U></B></FONT><B> SHOULD MORE THAN 2 OUNCES BE USED BY ONE PERSON IN ONE APPLICATION. DO NOT INGEST. KEEP AWAY FROM |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>MOUTH</U></B></FONT><B> AND EYES. DO NOT USE IF |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>OPEN</U></B></FONT><B> WOUNDS, CUTS OR SORES ARE |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>PRESENT</U></B></FONT><B> ON |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>SCALP</U></B></FONT><B> OR |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>GROIN</U></B></FONT><B>, UNLESS DIRECTED BY YOUR |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>PHYSICIAN</U></B></FONT><B>. </B></div> <div> <B>AVOID USING OIL TREATMENTS, OIL BASED |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>HAIR</U></B></FONT><B> DRESSINGS OR CONDITIONERS IMMEDIATELY BEFORE AND AFTER APPLYING |"</B><FONT SIZE="2" COLOR="#0000FF" FACE="Arial" ><B><U>LINDANE</U></B></FONT><B> SHAMPOO</B><B>. </B></div> <bR> <div> <B>(SHAKE WELL) </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">BEFORE APPLYING |"</B><B>LINDANE</B><B> SHAMPOO, </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">USE REGULAR SHAMPOO (WITHOUT CONDITIONERS), </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">RINSE AND COMPLETELY DRY |"</B><B>HAIR</B><B>. </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">USE</B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1----</B><B>OUNCE</B><B>  FOR SHORT </B><B>HAIR</B><B>; </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1.5--</B><B>OUNCES FOR </B><B>MEDIUM</B><B> </B><B>LENGTH</B><B> </B><B>HAIR</B><B>; </B></div> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"> 2---</B><B> </B><B>OUNCES</B><B> | FOR LONG "</B><B>HAIR</B><B>. </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">APPLY SHAMPOO DIRECTLY TO DRY |"</B><B>HAIR</B><B> WITHOUT ADDING |"</B><B>WATER</B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">WORK</B><B> THOROUGHLY INTO THE |"</B><B>HAIR</B><B> </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ALLOW TO REMAIN IN PLACE FOR </B><FONT SIZE="5" COLOR="#FF0000" FACE="Arial" ><B>4 MINUTES ONLY. </B></FONT></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AFTER THE  4 MINUTES, ADD SMALL QUANTITIES OF </B><B>WATER</B><B> TO </B><B>HAIR</B><B> UNTIL A GOOD LATHER FORMS. </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f00000ff00.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">IMMEDIATELY RINSE ALL LATHER AWAY. </B></div> <bR> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AVOID UNNECESSARY |"</B><B>CONTACT</B><B> OF LATHER WITH OTHER |"</B><B>BODY</B><B> SURFACES. </B></div> <bR> <div> <B><IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">TOWEL BRISKLY AND REMOVE NITS WITH NIT COMB OR |"</B><B>TWEEZERS</B><B>.</B></div> <div> <B> </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">AVOID UNNECESSARY |"CONTACT WITH YOUR |"SKIN IF YOU ARE APPLYING SHAMPOO TO ANOTHER PERSON. IF TREATING MORE THAN ONE PERSON, PERSON APPLYING SHAMPOO (ESPECIALLY |"PREGNANT AND/OR |"NURSING WOMEN) SHOULD |"WEAR |"RUBBER GLOVES. </div> <bR> <div> RE-TREATMENT IS USUALLY NOT NECESSARY, BUT PRESENCE OF LIVING |"<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>LICE</U></FONT> IN |"<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>HAIR</U></FONT> 7 DAYS AFTER |"<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>TREATMENT</U></FONT> INDICATES THAT RE-TREATMENT MAY BE NECESSARY. DO NOT RE-TREAT WITHOUT THE ADVICE OF A |"<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>PHYSICIAN</U></FONT>. </div> <bR> <div> <B><U> <A NAME="fluconazole_oral___floo_kon__na_zole__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Fluconazole Oral </U></B><FONT SIZE="3" COLOR="#660099" FACE="Arial" > </FONT><FONT SIZE="3" COLOR="#660099" FACE="arial" >(floo kon' na zole)  Brand name(s): Diflucan Oral</FONT></div> <div>  <A NAME="why_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> Why is this medication prescribed?</div> <bR> <div> Fluconazole is used to treat pneumonia, meningitis, and fungal infections of the mouth, throat, liver, kidneys, heart, urinary tract, and abdomen. It also has been used to treat vaginal infections and oral thrush in certain patients.</div> <div> This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.</div> <div>  <A NAME="how_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> How should this medicine be used?</div> <bR> <div> Fluconazole comes as a tablet and liquid to take by mouth. It is usually taken once a day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take fluconazole exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.</div> <div> Shake the liquid well before each use to mix the medication evenly.</div> <div> Continue to take fluconazole even if you feel well. Do not stop taking fluconazole without talking to your doctor.</div> <div>  <A NAME="precautions_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What special precautions should I follow?</div> <bR> <div> Before taking fluconazole,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor and pharmacist if you are allergic to fluconazole or any other drugs. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor and pharmacist what prescription and nonprescription medications you are taking, especially anticoagulants ('blood thinners') such as warfarin (Coumadin), antiviral agents such as zidovudine (Retrovir, AZT), astemizole (Hismanal), asthma medication, cisapride (Propulsid), cyclosporine (Neoral, Sandimmune), didanosine (DDI), hydrochlorothiazide (HCTZ), medications for stomach problems such as cimetidine (Tagamet), oral contraceptives, oral medicine for diabetes, phenytoin (Dilantin), rifabutin (Mycobutin), rifampin (Rifadin, Rimactane), tacrolimus (Prograf), terfenadine (Seldane), and vitamins. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor if you have or have ever had kidney or liver disease or a history of alcohol abuse. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking fluconazole, call your doctor. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor if you drink alcohol. </div> <div>  <A NAME="if_i_forget_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What should I do if I forget a dose?</div> <bR> <div> Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.</div> <div>  <A NAME="side_effects_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What side effects can this medication cause?</div> <bR> <div> Although side effects from fluconazole are not common, they can occur. Tell your doctor if any of these symptoms are severe or do not go away: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">upset stomach </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">loss of appetite </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">altered taste </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diarrhea or loose stools </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">headache </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dizziness </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">fatigue </div> <div> If you experience any of the following symptoms, call your doctor immediately: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rash </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">itching </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vomiting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">yellowing of the skin or eyes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dark urine </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pale stools </div> <div>  <A NAME="storage_conditions_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What storage conditions are needed for this medicine?</div> <bR> <div> Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Throw away any unused liquid medication after 14 days. Talk to your pharmacist about the proper disposal of your medication.</div> <div>  <A NAME="other_information_1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What other information should I know?</div> <bR> <div> Keep all appointments with your doctor and the laboratory. Your doctor will order certain lab tests to check your response to fluconazole.</div> <div> Do not let anyone else take your medication. Your prescription is probably not refillable. If you still have symptoms of infection after you finish fluconazole, call your doctor.</div> <div> Last Revised - 11/01/2001</div> <bR> <div> <B><U> <A NAME="thrush"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Thrush</U></B></div> <div> Thrush is the widely used term for a common fungal infection caused by Candida albicans. Usually this takes the form of trivial vaginal or mouth infections, although it can affect the body more widely and seriously on rare occasions. </div> <div>  <A NAME="symptoms"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Symptoms</div> <div> Vaginal Thrush</div> <div> This causes itch and a cheesy discharge. The area is often redder than usual. It is often painful too, especially on intercourse, and may be associated with frequency of passing water and burning or pain on passing water. It may, therefore be confused with bladder infections (<FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>cystitis</U></FONT>). Thrush, however is usually associated with itching, which cystitis is not. </div> <div> Oral Thrush</div> <div> This may cause a sore mouth and throat, and as well as redness, it is characterised by white discharge on the surface. Babies, especially those being bottle fed, may suffer from this, as well as adults. </div> <div> Nappy rash</div> <div> One cause of a persistent <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>nappy/diaper rash</U></FONT> is infection of the area with thrush. </div> <div>  <A NAME="causes"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Causes</div> <div> The cause is a fungus which is found widely in nature (Candida albicans), and indeed, is frequently present in the mouth and motions of people in good health. It seems that it is at periods when the defence mechanisms are down that it actually causes a problem. This can be when physically or mentally "run down", in women either pregnant, or on the oral contraceptive pill, in <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>diabetes</U></FONT> and people either on steroids, or whose immune systems are suppressed. </div> <div> Antibiotics, which deplete the naturally occurring bacteria, which are useful to the body, as well as the invading bacteria which they are being used to treat, may disturb the natural balance of the body and lead to thrush developing. </div> <div> Thrush is otherwise known as <B>Candidiasis</B> or <B>Moniliasis</B>. </div> <div>  <A NAME="diagnosis"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Diagnosis</div> <div> This can usually be made from the symptoms and the look of the affected area, but may be confirmed by a swab being taken by the nurse or doctor, which is examined at the laboratory. </div> <div>  <A NAME="treatment"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Treatment</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Locally applied creams, pessaries, lozenges or gels, depending on the site affected. The most widely used are the <I>imidazoles</I> although there are other useful preparations. If in doubt consult with your doctor or pharmacist. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Systemically administered preparations. These are costly, but very effective, and usually only require a single dose. </div> <div>  <A NAME="prevention"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A>Prevention</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Avoid unnecessary antibiotics. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">When bottle feeding babies, ensure careful sterilisation of the bottles, including the whole teat. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">If taking antibiotics, especially repeated courses, consider taking live yoghurts or preparations containing the same sort of micro-organisms. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Diabetics should attempt to control their blood glucose level as recommended by their doctor. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">People using <I>inhaled steroids</I> for <FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><U>asthma</U></FONT> should always rinse out their mouths after using their inhalers, and may find that their doctor can recommend a different inhaler device, if they seem to be unduly suffering from thrush. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Some women prone to vaginal thrush find that using cotton underwear and the avoidance of tight clothing help to reduce the risk. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">In women with recurrent vaginal thrush, it is often worth their partner using some treatment at the same time as them, as the infection may affect him without symptoms, and be causing reinfection. </div> <bR> <bR> <div> <B><U> <A NAME="ringworm_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Ringworm </U></B></div> <div> Ringworm is a contagious fungus infection that can affect the scalp, the body, the feet (athlete's foot), or the nails.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">People can get Ringworm from: 1) direct skin-to-skin contact with an infected person or pet, 2) indirect contact with an object or surface that an infected person or pet has touched, or 3) rarely, by contact with soil. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ringworm can be treated with fungus-killing medicine. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">To prevent Ringworm, 1) make sure all infected persons and pets get appropriate treatment, 2) avoid contact with infected persons and pets, 3) do not share personal items, and 4) keep common-use areas clean. </div> <div> <B>What is Ringworm?</B></div> <div> Ringworm is a contagious fungus infection that can affect the scalp, the body (particularly the groin), the feet, and the nails. Despite its name, it has nothing to do with worms. The name comes from the characteristic red ring that can appear on an infected person's skin. Ringworm is also called Tinea.</div> <div> <B>What is the infectious agent that causes Ringworm?</B></div> <div> Ringworm is caused by several different fungus organisms that all belong to a group called "Dermatophytes." Different Dermatophytes affect different parts of the body and cause the various types of Ringworm:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ringworm of the scalp </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ringworm of the body </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ringworm of the foot (athlete's foot) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Ringworm of the nails </div> <div> <B>Where is Ringworm found?</B></div> <div> Ringworm is widespread around the world and in the United States. The fungus that causes scalp Ringworm lives in humans and animals. The fungus that causes Ringworm of the body lives in humans, animals, and soil. The fungi that cause Ringworm of the foot and Ringworm of the nails live only in humans.</div> <div> <B>How do people get Ringworm?</B></div> <div> Ringworm is spread by either direct or indirect contact. People can get Ringworm by direct skin-to-skin contact with an infected person or pet. People can also get Ringworm indirectly by contact with objects or surfaces that an infected person or pet has touched, such as hats, combs, brushes, bed linens, stuffed animals, telephones, gym mats, and shower stalls. In rare cases Ringworm can be spread by contact with soil.</div> <div> <B>What are the signs and symptoms of Ringworm?</B></div> <div> Ringworm of the scalp usually begins as a small pimple that becomes larger, leaving scaly patches of temporary baldness. Infected hairs become brittle and break off easily. Yellowish crusty areas sometimes develop.</div> <div> Ringworm of the body shows up as a flat, round patch anywhere on the skin except for the scalp and feet. The groin is a common area of infection (groin Ringworm). As the rash gradually expands, its center clears to produce a ring. More than one patch might appear, and the patches can overlap. The area is sometimes itchy.</div> <div> Ringworm of the foot is also called athlete's foot. It appears as a scaling or cracking of the skin, especially between the toes.</div> <div> Ringworm of the nails causes the affected nails to become thicker, discolored, and brittle, or to become chalky and disintegrate.</div> <div> <B>How soon after exposure do symptoms appear?</B></div> <div> Scalp Ringworm usually appears 10 to 14 days after contact, and Ringworm of the skin 4 to 10 days after contact. The time between exposure and symptoms isnot known for the other types of Ringworm.</div> <div> <B>How is Ringworm diagnosed?</B></div> <div> A health-care provider can diagnose Ringworm by examining the site of infection with special tests.</div> <div> <B>Who is at risk for Ringworm?</B></div> <div> Anyone can get Ringworm. Scalp Ringworm often strikes young children; outbreaks have been recognized in schools, day-care centers, and infant nurseries. School athletes are at risk for scalp Ringworm, Ringworm of the body, and foot Ringworm; there have been outbreaks among high school wrestling teams. Children with young pets are at increased risk for Ringworm of the body.</div> <div> <B>What is the treatment for Ringworm?</B></div> <div> Ringworm can be treated with fungus-killing medicine. The medicine can be in taken in tablet or liquid form by mouth or as a cream applied directly to the affected area.</div> <div> <B>What complications can result from Ringworm?</B></div> <div> Lack of or inadequate treatment can result in an infection that will not clear up.</div> <div> <B>Is Ringworm an emerging infection?</B></div> <div> Although Ringworm is not tracked by health authorities, infections appear to be increasing steadily, especially among pre-school and school-age children. Early recognition and treatment are needed to slow the spread of infection and to prevent re-infection.</div> <div> <B>How can Ringworm be prevented?</B></div> <div> Ringworm is difficult to prevent. The fungus is very common, and it is contagious even before symptoms appear.</div> <div> Steps to prevent infection include the following:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Educate the public, especially parents, about the risk of Ringworm from infected persons and pets. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Keep common-use areas clean, especially in schools, day-care centers, gyms, and locker rooms. Disinfect sleeping mats and gym mats after each use. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Do not share clothing, towels, hair brushes, or other personal items. </div> <div> Infected persons should follow these steps to keep the infection from spreading:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete treatment as instructed, even after symptoms disappear. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Do not share towels, hats, clothing, or other personal items with others. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Minimize close contact with others until treated. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Make sure the person or animal that was the source of infection gets treated. </div> <div> This fact sheet is for information only and is not meant to be used for self-diagnosis or as a substitute for consultation with a health-care provider. If you have any questions about the disease described above or think that you might have a fungus infection, consult a health-care provider.</div> <bR> <bR> <div> <B><U> <A NAME="duofilm_patch__"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>DuoFilm Patch </U></B> </div> <div> Convenient medicated-patch system for the removal of common warts.</div> <div>  </div> <div> Indications: </div> <div> For the concealment and removal of common warts. Common warts can be easily recognized by the rough cauliflower-like appearance of the surface. </div> <bR> <div> Directions: </div> <div> 1. Wash affected area. May soak wart in warm water for 5 minutes.</div> <div> 2. Dry area thoroughly.</div> <div> 3. Apply medicated disc(packet a). If necessary, cut disc to fit wart. Repeat procedure every 48 hours as needed (until wart is removed) for up to 12 weeks.</div> <div> Note: Self-adhesive comfort cushions (packet b) may be used to conceal medicated disc and wart. </div> <bR> <div> Ingredients: </div> <div> Active Ingredients: Each patch contains: Salicylic Acid (40%) </div> <bR> <div> Warnings: </div> <div> For external use only. Do not use this product on irritated skin, on any area that is infected or reddened, if you are a diabetic, or if you have poor blood circulation. If discomfort persists, see your doctor. Do not use on moles, birthmarks, warts with hair growing from them, genital warts, or warts on the face or mucous membranes. Keep this and all drugs out of the reach of children. In case of accidental ingestion, seek professional assistance or contact a poison control center immediately. Not recommended for children under two, except at the advice of a physician. </div> <bR> <bR> <bR> <bR> <bR> <bR> <div>  </div> <div>   </div> <bR> <div> <B><U> <A NAME="sporanox__itraconazole"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Sporanox </U></B><FONT SIZE="3" COLOR="#660099" FACE="arial" > </FONT><FONT SIZE="3" COLOR="#660099" FACE="Arial" >Itraconazole</FONT></div> <div>  <FONT SIZE="3" COLOR="#660099" FACE="Arial" >IMPORTANT WARNING: </FONT></div> <div> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="632" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 134 WIDTH="622"><div> Itraconazole can cause heart failure. Tell your doctor if you have or have ever had heart disease. If you experience any of the following side effects, call your doctor immediately: shortness of breath, cough, weakness, excessive tiredness, confusion, swelling of the legs or feet, and weight gain.Do not take cisapride (Propulsid), pimozide (Orap), quinidine (Quinaglute, Quinidex, others), or dofetilide (Tikosyn) while taking itraconazole. Taking these medications together with itraconazole can cause serious irregular hearbeats. Talk to your doctor about the risk of taking itraconazole.</div> </tD> </tR> </TABLE></div> <div>  <A NAME="why"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> Why is this medication prescribed?</div> <bR> <div> Itraconazole capsules are used to treat fungal infections of the lungs, blood, and toenails. Itraconazole oral solution is used to treat fungal infections of the mouth and throat and suspected fungal infections in patients with fever and signs of infection.</div> <div> This medication is sometimes prescribed for other uses; ask your doctor or pharmacist for more information.</div> <div>  <A NAME="how"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> How should this medicine be used?</div> <bR> <div> Itraconazole comes as a capsule and an oral solution to take by mouth. Itraconazole capsules are usually taken with a full meal one to three times a day for at least 3 months. Itraconazole solution is usually taken on an empty stomach Ifonce or twice a day for 1 to 4 weeks or longer. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take itraconazole exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.</div> <div> If you have achlorhydria (stomach does not produce acid), take itraconazole capsules with a cola beverage.</div> <div> To take itraconazole oral solution for fungal infections of the mouth or throat, take 10 mL of solution at a time, swish in the mouth for a few seconds and swallow.</div> <div> Continue to take itraconazole even if you feel well. Do not stop taking itraconazole without talking to your doctor.</div> <div>  <A NAME="precautions"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What special precautions should I follow?</div> <bR> <div> Before taking itraconazole,</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor and pharmacist if you are allergic to itraconazole or any other drugs. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">in addition to the drugs listed in the IMPORTANT WARNING section, also tell your doctor and pharmacist what other prescription and nonprescription medications you are taking, especially alfentanil (Alfenta), alprazolam (Xanax), anticoagulants ('blood thinners') such as warfarin (Coumadin), buspirone (BuSpar), busulfan (Myleran), calcium channel blockers such as nifedipine (Adalat, Procardia) and nicardipine (Cardene), cholesterol-lowering medications, cisapride (Propulsid), clarithromycin (Biaxin), cyclosporine (Neoral, Sandimmune), diazepam (Valium), docetaxel (Taxotere), erythromycin (E.E.S., Erythrocin, E-Mycin), heart medications, HIV protease inhibitors such as indinavir (Crixivan) and ritonavir (Norvir), isoniazid (INH), medications for seizures such as carbamazepine (Tegretol) and phenytoin (Dilantin), medications for stomach problems such as cimetidine (Tagamet) or antacids (Mylanta), methylprednisolone (Medrol), midazolam (Versed), nevirapine (Viramune), oral contraceptives, oral medicine for diabetes, quinidine, rifabutin (Mycobutin), rifampin (Rifadin, Rimactane), sirolimus (Rapamune), tacrolimus (Prograf), triazolam (Halcion), trimetrexate (Neutrexin), verapamil (Calan, Covera, Verelan), vinblastine (Velban), vincristine (Oncovin), vinorelbine (Navelbine), and vitamins. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">in addition to the condition listed in the IMPORTANT WARNING section, tell your doctor if you have or have ever had liver disease, achlorhydria (stomach does not produce acid), or a history of alcohol abuse. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking itraconazole, call your doctor. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">tell your doctor if you drink alcohol. </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">itraconazole capsules and itraconazole oral solution should not be interchanged. </div> <div>  <A NAME="if_i_forget"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What should I do if I forget a dose?</div> <bR> <div> Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.</div> <div>  <A NAME="side_effects"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What side effects can this medication cause?</div> <bR> <div> Although side effects from itraconazole are not common, they can occur. Tell your doctor if any of these symptoms are severe or do not go away: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">upset stomach </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">vomiting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diarrhea or loose stools </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">headache </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dizziness </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">loss of appetite </div> <div> If you experience any of the following symptoms or those listed in the IMPORTANT WARNING section, call your doctor immediately: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rash </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">itching </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">yellowing of the skin or eyes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dark urine </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">pale stools </div> <div>  <A NAME="storage_conditions"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What storage conditions are needed for this medicine?</div> <bR> <div> Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.</div> <div>  <A NAME="other_information"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></div> <div> What other information should I know?</div> <bR> <div> Keep all appointments with your doctor and the laboratory. Your doctor will order certain lab tests to check your response to itraconazole.</div> <div> Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription. If you still have symptoms of infection after you finish the itraconazole, call your doctor.</div> <bR> <bR> <bR> <div> <B><U> <A NAME="benzamycin"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Benzamycin</U></B></div> <div> Description</div> <div> Erythromycin and benzoyl peroxide (eh-rith-roe-MYE-sin and BEN-zoe-ill per-OX-ide) combination is used to help control acne.</div> <bR> <div> This medicine is applied to the skin. It may be used alone or with other medicines that are applied to the skin or taken by mouth for acne.</div> <bR> <div> Erythromycin and benzoyl peroxide combination is available only with your doctor's prescription, in the following dosage form: </div> <bR> <div> Topical </div> <div> Topical gel (U.S.) </div> <bR> <bR> <bR> <div> Before Using This Medicine</div> <div> In deciding to use a medicine, the risks of using the medicine must be weighed against the good it will do. This is a decision you and your doctor will make. For erythromycin and benzoyl peroxide combination, the following should be considered:</div> <bR> <div> Allergies—Tell your doctor if you have ever had any unusual or allergic reaction to this medicine, to any of the other erythromycins, or to benzoyl peroxide (e.g., PanOxyl). Also tell your health care professional if you are allergic to any other substances, such as preservatives or dyes. </div> <bR> <div> Pregnancy—Studies on effects in pregnancy have not been done in either humans or animals. However, the benzoyl peroxide in this medicine may be absorbed into the body. Before using this medicine, make sure your doctor knows if you are pregnant or if you may become pregnant.</div> <bR> <div> Breast-feeding—It is not known whether topical erythromycin or topical benzoyl peroxide passes into the breast milk. Erythromycin (e.g., E-Mycin), given by mouth or by injection, does pass into the breast milk. In addition, the benzoyl peroxide in this medicine may be absorbed into the mother's body. However, erythromycin and benzoyl peroxide combination has not been reported to cause problems in nursing babies.</div> <bR> <div> Children—Studies on this medicine have been done only in adult patients, and there is no specific information comparing use of this medicine in children up to 12 years of age with use in other age groups.</div> <bR> <div> Older adults—Many medicines have not been studied specifically in older people. Therefore, it may not be known whether they work exactly the same way they do in younger adults or if they cause different side effects or problems in older people. There is no specific information comparing use of this medicine in the elderly with use in other age groups.</div> <bR> <div> Other medicines—Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. Tell your health care professional if you are using any other topical prescription or nonprescription (over-the-counter [OTC]) medicine that is to be applied to the same area of the skin.</div> <bR> <bR> <bR> <bR> <div> Proper Use of This Medicine</div> <div> Do not use this medicine on raw or irritated skin</div> <bR> <div> Before applying this medicine, thoroughly wash the affected area(s) with warm water and soap, rinse well, and gently pat dry. After washing or shaving, it is best to wait 30 minutes before applying the medicine. The alcohol in it may irritate freshly washed or shaved skin.</div> <bR> <div> Avoid washing the acne-affected area(s) too often. This may dry your skin and make your acne worse. Washing with a mild, bland soap 2 or 3 times a day should be enough, unless you have oily skin. If you have any questions about this, check with your doctor.</div> <bR> <div> To use: </div> <bR> <div> Use this medicine only as directed. Do not use more of it and do not use it more often than your doctor ordered. To do so may cause your skin to become too dry or irritated. </div> <div> After washing the affected area(s), you may apply this medicine with your fingertips. However, be sure to wash the medicine off your hands afterward. </div> <div> Apply and rub in a thin film of medicine, using enough to cover the affected area(s) lightly. You should apply the medicine to the whole area usually affected by acne, not just to the pimples themselves . </div> <div> Since this medicine contains alcohol, it may sting or burn. Therefore, do not get this medicine in or around your eyes, nose, or mouth, or on other mucous membranes. Spread the medicine away from these areas when applying. If this medicine does get in your eyes, wash them out immediately, but carefully, with large amounts of cool tap water. If your eyes still burn or are painful, check with your doctor. </div> <div> Do not use this medicine after the expiration date on the label. The medicine may not work properly. Get a fresh supply from your pharmacist. Check with your pharmacist if you have any questions about this.</div> <bR> <div> To help keep your acne under control, keep using this medicine for the full time of treatment. You may have to continue using this medicine every day for months or even longer in some cases.</div> <bR> <bR> <div> Dosing—</div> <div> The dose of erythromycin and benzoyl peroxide combination will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average dose of erythromycin and benzoyl peroxide combination. If your dose is different, do not change it unless your doctor tells you to do so. </div> <bR> <div> For gel dosage form: </div> <div> For acne: </div> <div> Adults and children 12 years of age and over—Apply to the affected area(s) of the skin two times a day, morning and evening, or as directed by your doctor. </div> <div> Children up to 12 years of age—Dose must be determined by your doctor. </div> <bR> <bR> <div> Missed dose—</div> <div> If you miss a dose of this medicine, apply it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule.</div> <bR> <bR> <div> Storage—</div> <div> To store this medicine: </div> <bR> <div> Keep out of the reach of children. </div> <div> Store in the refrigerator. Heat will cause this medicine to break down. However, keep the medicine from freezing. Follow the directions on the label. </div> <div> Do not keep outdated medicine or medicine no longer needed. Be sure that any discarded medicine is out of the reach of children. </div> <bR> <bR> <bR> <div> Precautions While Using This Medicine</div> <div> If your acne does not improve within 3 to 4 weeks, or if it becomes worse, check with your health care professional. However, treatment of acne may take up to 8 to 12 weeks before you see full improvement.</div> <bR> <div> If your doctor has ordered another medicine to be applied to the skin along with this medicine, it is best to apply the second medicine at least 1 hour after you apply the first medicine. This may help keep your skin from becoming too irritated. Also, if the medicines are used too close together, they may not work properly.</div> <bR> <div> Mild stinging or burning of the skin may be expected after this medicine is applied. These effects may last up to a few minutes or more. If irritation continues, check with your doctor. You may have to use the medicine less often. Follow your doctor's directions.</div> <bR> <div> This medicine may also cause the skin to become unusually dry, even with normal use. If this occurs, check with your doctor.</div> <bR> <div> This medicine may bleach hair or colored fabrics</div> <bR> <div> You may continue to use cosmetics (make-up) while you are using this medicine for acne. However, it is best to use only ``oil-free'' cosmetics. Also, it is best not to use cosmetics too heavily or too often. They may make your acne worse. If you have any questions about this, check with your doctor. </div> <bR> <bR> <div> Side Effects of This Medicine</div> <div> Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.</div> <bR> <div> Check with your doctor as soon as possible if any of the following side effects occur:</div> <bR> <div> Less common or rare </div> <div> Burning, blistering, crusting, itching, severe redness, or swelling of the skin;  painful irritation of the skin;  skin rash  </div> <bR> <bR> <div> Symptoms of topical overdose </div> <div> Burning, itching, scaling, redness, or swelling of the skin (severe)   </div> <bR> <bR> <div> Other side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. However, check with your doctor if any of the following side effects continue or are bothersome:</div> <bR> <div> Less common </div> <div> Dryness or peeling of the skin;  feeling of warmth, mild stinging, or redness of the skin  </div> <bR> <bR> <div> Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor.</div> <bR> <bR> <bR> <div> <B> <A NAME="duct_tape_can_get_rid_of_warts_study_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></div> <div> <B>Duct Tape Can Get Rid of Warts: Study </B></div> <div> Mon Oct 14, 6:08 PM ET </div> <div> NEW YORK (Reuters Health) - <FONT SIZE="3" COLOR="#660099" FACE="arial" >The next time you're in need of a wart cure-all, forget combing the aisles of the local pharmacy and head over to the hardware store instead. </FONT></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="12" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 19 WIDTH="4"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="4" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER WIDTH="1"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <div> According to the findings of a small study in children, applying plain old duct tape to the common wart (scientifically known as Verruca vulgaris) appears to be superior to traditional cryotherapy with liquid nitrogen. </div> <div> While anecdotal reports abound of duct tape's wart-removing abilities, the therapy has not gone head-to-head with other wart removal techniques, according to the report published in the October issue of the Archives of Pediatric and Adolescent Medicine. </div> <div> In the current study, the researchers compared duct tape therapy to cryotherapy, which involves several visits to the doctor's office. During the treatment, a physician freezes the wart by applying a quick, narrow blast of liquid nitrogen to the offending blemish. This is repeated once every two or three weeks until the wart is gone. </div> <div> Aside from the inconvenience of frequent visits to the doctor's office, another potential drawback to this method is that many children are afraid of the treatment and may find it painful, according to lead author Dr. Dean R. Focht III, who conducted the study with colleagues Dr. Mary Fairchok and Carole Spicer while at the Madigan Army Medical Center in Tacoma, Washington. </div> <div> "Tape occlusion, if proven effective, could be an inexpensive, convenient and painless alternative to cryotherapy in the treatment of pediatric warts," they write. Focht is now at the Children's Hospital Medical Center in Cincinnati. </div> <div> In the study, the researchers randomly assigned 51 patients between the ages of 3 and 22 to receive either a maximum of 6 cryotherapy treatments, once every two to three weeks, or two months of duct tape therapy. </div> <div> In duct tape therapy, a nurse covered the wart with a piece of duct tape roughly the same size as the wart. Patients (or their parents) were instructed to keep the duct tape on for 6 consecutive days and if the tape peeled off during that time, apply another at home. </div> <div> At the end of 6 days, patients soaked the wart in water and rubbed it with an emery board or pumice stone. The next morning a new piece of tape was applied. The routine was repeated for a maximum of two months. </div> <div> During the study, all of the patients returned frequently to the doctor's office to have their warts measured and evaluated by a nurse. </div> <div> The investigators found that 85% of those in the duct tape group, compared to 60% of those in the cryotherapy group "had complete resolution of their warts. </div> <div> "This study shows that duct tape occlusion therapy is not only equal to but exceeds the efficacy of cryotherapy in the treatment of the common wart. Tape occlusion therapy can now be offered as a nonthreatening, painless, and inexpensive technique for the treatment of warts in children," according to the report. </div> <div> It's not clear exactly how the duct tape sends warts packing, according to the report, "but, as with other therapies, it may involve stimulation of the patient's immune system through local irritation." </div> <div> SOURCE: Archives of Pediatric and Adolescent Medicine 2002;156:971-974. </div> <bR> <div> <B> <A NAME="people_at_highest_risk_are_those_who_"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></div> <div> <B>People at highest risk for melanoma are those who: </B></div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">have a family history -- meaning having two or more close relatives who have been diagnosed with melanomas; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">have displastic (atypical) moles; </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">or have numerous moles -- more than 50 or so. </div> <bR> <bR> <div>  <A NAME="melanoma_gene"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A><B>Melanoma Gene</B></div> <div> New treatments for melanoma may be developed thanks to some</div> <div> results from the Cancer Genome Project. In a study published</div> <div> online in the journal Nature, researchers say they have found the</div> <div> same genetic changes in about 70 percent of cases of the deadly</div> <div> skin cancer. Using the map of the 30,000 genes in the human</div> <div> genome, the researchers have taken samples of cancerous tumors</div> <div> and in each sample analyzed all the genes, looking for</div> <div> abnormalities, The Associated Press reports. The first</div> <div> abnormality they have identified is in a gene called B-RAF, which</div> <div> plays a role in cell division and growth. The researchers found</div> <div> that a spontaneous mutation in this gene cause cells to multiply</div> <div> unchecked, leading to cancer, the AP says. The B-RAF gene is the</div> <div> one most likely to be abnormal in melanoma, and is also abnormal</div> <div> in about 10 percent of colon cancers, the researchers found.</div> <div> They say that pinpointing this specific gene fault may offer a</div> <div> target for new melanoma drugs, the AP says.</div> <bR> <bR> <div> <B><U> <A NAME="accutane"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></U></B><B><U>Accutane</U></B></div> <div> Using Isotretinoin the Right Way for Acne</div> <div> <B>What is isotretinoin?</B></div> <div> Isotretinoin (brand name: Accutane) is a medicine for very bad acne that did not get better after you tried other medicines. It is important for you to take isotretinoin the right way. You should know about the side effects of isotretinoin. Talk to your doctor if you have any questions about this medicine or if you have side effects when you take it.</div> <div> <B>General Information</B></div> <div> You should take isotretinoin with food. You don't have to keep the medicine in the refrigerator, but keep it out of sunlight. Try not to keep it in a place that is very warm. </div> <div> Isotretinoin has been prescribed just for you. Don't share it with other people. Keep isotretinoin away from children. You may not give blood while you are taking this medicine or for at least one month after you stop taking it.</div> <div> <B>Before Treatment Starts</B></div> <div> Tell your doctor if you or anyone in your family has diabetes, liver disease, heart disease or depression. You should also tell your doctor if you are allergic to any medicines, especially parabens (which are in the isotretinoin capsules). Be sure to tell your doctor if you are taking any other medicines, even over-the-counter medicines. </div> <div> Isotretinoin is like vitamin A, so you should not take vitamin A pills or multivitamins with vitamin A while you are taking isotretinoin. </div> <div> <B>During Your Treatment</B></div> <div> Your acne may get worse when you start using isotretinoin. This usually just lasts for a little while. You can tell your doctor if this happens to you because you might need to use other medicines along with the isotretinoin in this stage.</div> <div> The dosage of isotretinoin is different for each person. During your treatment, your doctor may change your dosage. Be sure to take isotretinoin just the way your doctor tells you. If you miss one dose, don't take extra the next time.</div> <div> Be sure you keep all of your appointments with your doctor because your doctor needs to check on you often. Your doctor may check your liver tests and cholesterol levels. During treatment you may have some of the following side effects. These side effects usually go away when you stop taking isotretinoin:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dry skin and lips (your doctor can tell you which lotions or creams to use) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Fragile skin (easily injured), itching or rash </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Increased sensitivity to the sun (easily sunburned) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Peeling skin on your palms and soles </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Thinning hair </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Dry, red eyes (you may find that you can't wear your contact lenses during treatment) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nosebleeds </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Bleeding gums </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Pain in your muscles </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Decreased night vision. If you have any vision problems, you should stop taking isotretinoin and talk to your doctor right away. </div> <div> A few people have even more serious side effects. If they aren't treated, the problem could last forever. If you have any of the side effects listed below, stop taking isotretinoin and check with your doctor right away:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Headaches, nausea, vomiting or blurred vision </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Depression or changes in your mood </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Severe stomach pain, diarrhea or bleeding from your rectum </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Very dry eyes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f099006600.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">A yellow color in your skin or eyes, and dark yellow urine </div> <div> <B>After You Stop Taking Isotretinoin</B></div> <div> Your skin might go on getting better even after you stop taking isotretinoin. Most of the side effects of isotretinoin go away in a few days or weeks after you stop taking isotretinoin. If your side effects last more than a few weeks after you stop taking isotretinoin, talk to your doctor. </div> <div> Some patients have to take isotretinoin more than one time. If you need to take isotretinoin again, you can start taking it again 8 to 10 weeks after your first treatment is over. Do not give blood for at least one month after you stop taking isotretinoin.</div> <div> <B>Attention, Girls and Women: </B></div> <div> <B>You must not take isotretinoin if you are pregnant or if there is any chance you might get pregnant while taking this medicine!</B></div> <div> Isotretinoin causes severe birth defects, including malformation of the head and face, mental retardation and severe internal defects of the brain, heart, glands and nervous system. It can also cause miscarriage, premature birth and death of the fetus.</div> <div> You <B>must</B> use two forms of birth control at the same time for at least one month before you start taking isotretinoin and for all the time you are taking this medicine. Keep using two kinds of birth control for one month after you stop taking isotretinoin. If you are using Depo-Provera as your form of birth control, you may not need to use two forms of birth control. Check this with your doctor.</div> <div> Your doctor will make sure you are not pregnant before starting isotretinoin and check again every month while you are taking it. You will be asked to read and sign a consent form to show that you understand the dangers of birth defects and agree to use birth control. If your period is late, stop taking isotretinoin and call your doctor right away. If you get pregnant while you are taking isotretinoin, talk with your doctor about going on with the pregnancy.</div> <bR> <div> This handout provides a general overview on this topic and may not apply to everyone. To find out if this handout applies to you and to get more information on this subject, talk to your family doctor. </div> <div> Visit <U>familydoctor.org</U> for information on this and many other health-related topics.</div> <div> Copyright © 2000 by the American Academy of Family Physicians. </div> <div> Permission is granted to print and photocopy this material for nonprofit educational uses. Written permission is required for all other uses, including electronic uses.</div> <bR> <div> <B> <A NAME="afp_article"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></A></B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="973" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#004A8A HEIGHT= 11440 ><NOBR><div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="968" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 11411 ><NOBR><div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="965" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 11382 ><NOBR><div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="832" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 11353 WIDTH="12"><div> <IMG SRC="35104040.png" border=0 width="4" height="4" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="813"><div> <A HREF="http://www.aafp.org/afp/20050715/contents.html" TARGET="_top" TITLE="http://www.aafp.org/afp/20050715/content"><U><IMG SRC="37af4490.png" border=0 width="500" height="73" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></U></A></div> <bR> <div> <B>Cutaneous Melanoma: Update on Prevention, Screening, Diagnosis, and Treatment</B></div> <div> <B>ERIKA L. RAGER, M.D., M.P.H., EDWARD P. BRIDGEFORD, M.D., and DAVID W. OLLILA, M.D.</B></div> <div> <B>University of North Carolina at Chapel Hill, Chapel Hill, North Carolina</B></div> <div> <B>Melanoma is an increasingly common malignancy, and it affects a younger population than most cancers. Risk factors for melanoma include white race, sun sensitivity, family history of melanoma, and melanocytic nevi. Sunburn and intermittent sun exposure appear to increase the risk of developing melanoma. The role of population-based screening for skin cancer remains unclear. Consistent screening results in the diagnosis of thinner melanomas, but there is no evidence that this leads to decreased mortality. The ABCDs-asymmetry, border, color, diameter-can be used as a guide to differentiate melanoma from benign lesions. Suspicious pigmented lesions should undergo full thickness biopsy. Treatment consists of surgical resection, lymph node evaluation, and systemic therapy for some patients. Prognosis depends on the stage at diagnosis. Patients with melanoma require close follow-up because they are at risk for recurrence and diagnosis of a second primary tumor. Preventive strategies for melanoma should emphasize seeking shade when outdoors, wearing </B><FONT SIZE="3" COLOR="#66334C" FACE="Arial Unicode MS Western" ><B>protective clothing, and avoiding exposure during the peak sunlight hours. (Am Fam Physician 2005;72:269-76. Copyright© 2005 American Academy of Family Physicians.)</B></FONT></div> <div> <B>Skin cancer is the most common malignancy in the United States. Although melanoma represents a small subset, it is the most deadly cutaneous neoplasm. The American Cancer Society estimates that there will be 59,580 new cases of melanoma and 7,770 deaths from melanoma in 2005.1 The incidence of melanoma increases by 4.1 percent per year, faster than any other malignancy.</B></div> <div> <B>Epidemiology</B></div> <div> <B>According to data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute, from 1995 to 1999 the annual age-adjusted incidence of melanoma was 20 per 100,000 persons among whites.2 The incidence was higher in men (24.4 per 100,000 persons) than in women (16.8 per 100,000 persons).2 The lifetime risk of developing invasive melanoma is 2.04 percent for white men and 1.45 percent for white women; about one in 74 Americans will be diagnosed with melanoma.2</B></div> <div> <B>Melanoma affects a younger patient population than many malignancies. The median age at diagnosis is 57 years. Sixty-two percent of cases are diagnosed before patients reach 65 years of age, and the median age at death is 67 years. Melanoma is the sixth leading cause of cancer death in the United States. According to statistics from SEER, an average of 18.8 life-years are lost per melanoma death.2</B></div> <div> <B>Melanoma is much more common in whites than in non-whites. California Cancer Registry data from 1988 to 1993 show the average annual age-adjusted incidence rates per 100,000 persons were 17.2 in men and 11.3 in women for non-Hispanic whites; 2.8 (men) and 3.0 (women) for Hispanics; 0.9 (men) and 0.8 (women) for Asians; and 1.0 (men) and 0.7 (women) for blacks.3</B></div> <div> <B>Risk Factors</B></div> <div> <B>Numerous risk factors for the development of melanoma have been identified, including sun sensitivity, white skin, fair hair, light eyes, tendency to freckle, family history of melanoma, dysplastic nevi, increased numbers of typical nevi, large congenital nevi </B><I><B>(Figure 1)</B></I><B>, and immunosuppression.4 The risk associated with sun exposure is not completely clear. Although sun exposure is a risk factor for melanoma, cutaneous melanomas can arise frequently in areas of the body not exposed to the sun </B><I><B>(Figure 2)</B></I><B>. Sunburn and intermittent sun exposure increase the risk of melanoma, but cumulative and occupational sun exposure do not appear to increase risk.5 Sun exposure in childhood and having more than one blistering sunburn in childhood are associated with an increased risk of melanoma.6</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="608" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 276 ><NOBR><div> <IMG SRC="37b1dfa0.jpg" border=0 width="285" height="250" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 1. Congenital nevus.</B></div> </NOBR></tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="12"><div>  </div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF><NOBR><div> <IMG SRC="37c1dfa0.jpg" border=0 width="285" height="250" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 2. Acral lentiginous melanoma.</B></div> </NOBR></tD> </tR> </TABLE></div> <div> <B>The evidence regarding the use of sunlamps and tanning beds is mixed. About one half of the case-control studies performed revealed an association between sunlamp or tanning bed use and melanoma, especially if the dose of exposure was high or if it caused skin burning.5</B></div> <div> <B>Melanocytic nevi consistently are identified as risk factors for the future development of melanoma. Most melanocytic nevi develop during childhood and adolescence. Sunburn and moderate sun exposure also appear to be related to the development of melanocytic nevi.</B></div> <div> <B>In addition to environmental factors, genetic factors influence the risk of melanoma. A family history of melanoma in a first-degree relative is associated with an eight- to 12-fold increase in the risk of melanoma.</B></div> <div> <B>Screening</B></div> <div> <B>screening by physicians</B></div> <div> <B>The U.S. Preventive Services Task Force reviewed the evidence in 2001 and concluded that there is insufficient evidence to recommend for or against routine screening for skin cancer in asymptomatic patients in the primary care clinical setting using a total-body skin examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer.7,8 </B><I><B>Table 1</B></I><B>4,5,8-18 provides additional screening recommendations.</B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="689" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 49 WIDTH="685"><div> <B>Table 1</B></div> <div> <B>Prevention Recommendations</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="690" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 1042 WIDTH="359"><div> <B>U.S. Preventive Services Task Force</B></div> <div> <B>Insufficient evidence to recommend for or against routine screening for skin cancer in the primary care setting using a total-body skin examination for the early detection of cutaneous melanoma, basal cell carcinoma, or squamous cell carcinoma8</B></div> <div> <B>Insufficient evidence to recommend for or against counseling on sun avoidance and use of protective clothing for adults and children at high risk5</B></div> <div> <B>Insufficient evidence to recommend for or against sunscreen use5</B></div> <bR> <div> <B>American Academy of Family Physicians</B></div> <div> <B>Insufficient evidence to recommend for or against routine skin cancer screening in asymptomatic persons9</B></div> <div> <B>Recommends sun avoidance strategies and use of sunscreen with sun protection factor (SPF) of at least 1510</B></div> <bR> <div> <B>American Academy of Dermatology</B></div> <div> <B>Recommends that patients at high risk for melanoma should be examined regularly by a dermatologist11</B></div> <div> <B>Recommends sun avoidance and covering up with protective clothing4</B></div> <div> <B>Recommends sunscreen with SPF of at least 15, covering the entire body, reapplied every two hours4</B></div> <bR> <div> <B>American College of Preventive Medicine</B></div> <div> <B>Recommends periodic total cutaneous examinations, targeting populations at high risk for malignant melanoma, defined as persons with family or personal history of skin cancer, predisposing phenotypic characteristics, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions12</B></div> <div> <B>Recommends sun avoidance and sun protective measures; counseling not necessary with every patient, but should be given with persons at particular risk13</B></div> <div> <B>Insufficient evidence to recommend for or against the use of sunscreen13</B></div> </tD> <tD VALIGN=TOP WIDTH="324"><div> <B>National Cancer Institute</B></div> <div> <B>Insufficient evidence, according to expert opinion, to establish whether a decrease in mortality occurs with routine skin examination14</B></div> <div> <B>Insufficient evidence to establish whether other theoretic benefits or harms associated with incorrect diagnosis occur14</B></div> <bR> <div> <B>Institute of Medicine</B></div> <div> <B>Insufficient evidence to recommend skin cancer screening; however, physicians and patients must remain alert to the common signs of skin malignancies, with special attention to older white men15</B></div> <bR> <div> <B>Canadian Task Force on Preventive Health Care</B></div> <div> <B>Insufficient evidence to recommend for or against skin cancer screening among the general population, but suggests regular total-body skin examinations for persons at high risk16</B></div> <bR> <div> <B>American Cancer Society</B></div> <div> <B>Recommends monthly self-examination and physician skin examination as part of a cancer checkup every three years for persons 20 to 40 years of age and annually for persons older than 40 years17</B></div> <bR> <div> <B>National Institutes of Health</B></div> <div> <B>Consensus Panel recommends screening for melanoma as part of routine primary care18</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 39 WIDTH="684"><bR> <div> <B>Information from references 4, 5, and 8 through 18.</B></div> </tD> </tR> </TABLE></B></div> <div> <B>Selective screening ultimately may be most effective. Compared with the general population, persons with one or two risk factors (e.g., red or blond hair, freckling on the upper back, history of three or more blistering sunburns before 20 years of age, three or more outdoor summer jobs before 20 years of age, actinic keratosis) have</B></div> <div> <B>3.5 times the risk of developing melanoma, and in persons with three or more risk factors, the risk is increased 20 times.19 Other predictors of finding a confirmed melanoma during screening include changes in a mole, skin type, personal history of melanoma, and being a middle-aged or older man.20 The development of risk-assessment tools someday may facilitate appropriate selective screening. An unsupervised self-administered questionnaire used in a dermatology setting had moderate usefulness in identifying patients at high risk for melanoma.21 However, at this time there is no validated risk-assessment scale with which to screen patients for melanoma.</B></div> <div> <B>Although there is insufficient evidence to recommend routine screening of all patients, physicians should take advantage of the physical examination to screen opportunistically. Lesions that are detected by a physician are significantly thinner (0.40 mm) than those detected by the patient (1.17 mm) or a spouse (1.00 mm; </B><I><B>P</B></I><B> < .001).22 However, screening studies have not shown a decrease in mortality.</B></div> <div> <B>A randomized trial23 of population-based screening for melanoma is underway in Australia. Hopefully, this study will provide a definitive answer to the question of whether skin cancer screening can reduce mortality from melanoma.</B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="552" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 20 WIDTH="548"><div> <B>sort: key Recommendations for practice</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=BOTTOM HEIGHT= 39 WIDTH="386"><div> <B>Clinical recommendation</B></div> </tD> <tD VALIGN=BOTTOM WIDTH="75"><div> <B>Evidence rating</B></div> </tD> <tD VALIGN=BOTTOM><NOBR><div> <B>References</B></div> </NOBR></tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 77 WIDTH="386"><div> <B>Physicians may choose to screen patients with a total-body skin examination, especially those at higher risk (evidence insufficient to recommend for or against).</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>C</B></div> </tD> <tD VALIGN=TOP WIDTH="83"><div> <B>8</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 58 WIDTH="386"><div> <B>Suspicious lesions should undergo full thickness biopsy into the underlying subcutaneous tissue with a 1- to 2-mm border.</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>C</B></div> </tD> <tD VALIGN=TOP WIDTH="83"><div> <B>11</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="386"><div> <B>Shave biopsies should never be used if melanoma is suspected.</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>C</B></div> </tD> <tD VALIGN=TOP WIDTH="83"><div> <B>11</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="386"><div> <B>Surgical resection with wide margins (greater than 3 cm) no longer is recommended.</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>A</B></div> </tD> <tD VALIGN=TOP WIDTH="83"><div> <B>29, 30</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 77 WIDTH="386"><div> <B>Recommended margins are 0.5 cm for melanoma in situ, 1 cm for melanomas with a Breslow thickness of 0.5 to 1 mm, and 2 cm for melanomas with a Breslow thickness greater than 1 mm.</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>B</B></div> </tD> <tD VALIGN=TOP WIDTH="83"><div> <B>29-31</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 97 WIDTH="386"><div> <B>Nodal evaluation is recommended in patients with melanomas at least 1 mm in thickness. Sentinel lymph node biopsy is recommended in patients with intermediate thickness melanoma (1 to 4 mm) and clinically negative nodes.</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>B</B></div> </tD> <tD VALIGN=TOP><NOBR><div> <B>33, 37, 38</B></div> </NOBR></tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 58 WIDTH="386"><div> <B>Patients with melanoma need intensive follow-up, especially during the first two to three years after diagnosis.</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>C</B></div> </tD> <tD VALIGN=TOP WIDTH="83"><div> <B>41</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 77 WIDTH="386"><div> <B>Educational and policy changes in elementary schools and similar interventions for adults in recreational settings can increase sun-protective behaviors and are recommended.</B></div> </tD> <tD VALIGN=TOP WIDTH="75"><div> <B>C </B></div> </tD> <tD VALIGN=TOP WIDTH="83"><div> <B>5 </B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 115 WIDTH="546"><bR> <div> <B>A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 209 or </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.aafp.org/afpsort.xml" TARGET="_top" TITLE="http://www.aafp.org/afpsort.xml"><U><B><U>http://www.aafp.org/afpsort.xml</U></B></U></A></FONT><B>.</B></div> </tD> </tR> </TABLE></B></div> <div> <B>skin self-examination</B></div> <div> <B>The American Academy of Dermatology and the American Cancer Society provide educational materials for monthly skin self-examination and recommend regular self-examination for everyone. A large case-control study24 showed a decrease in "lethal" melanoma (i.e., death or distant metastases) in persons who performed skin self-examination (measured by interview questionnaire) compared with those who did not.</B></div> <div> <B>Diagnosis</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="608" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 260 WIDTH="293"><div> <IMG SRC="37d1dd70.jpg" border=0 width="285" height="215" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 3. Superficial spreading melanoma at the knee.</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="12"><div>  </div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="293"><div> <IMG SRC="37e1dbe0.jpg" border=0 width="285" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 4. Superficial spreading melanoma.</B></div> </tD> </tR> </TABLE></div> <div> <B>Benign pigmented lesions must be distinguished from early melanoma. The ABCDs (asymmetry, border, color, diameter) of melanoma provide a guide for making this diagnosis.25 Some dermatology experts also add E for evolution or for elevation above skin level. In general, benign lesions are round and symmetric, while melanomas are asymmetric. Benign lesions usually have regular margins, while melanomas have irregular borders. Benign lesions are uniform in color, while melanomas are more heterogeneous, with colors ranging from tan to brown and black, often with areas of red, white, or blue. Finally, most benign lesions are smaller than 6 mm in diameter, while melanomas often are larger than 6 mm at the time of diagnosis </B><I><B>(Figures 3 through 10)</B></I><B>. The ABCD checklist is a sensitive diagnostic test (90 to 100 percent, depending on whether a positive test is defined as the presence of one, two, or three of the ABCDs), but the specificity is not well defined.26 </B><I><B>Table 2</B></I><B>27 describes the histologic subtypes of cutaneous melanoma.</B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="552" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 49 WIDTH="548"><div> <B>table 2</B></div> <div> <B>Histologic Types of Cutaneous Melanoma</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="556" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=BOTTOM HEIGHT= 39 WIDTH="102"><div> <B>Type</B></div> </tD> <tD VALIGN=BOTTOM WIDTH="86"><div> <B>Frequency (%)</B></div> </tD> <tD VALIGN=BOTTOM WIDTH="85"><div> <B>Age at diagnosis</B></div> </tD> <tD VALIGN=BOTTOM WIDTH="68"><div> <B>Site</B></div> </tD> <tD VALIGN=BOTTOM WIDTH="199"><div> <B>Clinical features</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="556" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 58 WIDTH="102"><div> <B>Superficial spreading</B></div> </tD> <tD VALIGN=TOP WIDTH="86"><div> <B>70</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>Mid 40s</B></div> </tD> <tD VALIGN=TOP WIDTH="68"><div> <B>Any</B></div> </tD> <tD VALIGN=TOP WIDTH="199"><div> <B>Raised border; brown lesion with pinks, whites, grays, and blues</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="556" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 58 WIDTH="102"><div> <B>Nodular</B></div> </tD> <tD VALIGN=TOP WIDTH="86"><div> <B>15</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>Mid to late 40s</B></div> </tD> <tD VALIGN=TOP WIDTH="68"><div> <B>Any</B></div> </tD> <tD VALIGN=TOP WIDTH="199"><div> <B>Arises from normal skin or nevus; brown to black lesion</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="556" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="102"><div> <B>Acral lentiginous</B></div> </tD> <tD VALIGN=TOP WIDTH="86"><div> <B>10</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>60s</B></div> </tD> <tD VALIGN=TOP WIDTH="68"><div> <B>Hands and feet</B></div> </tD> <tD VALIGN=TOP WIDTH="199"><div> <B>Flat, irregular; dark brown to black lesion</B></div> </tD> </tR> </TABLE></B></div> <div> <B> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="556" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP HEIGHT= 39 WIDTH="102"><div> <B>Lentigo maligna</B></div> </tD> <tD VALIGN=TOP WIDTH="86"><div> <B>5</B></div> </tD> <tD VALIGN=TOP WIDTH="85"><div> <B>70s</B></div> </tD> <tD VALIGN=TOP WIDTH="68"><div> <B>Face</B></div> </tD> <tD VALIGN=TOP WIDTH="199"><div> <B>Very irregular border; tan to brown lesion</B></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=5 HEIGHT= 58 WIDTH="544"><bR> <div> <B>Adapted with permission from Balch CM, ed. Cutaneous melanoma. 3d ed. St. Louis: Quality Medical Publishing, 1998:89.</B></div> </tD> </tR> </TABLE></B></div> <div> <B>Suspicious lesions should undergo full-thickness biopsy into the underlying subcutaneous tissue. Excisional biopsy with 1- to 2-mm borders is preferred. The excisional biopsy should be oriented with the definitive treatment in mind. Incisional or punch biopsies may be performed if lesion size or location makes excisional biopsy inappropriate or impractical. Incisional or punch biopsies should include the area of the lesion that appears most suspicious.11,28 A negative incisional or punch biopsy does not necessarily rule out melanoma in a highly suspicious lesion. Shave biopsies should never be used if melanoma is suspected because lesion thickness is vitally important in determining treatment and prognosis.</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="297" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="LEFT" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 216 ><NOBR><div> <IMG SRC="37f1dbe0.jpg" border=0 width="285" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 5. Lentigo maligna on cheek.</B></div> </NOBR></tD> </tR> </TABLE></div> <div> <B>Treatment</B></div> <div> <B>local therapy</B></div> <div> <B>After melanoma is confirmed, patients must undergo complete excision of the tumor or tumor site. Surgical resection is curative for local disease. Randomized controlled trials comparing narrow excision (1 to 2 cm) with wide excision (more than 3 cm) consistently have found equivalent rates of local recurrence and disease-free and overall survival.29,30 Wide excision margins are no longer recommended. Although the exact margins have not been clarified, general recommendations are as follows: melanoma in situ, recommended margin 0.5 cm; melanomas with a Breslow thickness of 1 mm or less, recommended margin 1 cm; and melanomas with a Breslow thickness greater than 1 mm, recommended margin 2 cm.28</B></div> <div> <B>nodal evaluation</B></div> <div> <B>Patients who are diagnosed with nonulcerated melanoma less than 1 mm deep are unlikely to have nodal metastasis and do not require further surgical evaluation of the lymph nodes. Nodal evaluation is important in patients diagnosed with a melanoma at least 1 mm deep because it determines the overall prognosis and the need for therapeutic lymph node dissection or adjuvant treatment. Historically, the regional lymph node basin was evaluated with an elective lymph node dissection (i.e., removal of all the regional lymph nodes) in patients who did not have clinical evidence of nodal involvement. Elective lymph node dissection no longer is indicated. Local recurrence or overall survival is the same whether patients receive elective lymph node dissection or observation.31</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="608" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 260 WIDTH="293"><div> <IMG SRC="3801dd70.jpg" border=0 width="285" height="215" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 6a. Superficial spreading melanoma on back.</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="12"><div>  </div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="293"><div> <IMG SRC="3811dbe0.jpg" border=0 width="285" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 6b. Close-up of superficial spreading melanoma on back.</B></div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="608" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 402 WIDTH="293"><div> <IMG SRC="3821dbe0.jpg" border=0 width="285" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 7. Nodular melanoma on shoulder.</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="12"><div>  </div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="293"><div> <IMG SRC="3831d650.jpg" border=0 width="285" height="357" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 8. Superficial spreading melanoma on ear.</B></div> </tD> </tR> </TABLE></div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="608" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 235 WIDTH="293"><div> <IMG SRC="3841dbe0.jpg" border=0 width="285" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 9a. Superficial spreading melanoma on chest.</B></div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="12"><div>  </div> </tD> <tD VALIGN=TOP BGCOLOR=#FFFFFF WIDTH="293"><div> <IMG SRC="3851dbe0.jpg" border=0 width="285" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 9b. Close-up of superficial spreading melanoma on chest.</B></div> </tD> </tR> </TABLE></div> <div> <B>Sentinel lymph node biopsy is a highly accurate diagnostic test to stage the regional nodal basin and has minimal morbidity. This procedure is based on the premise that the primary tumor drains to the regional lymph nodes in a predictable way, and that the first, or sentinel, node can predict accurately the pathologic status of the entire draining nodal basin.32 Sentinel lymph node biopsy has become the standard of care for nodal staging in patients with intermediate thickness melanoma (1 to 4 mm) and clinically negative nodes. Sentinel lymph node biopsy also is feasible in patients who have had a wide local excision in the past.33 Performing sentinel lymph node biopsy requires coordinated expertise between nuclear medicine physicians, pathologists, and surgeons. Preoperative lymphatic mapping is used to accurately identify the draining nodal basin. The sentinel lymph node is examined at multiple levels with hematoxylin and eosin stains, and immunohistochemical stains.</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="297" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="LEFT" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 235 WIDTH="293"><div> <IMG SRC="3861dbe0.jpg" border=0 width="285" height="190" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <div> <B>Figure 10. Superficial spreading melanoma with regression.</B></div> </tD> </tR> </TABLE></div> <div> <B>No additional therapy is required for patients with a tumor-free sentinel lymph node. Patients with metastatic tumor in the sentinel lymph node and those who have clinically evident nodal metastasis should undergo therapeutic lymph node dissection of the entire draining nodal basin and a discussion of post-surgical adjuvant therapy options.34</B></div> <div> <B>adjuvant therapy</B></div> <div> <B>Although no effective chemotherapy is available for melanoma, interferon alfa-2b (Intron A) is a biologic therapy available for adjuvant treatment of melanoma. Investigators in the initial study35 found a significant increase in relapse-free and overall survival in the group that received high-dose interferon compared with observation alone. Subsequent trials were inconclusive or contradictory. A recent meta-analysis of all available randomized controlled trials found a statistically significant increase in relapse-free survival, but not in overall survival.36 At this time, the use of interferon alfa-2b in patients with melanoma is controversial, particularly in patients with micrometastases in the sentinel node. Clinical trials of other therapies, including combination chemotherapy, vaccines, and hyperthermic isolation limb perfusion, are ongoing.</B></div> <div> <B>Prognosis</B></div> <div> <B>Survival is influenced strongly by the stage at diagnosis. According to SEER data from 1992 to 1998, 82 percent of melanomas were localized at the time of diagnosis (stage I or II), 9 percent were regional (stage III), and 4 percent had distant metastases (stage IV).2 The overall five-year survival rates were 89 to 96 percent for localized disease, 60 percent for regional disease, and 14 percent for distant disease.2</B></div> <div> <B>Important prognostic factors in the primary tumor are tumor thickness and ulceration. Tumors on the head, neck, and trunk have a poorer prognosis, and the rate of disease-specific survival decreases with increasing age at diagnosis. For patients with regional (stage III) disease, the number of metastatic nodes, tumor burden within the nodes, and ulceration of the primary tumor are the most important predictors of survival.37 Evidence shows that patients staged by sentinel lymph node biopsy have improved five-year survival rates compared with patients staged by elective lymph node dissection or clinical examination.38 Another large study39 identified gender and histology as prognostic indicators: men have a lower survival rate than women, and nodular and acral lentiginous spreading indicates a poorer prognosis than lentigo maligna and superficial spreading </B><I><B>(Table 2)</B></I><B>.27</B></div> <div> <B>Follow-Up</B></div> <div> <B>Compared with the general population, patients diagnosed with melanoma are at significantly increased risk of developing additional melanomas in the future. Most of these second melanomas are diagnosed in the first two years following diagnosis of the first melanoma (mean, 2.8 years; median, one year).40 The one-year, five-year, and 10-year probabilities of developing a second primary tumor are reported to be 1.0, 2.1, and 3.2 percent respectively, more than 10 times the risk in the general population. For this reason, patients diagnosed with melanoma need intensive follow-up, especially during the first two to three years after diagnosis,41 although an optimal follow-up regimen has not been defined.</B></div> <div> <B>Nodal evaluation is important in patients diagnosed with a melanoma at least 1 mm deep because it determines the overall prognosis and the need for therapeutic lymph node dissection or adjuvant treatment.</B></div> <div> <B>Prevention</B></div> <div> <B>Effective strategies for the prevention of melanoma have been elusive. Evidence-based reviews have found little evidence that physician counseling in the primary care setting is effective in preventing skin cancer.42 A meta-analysis5 found no association between sunscreen use and decreased incidence of melanoma (odds ratio, 1.01). This may be because sunscreens provide a false sense of security and often are used incorrectly, thereby leading to inadequate overall protection from exposure to ultraviolet light.</B></div> <div> <B>Evidence shows that some community-level approaches effectively reduce sun exposure. Educational and policy approaches in elementary schools can change sun-protective behavior in children. Similar interventions in recreational and tourism settings can change sun-protective behavior in adults. The Task Force on Community Preventive Services recommends these multicomponent population-based approaches.43 The strongest evidence supports preventing intermittent sunburn in childhood. This is best accomplished by avoiding the midday sun and wearing protective clothing, including long pants, long sleeves, wide-brimmed hats, and sunglasses.5 Sun avoidance should be the cornerstone of preventive strategies.</B></div> <div> <B>Author disclosure: Nothing to disclose.</B></div> <div> <B>Figures 1 through 10 used with permission from David W. Ollila, M.D., Chapel Hill, N.C.</B></div> <bR> <div> <B>The Authors</B></div> <div> <B>ERIKA L. RAGER, M.D., M.P.H., is a resident in the Department of Surgery at the University of North Carolina at Chapel Hill School of Medicine. She also trained in preventive medicine on an American Cancer Society Physician Training Award, with an emphasis on cancer prevention and control. Dr. Rager received her medical degree from Vanderbilt University School of Medicine, Nashville.</B></div> <div> <B>EDWARD P. BRIDGEFORD, M.D., is a resident in preventive medicine at the University of North Carolina at Chapel Hill School of Medicine. He received his medical degree from the University of South Florida School of Medicine, Tampa. Dr. Bridgeford completed a residency in internal medicine at the University of North Carolina at Chapel Hill.</B></div> <div> <B>DAVID W. OLLILA, M.D., is assistant professor in the Department of Surgery at the University of North Carolina at Chapel Hill School of Medicine and director of the UNC Lineberger Comprehensive Cancer Center Sentinel Lymph Node Program. He received his medical degree from the University of Cincinnati College of Medicine and completed a residency in surgery at Riverside Methodist Hospital in Columbus, Ohio. Dr. Ollila also received fellowship training in surgical oncology at the John Wayne Cancer Institute, Santa Monica, Calif.</B></div> <div> <B>Address correspondence to Erika L. Rager, M.D., M.P.H., Department of Social Medicine, University of North Carolina at Chapel Hill School of Medicine, CB #7240, Wing D, Chapel Hill, NC 27599-7240 (e-mail: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="mailto:rager@email.unc.edu" TARGET="_top" TITLE="mailto:rager@email.unc.edu"><U><B><U>rager@email.unc.edu</U></B></U></A></FONT><B>). Reprints are not available from the authors.</B></div> <div> <B>REFERENCES</B></div> <div> <B>1. Cancer facts and figures 2005. Atlanta: American Cancer Society, 2005. Accessed online February 20, 2005, at: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.cancer.org/downloads/STT/estimated_new_cancer_cases_and_deaths_by_sex_for_all_sites,_US,_2005.pdf" TARGET="_top" TITLE="http://www.cancer.org/downloads/STT/esti"><U><B><U>http://www.cancer.org/downloads/STT/estimated_new_cancer_cases_and_deaths_</U></B></U></A></FONT></div> <div> <A HREF="http://www.cancer.org/downloads/STT/estimated_new_cancer_cases_and_deaths_by_sex_for_all_sites,_US,_2005.pdf" TARGET="_top" TITLE="http://www.cancer.org/downloads/STT/esti"><U><B><U>by_sex_for_all_sites,_US,_2005.pdf</U></B></U></A><FONT SIZE="3" COLOR="#66334C" FACE="Arial" ><B>.</B></FONT></div> <div> <B>2. Ries LA, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, et al., eds. SEER cancer statistics review, 1973-1999. Bethesda, Md.: National Cancer Institute, 2002. Accessed online November 9, 2004, at: gov/csr/1973_1999/" </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://seer.cancer." TARGET="_top" TITLE="http://seer.cancer."><U><B><U>http://seer.cancer.gov/csr/1973_1999/</U></B></U></A></FONT><B>.</B></div> <div> <B>3. Cress RD, Holly EA. Incidence of cutaneous melanoma among non-Hispanic whites, Hispanics, Asians, and blacks: an analysis of California cancer registry data, 1988-93. Cancer Causes Control 1997;8:246-52.</B></div> <div> <B>4. American Academy of Dermatology. MelanomaNet. Accessed online November 9, 2004, at: http://www.skincarephysicians.com/melanomanet/.</B></div> <div> <B>5. Helfand M, Krages KP. Counseling to prevent skin cancer: a summary of the evidence for the U.S. Preventive Services Task Force. Rockville, Md.: Agency for Healthcare Research and Quality, 2003. Accessed November 9, 2004, at: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.ahrq.gov/clinic/3rduspstf/skcacoun/skcounsum.htm" TARGET="_top" TITLE="http://www.ahrq.gov/clinic/3rduspstf/skc"><U><B><U>http://www.ahrq.gov/clinic/3rduspstf/skcacoun/skcounsum.htm</U></B></U></A></FONT><B>.</B></div> <div> <B>6. Whiteman DC, Whiteman CA, Green AC. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control 2001;12:69-82.</B></div> <div> <B>7. Helfand M, Mahon SM, Eden KB, Frame PS, Orleans CT. Screening for skin cancer. Am J Prev Med 2001;20(3 suppl):47-58.</B></div> <div> <B>8. U.S. Preventive Services Task Force. Screening for skin cancer: recommendations and rationale. Am J Prev Med 2001;20(3 suppl):44-6.</B></div> <div> <B>9. Summary of policy recommendations for periodic health examinations. August 2004. Accessed online March 11, 2005, at: http://www.aafp.org/PreBuilt/PHErev56.pdf.</B></div> <div> <B>10. Skin cancer: saving your skin from sun damage. Accessed online March 11, 2005, at: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://familydoctor.org/159.xml" TARGET="_top" TITLE="http://familydoctor.org/159.xml"><U><B><U>http://familydoctor.org/159.xml</U></B></U></A></FONT><B>.</B></div> <div> <B>11. American Academy of Dermatology Practice Management. Guidelines for care of primary cutaneous melanoma. Accessed online November 9, 2004, at: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.aadassociation.org/Guidelines/CutaneousMel.html" TARGET="_top" TITLE="http://www.aadassociation.org/Guidelines"><U><B><U>http://www.aadassociation.org/Guidelines/CutaneousMel.html</U></B></U></A></FONT><B>.</B></div> <div> <B>12. Ferrini RL, Perlman M, Hill L. American College of Preventive Medicine policy statement: screening for skin cancer. Am J Prev Med 1998;14: 80-2.</B></div> <div> <B>13. Ferrini RL, Perlman M, Hill L. American College of Preventive Medicine practice policy statement: skin protection from ultraviolet light exposure. The American College of Preventive Medicine. Am J Prev Med 1998;14:83-6.</B></div> <div> <B>14. National Cancer Institute. Skin cancer (PDQ): screening, health professional version. Accessed online March 11, 2005, at: http://cancer.gov/cancerinfo/pdq/screening/skin/healthprofessional.</B></div> <div> <B>15. Field MJ, Lawrence RS, Zwanziger L, eds., for the Institute of Medicine. Extending Medicare coverage for preventive and other services. Washington, D.C.: National Academy Press, 2000.</B></div> <div> <B>16. Feightner JW. Prevention of skin cancer. In: Canadian Task Force on the Periodic Health Examination. The Canadian guide to clinical preventive health care. Ottawa, Canada: Canada Communication Group-Publishing, 1994:850-9.</B></div> <div> <B>17. American Cancer Society. How is melanoma skin cancer found? Accessed online March 11, 2005, at: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_How_is_melanoma_skin_cancer_found_50.asp?sitearea=" TARGET="_top" TITLE="http://www.cancer.org/docroot/CRI/conten"><U><B><U>http://www.cancer.org/docroot/CRI/content/CRI_2_2_3X_How_is_melanoma_skin_cancer_found_50.asp?sitearea=</U></B></U></A></FONT><B>.</B></div> <div> <B>18. NIH Consensus Development Panel on Early Melanoma. Diagnosis and treatment of early melanoma. JAMA 1992;268:1314-9.</B></div> <div> <B>19. Rigel DS, Carucci JA. Malignant melanoma: prevention, early detection, and treatment in the 21st century. CA Cancer J Clin 2000;50:215-36.</B></div> <div> <B>20. Geller AC, Sober AJ, Zhang Z, Brooks DR, Miller DR, Halpern A, et al. Strategies for improving melanoma education and screening for men age >or= 50 years: findings from the American Academy of Dermatological National Skin Cancer Screening Program. Cancer 2002;95:1554-61.</B></div> <div> <B>21. Harbauer A, Binder M, Pehamberger H, Wolff K, Kittler H. Validity of an unsupervised self-administered questionnaire for self-assessment of melanoma risk. Melanoma Res 2003;13:537-42.</B></div> <div> <B>22. Schwartz JL, Wang TS, Hamilton TA, Lowe L, Sondak VK, Johnson TM. Thin primary cutaneous melanomas: associated detection patterns, lesion characteristics, and patient characteristics. Cancer 2002;95:1562-8.</B></div> <div> <B>23. Aitken JF, Elwood JM, Lowe JB, Firman DW, Balanda KP, Ring IT. A randomised trial of population screening for melanoma. J Med Screen 2002;9:33-7.</B></div> <div> <B>24. Berwick M, Begg CB, Fine JA, Roush GC, Barnhill RL. Screening for cutaneous melanoma by skin self-examination. J Natl Cancer Inst 1996;88:17-23.</B></div> <div> <B>25. Friedman RJ, Rigel DS, Kopf AW. Early detection of malignant melanoma: the role of physical examination and self-examination of the skin. CA Cancer J Clin 1985;35:130-51.</B></div> <div> <B>26. Whited JD, Grichnik JM. The rational clinical examination. Does this patient have a mole or a melanoma? JAMA 1998;279:696-701.</B></div> <div> <B>27. Balch CM, ed. Cutaneous melanoma. 3d ed. St. Louis: Quality Medical Publishing, 1998:89.</B></div> <div> <B>28. National Comprehensive Cancer Network. Clinical practice guidelines in oncology. Version 1.2004. Accessed online November 9, 2004, at: </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.nccn.org/professionals/physicians_gls/" TARGET="_top" TITLE="http://www.nccn.org/professionals/physic"><U><B><U>http://www.nccn.org/professionals/physicians_gls/</U></B></U></A></FONT><B>.</B></div> <div> <B>29. Lens MB, Dawes M, Goodacre T, Bishop JA. Excision margins in the treatment of primary cutaneous melanoma: a systematic review of randomized controlled trials comparing narrow vs wide excision. Arch Surg 2002;137:1101-5.</B></div> <div> <B>30. Balch CM, Soong SJ, Smith T, Ross MI, Urist MM, Karakousis CP, et al. Long-term results of a prospective surgical trial comparing 2 cm vs. 4 cm excision margins for 740 patients with 1-4 mm melanomas. Ann Surg Oncol 2001;8:101-8.</B></div> <div> <B>31. Balch CM, Soong S, Ross MI, Urist MM, Karakousis CP, Temple WJ, et al. Long-term results of a multi-institutional randomized trial comparing prognostic factors and surgical results for intermediate thickness melanomas (1.0 to 4.0 mm). Intergroup Melanoma Surgical Trial. Ann Surg Oncol 2000;7:87-97.</B></div> <div> <B>32. Morton DL, Wen DR, Wong JH, Economou JS, Cagle LA, Storm FK, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 1992;127:392-9.</B></div> <div> <B>33. Leong WL, Ghazarian DM, McCready DR. Previous wide local excision of primary melanoma is not a contraindication for sentinel lymph node biopsy of the trunk and extremity. J Surg Oncol 2003;82:143-6.</B></div> <div> <B>34. Blum A, Brand CU, Ellwanger U, Schlagenhauff B, Stroebel W, Rassner G, et al. Awareness and early detection of cutaneous melanoma: an analysis of factors related to delay in treatment. Br J Dermatol 1999;141:783-7.</B></div> <div> <B>35. Kirkwood JM, Strawderman MH, Ernstoff MS, Smith TJ, Borden EC, Blum RH. Interferon alfa-2b adjuvant therapy of high-risk resected cutaneous melanoma: the Eastern Cooperative Oncology Group Trial EST 1684. J Clin Oncol 1996;14:7-17.</B></div> <div> <B>36. Wheatley K, Ives N, Hancock B, Gore M, Eggermont A, Suciu S. Does adjuvant interferon-alpha for high-risk melanoma provide a worthwhile benefit? A meta-analysis of the randomised trials. Cancer Treat Rev 2003;29:241-52.</B></div> <div> <B>37. Balch CM, Soong SJ, Gershenwald JE, Thompson JF, Reintgen DS, Cascinelli N, et al. Prognostic factors analysis of 17,600 melanoma patients: validation of the American Joint Committee on Cancer melanoma staging system. J Clin Oncol 2001;19:3622-34.</B></div> <div> <B>38. Dessureault S, Soong SJ, Ross MI, Thompson JF, Kirkwood JM, Gershenwald JE, et al. Improved staging of node-negative patients with intermediate to thick melanomas (> 1 mm) with the use of lymphatic mapping and sentinel lymph node biopsy [published correction appears in Ann Surg Oncol 2002;9:318]. Ann Surg Oncol 2001;8:766-70.</B></div> <div> <B>39. Chang AE, Karnell LH, Menck HR. The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. Cancer 1998;83:1664-78.</B></div> <div> <B>40. Schmid-Wendtner MH, Baumert J, Wendtner CM, Plewig G, Volkenandt M. Risk of second primary malignancies in patients with cutaneous melanoma. Br J Dermatol 2001;145:981-5.</B></div> <div> <B>41. Goggins WB, Tsao H. A population-based analysis of risk factors for a second primary cutaneous melanoma among melanoma survivors. Cancer 2003;97:639-43.</B></div> <div> <B>42. U.S. Preventive Services Task Force. Counseling to prevent skin cancer: recommendations and rationale. Rockville, Md.: Agency for Healthcare Research and Quality, 2003. Accessed online November 9, 2004, at: f/skcacoun/skcarr.htm" </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><A HREF="http://www.ahrq.gov/clinic/3rduspst" TARGET="_top" TITLE="http://www.ahrq.gov/clinic/3rduspst"><U><B><U>http://www.ahrq.gov/clinic/3rduspstf/skcacoun/skcarr.htm</U></B></U></A></FONT><B>.</B></div> <div> <B>43. Saraiya M, Glanz K, Briss P, Nichols P, White C, Das D. Preventing skin cancer: findings of the Task Force on Community Preventive Services on Reducing Exposure to Ultraviolet Light. MMWR Recomm Rep 2003;52(RR-15):1-12.</B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="554" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER HEIGHT= 183 WIDTH="550"><bR> <div> <B>Copyright © 2005 by the American Academy of Family Physicians.</B></div> <div> <FONT SIZE="3" COLOR="#66334C" FACE="Arial Unicode MS Western" ><B>This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his o</B></FONT><B>r her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact  "mailto:afpserv@aafp.org" </B><FONT SIZE="3" COLOR="#0000FF" FACE="Arial" ><B><U>afpserv@aafp.org</U></B></FONT><B> for copyright questions and/or permission requests.</B></div> </tD> </tR> </TABLE></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <A HREF="http://www.aafp.org/afp/20050715/contents.html" TARGET="_top" TITLE="http://www.aafp.org/afp/20050715/content"><U><U>July 15, 2005 Contents</U></U></A><FONT SIZE="3" COLOR="#660099" FACE="Arial" > | </FONT><A HREF="http://www.aafp.org/afp" TARGET="_top" TITLE="http://www.aafp.org/afp"><U><I><U>AFP</U></I></U></A><A HREF="http://www.aafp.org/afp" TARGET="_top" TITLE="http://www.aafp.org/afp"><U><U> Home Page</U></U></A><FONT SIZE="3" COLOR="#660099" FACE="Arial" > | </FONT><A HREF="http://www.aafp.org/" TARGET="_top" TITLE="http://www.aafp.org/"><U><U>AAFP Home</U></U></A><FONT SIZE="3" COLOR="#660099" FACE="Arial" > | </FONT><A HREF="http://search.aafp.org/" TARGET="_top" TITLE="http://search.aafp.org/"><U><U>Search</U></U></A></div> <bR> <div> <IMG SRC="35104040.png" border=0 width="4" height="4" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> </tD> </tR> </TABLE></div> <bR> </NOBR></tD> </tR> </TABLE></div> <bR> </NOBR></tD> </tR> </TABLE></div> <bR> </NOBR></tD> </tR> </TABLE></div> <bR> <div> <IMG SRC="373140f0.png" border=0 width="20" height="15" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></div> <bR> <bR> </td> </tr></table></body>