YOUNG ADULTS YOUNG ADULTS (20 - 35 YEARS)

A large number of reach their peak of expression during the young adult years, and these individuals also represent a large and growing proportion of the South African population, in common with other developing countries.

Young adults are especially distressed by skin conditions that are uncomfortable, disfiguring or contagious. This group has also been severely affected by HIV/AIDS, with a consequent increase in the frequency and severity of the HIV- associated dermatoses. Some of these conditions have been discussed in other sections of this review.

ACNE KELOIDALIS

Inflammatory and pustules located mainly on the nape of the neck and occiput characterise this -like condition. It primarily affects black males. The lesions heal with scarring, creating huge if this tendency exists. The cause is unknown, and unlikely to result from repeated shaving or short hair cutting. It DENGA A MAKHADO may be caused by unusually thick collagen, which traps and disrupts terminal MB ChB, FCDerm (SA) hair follicles. Treatment is not very successful, and large keloids are best excised Consultant Dermatologist by a surgeon. Mild cases can be helped by intralesional injection of steroids like

Division of Celestone Soluspan into individual papules and scars. Long-term oral tetracy- clines, as for acne, can also be beneficial, as can topical like erythro- University of the Witwatersrand and mycin and . Chris Hani Baragwanath Hospital Johannesburg ACNE VULGARIS

Denga Anna Makhado is a consultant der- There has been a recent tendency for acne to persist beyond the teens, or even matologist at Chris Hani Baragwanath occur for the first time in adulthood, called persistent adult acne. Adult acne has the same pathogenesis as ordinary acne, but is often more resistant to treatment; Hospital and the University of the individuals are also less likely to leave the condition untreated. The principles of Witwatersrand. She is also in private prac- treatment are as for teenage acne. It is important to exclude drug causes such as tice in Johannesburg. She was a general , phenytoin and other anticonvulsants, steroids and cyclosporin. practitioner for 5 years prior to specialis- Widespread misuse of potent creams for acne and other facial ing. conditions will aggravate acne in the long term, and cause other side-effects like atrophy and .

CHLOASMA

This is an acquired tan-brown symmet- rical discolouration of facial skin on the , nose, cheeks, upper lip and chin (Fig. 1). It is much more com- mon in women, and is thought to be due to a combination of sun exposure and hormonal changes such as preg- nancy and hormonal contraceptives. It is darker and more disfiguring on dark- er . Chloasma is very difficult to treat: sun avoidance and strong sun- screens are important to prevent wors- ening of the condition. Bleaching agents like 2 - 4% are widely used. There are many propri- etary compounds that contain mild bleaches: kojic acid, vitamin C and Fig. 1. Chloasma.

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liquorice extract. Retinoid creams like to allergic contact , con- tretinoin (Renova, Retin-A), azelaic firmed on patch tests. The condition acid (Skinoren) and glycolic acid can also be triggered by psychogenic products can also be tried. In fair- factors like stress, but this is difficult to skinned people, certain prove. Finally dyshidrotic eczema can devices can alleviate chloasma. be an allergic reaction to a distant focus of fungal , especially CONDYLOMATA ACUMINATA tinea pedis, giving rise to the id reac- tion. All types tend to be resistant to These are genital caused partic- therapy, and a treatable cause gives ularly by human papillomavirus (HPV), the best results. Failing this, milder types 6 and 11. They appear initially cases should be treated with a potent as small, raised, flesh-coloured or pale topical steroid cream like clobetasol papules with an irregular surface, on propionate or mometasone, together the skin or mucous membranes of the with a course of oral antibiotics. More penis, , , anus and sur- severe cases are better treated with a rounding areas (Fig. 2). Infection can Fig. 3. Discoid erythematosus. short course of oral steroids, such as be latent or subclinical, enhancing the 20 - 60 mg daily for 5 - risk of unexpected spread. Without trally leaving depigmentation (Fig. 3). 10 days. prompt treatment, or in the presence Plaques on the are associated of , the lesions can with scarring alopecia, which is per- grow to a huge size, obscuring the manent. The diagnosis is normally con- normal anatomy. There is also firmed on , and SLE is increased risk of malignancy, especial- excluded through history and examina- ly carcinoma of the cervix, and squa- tion and testing for antinuclear anti- mous carcinoma of the genital skin. body (ANA), although this may be Treatment is generally difficult and the positive in low titre with DLE. The con- principles are the same as in dition is more common with HIV. DLE (see article on infants, pp.). is resistant to therapy, and the result- ant scarring is permanent. Mild cases are treated with sun avoidance, sun- screens and potent topical steroids: clobetasol (Dermovate, Dovate) or betamethasone dipropionate (Diprosone, Diprolene). More exten- sive cases are treated with low to medium doses of systemic steroids: prednisone, together with chloroquine (remember retinal toxicity).

Fig. 4. Dyshidrotic eczema. DYSHIDROTIC ECZEMA Fig. 2. Condylomata acuminata — perianal. This common and potentially severe DYSPLASTIC NAEVI form of dermatitis affects the hands and feet, but can spread. It starts with These are acquired melanocytic naevi DISCOID LUPUS intensely itchy small vesicles on the (moles) that are larger than usual and ERYTHEMATOSUS (DLE) palms and/or soles, and the sides of slightly irregular in shape, border and the fingers or toes (Fig. 4). These colour, with features suggestive of This form of lupus erythematosus is not enlarge, coalesce and rupture to leave (Fig. 5). They increasingly uncommon, mainly affecting women. red, fissured, scaly and painful areas. appear from the late teens into the In most cases the condition occurs The condition usually occurs intermit- twenties, often with a family history of independently of systemic lupus erythe- tently, but can persist. Dyshidrotic similar moles. Sun exposure probably matosus (SLE), but can occur as part eczema can represent hand and foot plays a major role in converting a of, or progress to, SLE. Typical lesions involvement in , when benign melanocytic naevus into a dys- start as itchy, painful, reddish, scaly the usual trigger is a contact irritant plastic naevus. Their natural history is swellings or plaques on sun-exposed such as frequent hand washing, not clear, but some may become areas: the , lips, chest, upper soaps, detergents and solvents. It can melanomas, hence the importance back and hands. The lesions heal cen- also occur independently and be due attached to these lesions. Some recom-

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mend elective removal of all suspected lococcal antibiotics like cloxacillin can 250 mg bd. HIV or another cause of dysplastic naevi, but this is seldom also be used. Another type is caused immune suppression results in progres- practical. Regular examination is pru- by a commensal , , sion to painful, chronic ulcers. dent, often by means of epilumines- and presents as itchy follicular papules cence microscopy (Molemax machine), and pustules on the upper chest, back to highlight more suspicious lesions, or and arms (Fig. 6). This is best diag- those which are changing: these are nosed on biopsy, and is treated with then excised surgically. like (Nizshampoo) or econazole (Pevaryl foaming solution), or with oral antifun- gals like (Sporanox). This fungal , also known as pity- rosporum folliculitis, can closely resem- Fig. 7. . ble acne. Another type of folliculitis occurs exclusively in HIV infection, and is due to eosinophil infiltration of the follicle. This so-called Hyperhidrosis is excessive sweating, eosinophilic folliculitis is exceptionally objectively apparent and which inter- itchy, and untreatable. Fortunately the feres with daily activities, usually on condition usually remits spontaneously. the palms, soles and axillae and trig- Potent topical steroids, , gered by heat, stress or anxiety, and B photother- although there may be no obvious apy may help. All types of folliculitis stimulation. Hyperhidrosis can cause are more common in HIV, and follow- loss of confidence, and , ing cancer chemotherapy. and should not be trivialised. A simple but effective treatment of axillary hyperhidrosis is aluminium chloride hexahydrate antiperspirant roll-on Fig. 5. Dysplastic naevi. Human herpesviruses 1 and 2 cause (Driclor). Irritation and contact der- the common cold sore (recurrent labial matitis are possible side-effects. An FOLLICULITIS herpes) and genital herpes. Frequent effective and long-lasting alternative is recurrences are a hallmark of the con- Botox injection. Palmoplantar hyper- Folliculitis occurs when small pustules dition, often with 2 - 4 attacks per hidrosis is treated with either ion- occur within the hair follicles covering month. Each attack is preceded by tophoresis (galvanic current applied to most of the skin (vellus hairs). One mild paraesthesia, followed by the hands and/or feet immersed in water), type of folliculitis is a simple superfi- appearance of grouped erythematous Botox injection or sympathectomy, cial bacterial infection of the hair, papules, vesicles and pustules in the generally laparoscopic and successful. mainly with . nasolabial or genital region (Fig. 7), However, compensatory hyperhidrosis This is usually mild and self-limiting, which crust and resolve in a few days. at distant sites can occur as a compli- and can be triggered by friction, shav- Triggers include sun exposure, trauma, cation of sympathectomy. ing, waxing or scratching. More fever, menstruation and stress. severe cases are treated with a topical Antiviral creams like acyclovir KAPOSI’S SARCOMA like (Bactroban (Zovirax, Activir) can be helpful if cream), (Fucidin cream), applied early and often. Antiviral This vascular neoplasm due to prolifer- (Ilotycin, Zineryt) or clin- tablets like acyclovir (Zovirax, Lovire ation of abnormal endothelial cells has damycin (Dalacin T). Oral antistaphy- and many other generics) 200 mg become distressingly common in 5 times daily for 5 days will shorten young HIV-positive adults, whereas it the length and severity of the attack. was previously seen as a of Alternatives include valacyclovir the middle-aged, or those on immuno- (Zelitrex) 500 mg bd for 5 days and suppressive therapy for renal trans- famciclovir (Famvir) 125 - 250 mg tds plants. It presents insidiously as pur- for 5 days. Preventive therapy with plish macules, patches and plaques long-term oral antivirals can be used if anywhere on the skin surface, but usu- necessary, and will inhibit transmis- ally affects the face or lower extremi- sion. Titrate down to the lowest effec- ties. These progress into indurated tive dose which suppresses outbreaks: plaques and nodules, and lesions can acyclovir 200 - 400 mg bd, valacy- coalesce into huge fungating masses clovir 500 mg daily, famciclovir 125 - with associated severe lymphoedema Fig. 6. Pityrosporum (fungal) folliculitis.

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sition to keloids. Occasionally they water. Shallow pits occur on a macer- occur without any antecedent trauma, ated background; a foul odour is particularly on the chest or breasts. apparent (Fig. 10). Usually asympto- Treatment is difficult, and small lesions matic, the condition can coexist with are generally injected with potent tinea pedis. The major organism impli- steroids like Celestone Soluspan. Large cated is a species of . lesions can be excised, but adjuvant Treatment includes attention to predis- therapy like steroid injection or a short posing factors, together with oral or Fig. 8. Kaposi’s sarcoma. course of radiation is needed to pre- topical antibiotics like erythromycin, vent recurrence, which can be worse clindamycin or fusidic acid. Imidazole (Fig. 8). Lesions are often painful and than the original condition. Silicone antifungal creams are also effective can involve mucous membranes caus- sheets (Cica-care) applied for several because of their Gram-positive anti- ing impaired function. Flexion contrac- hours daily can prevent or improve bacterial action. tures of limbs are frequent. Internal some keloids. organ involvement is common, even in ROSEA the absence of skin lesions, and is a self-limiting papu- includes lymph nodes, lung, gastroin- Erythematous papules, tiny pustules losquamous eruption of presumed viral testinal tract and bone marrow. Organ and scaling occur around the mouth, origin, primarily affecting young involvement eventually causes death. spreading to the nasolabial fold, usu- adults. Commoner at season change, Kaposi’s sarcoma can occur at any ally in healthy young women, resem- the starts with an annular, scaly, stage of HIV infection, sometimes even bling acne and . erythematous patch resembling ring- in the absence of profound immuno- Cosmetics, toothpaste, steroid creams worm, usually on the trunk. Several suppression. Skin biopsy confirms the and emotional stress have all been weeks later a disseminated eruption diagnosis, and treatment depends on implicated in the aetiology. Treatment occurs, consisting of small pinkish extent, severity, general condition and with any oral such as macules and papules that form oval symptoms caused by the neoplasm. tetracycline HCl 500 mg bd, lymecy- scaling patches. These patches lie par- Localised symptomatic disease cline (Tetralysal) 300 mg daily, doxy- allel to the skin creases, mainly on the responds best to irradiation, and wide- cycline 100 mg daily or trunk and proximal extremities, in the spread disease, or internal organ 100 mg daily for a few months is so-called fir tree distribution (Fig. 11). involvement, is treated with chemother- effective. Alternatives include topical apy. Unless the underlying HIV is treat- antibiotics like erythromycin, clin- ed with antiretrovirals the treatment is damycin and . at best palliative. Kaposi’s sarcoma is closely, and perhaps causally, associ- ated with human herpesvirus 8 infec- tion. Pitted keratolysis is a bacterial infec- tion of the weight-bearing areas of the soles. Predisposing factors are male sex, occlusive footware, excessive Keloids are scars that proliferate sweating and frequent contact with beyond the original site of injury or Fig. 11. Pityriasis rosea. burn. These itchy and often painful lesions are commonest in sites exposed to continuous straining forces, The whole eruption, which may be such as the upper chest, back and pruritic, lasts about 2 months. arms. They are also common on the Postinflammatory pigmentation can face and earlobes (Fig. 9). There is a occur in darker skinned individuals. strong hereditary and racial predispo- Pityriasis rosea might be caused by human herpesvirus 7. No specific ther- apy is required, but topical steroid creams can help the itching, and sun exposure is said to hasten resolution.

PITYRIASIS VERSICOLOR

This superficial fungal infection is caused by the commensal yeast Fig. 9. Keloid — chest. Fig. 10. Pitted keratolysis. . The condition is

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characterised by fine scaling brownish Relatively intense UV exposure is usu- PSEUDOFOLLICULITIS and whitish macules that coalesce into ally required to evoke PLE, e.g. during large patches, affecting mainly the a beach holiday. Avoidance of further Close shaving of coarse, curly hair upper trunk and neck (Fig.12). Mild sun leads to spontaneous healing with- causes the hair to bend and penetrate itching may be present. Tanning of the out scarring. Chronically sun-exposed the skin as it grows, causing a foreign infected skin is inhibited, which may parts are seldom affected by PLE, body-type reaction with inflamed take months to repigment, even after which targets mainly the chest, back papules and pustules characteristic of treatment. Its other name is ‘beach fun- and forearms. An important differen- pseudofolliculitis. The condition closely gus’ since it is often noticed after tan- tial diagnosis is lupus erythematosus. mimics staphylococcal folliculitis, but is ning. PLE can be prevented with very strong, not an infection. The most common site broad-spectrum sunscreens, and indi- is the beard, but other regions with vidual lesions are improved with coarse terminal hair can be affected. potent topical steroid creams. The con- Pseudofolliculitis occurs primarily in dition tends to improve with age. black men. The lesions resolve with often disfiguring postinflammatory pig- mentation. Treatment is aimed at avoiding close shaves, using older This type of porphyria has become types of single-blade razors rather predominant in South Africa, because than newer multiblade devices. Electric razors are sometimes preferred. Fig. 12. Pityriasis versicolor — whitish it is associated with HIV infection. patches. Some cases are inherited, but most Ingrowing portions of hairs should be are acquired and due to liver dysfunc- gently extracted with a needle, and A variety of treatments are successful, tion associated with either iron over- the hair cut with scissors. Acne-type but the condition tends to recur. load, hepatitis C infection, alcoholic therapy with and Antifungal shampoos like Nizshampoo liver disease, SLE or HIV. There is an oral may give some and Pevaryl foaming solution are defect in the hepatic haem relief, and 1% cream applied to the whole upper trunk and pathway, and porphyrins accumulate can be used as well. If possible shav- scalp. They can be left on overnight or in the skin, giving rise to reactive oxy- ing should be avoided, but this is rinsed off after 10 minutes, depending gen molecules on exposure to light. often difficult. Definitive therapy is on the severity of the infection. The Sun-exposed areas, the face and dor- laser epilation. treatment is repeated a few times. sal surface of the hands, are dam- Antifungal sprays like aged, causing fragility of skin with (Lamisil spray) or imidazole creams , scars and milia. Diffuse hyper- These benign tumours composed of can also be used. Oral treatment with pigmentation and granulation tissue usually follow a itraconazole (Sporanox) 200 mg daily (excessive facial hair) occur and the minor injury, and occur especially on for 1 week or ketoconazole (Nizoral, skin has a weather-beaten look (Fig. the lips, fingers and face. A rapidly Ketazol) 200 mg daily for 10 days is 13). growing exudative, exophytic, reddish simple and effective. Older treatments tumour occurs, which bleeds on the include 2% sulphur in aqueous cream slightest rubbing (Fig.14). The lesions or sulphide do not resolve spontaneously, and (Selsun). Selsun is particularly useful should be removed by curettage and as a prophylactic regimen in cases of electrodesiccation, or by surgical exci- frequent recurrence: the scalp and sion. Histology should always be upper trunk are treated once or twice obtained, as amelanotic monthly by applying the foamed sham- and Kaposi’s sarcoma can present in poo for 10 minutes before rinsing. Fig. 13. Porphyria cutanea tarda. a similar way. POLYMORPHIC LIGHT ERUPTION (PLE) The diagnosis is confirmed by high porphyrin levels in urine. Unless the Polymorphic light eruption is the com- original liver disease is treatable, the monest idiopathic photodermatosis condition tends to be persistent. worldwide, with a prevalence estimat- Avoiding sun and mechanical trauma ed at 10 - 20%. Usually affecting to the skin are important. Multivitamins women, there is often a family history. and chloroquine have been beneficial Itchy, erythematous papules and vesi- in some cases. cles occur in certain sun-exposed sites Fig. 14. Pyogenic granuloma. a few days after sun exposure.

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PYODERMA GANGRENOSUM The , glabellar, nasolabial, paranasal and perioral regions of the gangrenosum is a severe face are mostly affected. The eruption disease where large painful ulcers can be acute, weeping and secondari- occur spontaneously at any site on the ly infected on occasions, especially on skin, usually on the leg, starting as the scalp. Seborrhoeic dermatitis is a pustules which ulcerate and extend chronic disease that remits and relaps- peripherally. The edge is violaceous es throughout the adult years; it is and undermined (Fig.15). The ulcers exacerbated by cold weather, stress do heal slowly, but new ones occur. and intercurrent illness. In the setting Fig. 16. Secondary . This is a clinical diagnosis, as histo- of HIV infection seborrhoeic dermatitis logical findings are nonspecific; how- is much more common, and also more Secondary syphilis can mimic guttate ever, other causes of cutaneous ulcera- severe. Mild cases are treated with , pityriasis rosea and lichen tion need to be excluded. mild topical steroid creams like 1% planus. Any suspicion should be con- Approximately 50% of cases are asso- hydrocortisone (Procutan), or slightly firmed with serological testing for ciated with an underlying disease, stronger agents like hydrocortisone syphilis, which will invariably be posi- particularly inflammatory bowel dis- butyrate (Locoid), clobetasol butyrate tive in secondary syphilis. Treatment ease, rheumatoid arthritis and lympho- (Eumovate), ace- consists of benzathine penicillin 2.4 proliferative disorders. Treatment is dif- ponate (Advantan) or diluted million units IMI weekly x 3. ficult, and consists largely of high- betamethasone valerate (Betnovate, dose oral . Other agents Persivate, Lenovate). Signs of dermati- SYRINGOMA used include cyclosporin and thalido- tis disappear rapidly, but recur when These small, flesh-coloured papules mide. the cream is stopped. Adjuvant thera- occur around the eyes, and are of cos- py with a non-irritating cleanser to metic importance only (Fig. 17). They remove excessive oil from the face is may be confused with xanthelasmata, helpful. Alternatives to steroid creams which are a yellowish colour. include sulphur preparations and anti- fungal creams like the imidazoles (ketoconazole, econazole, clotrima- zole). Weeping dermatitis is treated with oral antibiotics and a short course of oral steroids. Scalp involve- ment is treated in mild cases with any of the proprietary antidandruff sham- poos, including tar, selenium, and antifungal shampoos. Fig. 17. Syringomata. More severe scalp disease warrants a steroid scalp application such as Reassurance is the best advice, but the Locoid crelo, Elocon lotion, Advantan lesions can be excised if desired. scalp solution or Synalar gel.

SECONDARY SYPHILIS TINEA PEDIS Tinea pedis or athlete’s foot occurs Secondary syphilis occurs 2 - 6 months Fig. 15. Pyoderma gangrenosum. between the toes or on the soles of the after the primary without treat- feet. It is caused mainly by ment, resulting from haematogenous rubrum and Trichophyton SEBORRHOEIC DERMATITIS dissemination of . mentagrophytes. The condition pres- Associated HIV infection accelerates ents as itchy or painful scaling, macer- This is one of the commonest forms of this progression. Skin manifestations ation and fissuring in the toe webs, dermatitis worldwide, and in its are protean, and occur in 80% of especially the 4th webspaces. mildest forms includes all cases of cases. Widely distributed brownish Infection can spread to the soles and itchy . Men are more often red scaling papules occur, also involv- sides of the feet as a red, scaly erup- affected than women. Sites of predilec- ing the palms and soles (Fig. 16). tion. Another type of tinea pedis caus- tion are those rich in sebaceous Later more isolated round, dark lesions es small, inflamed blisters on the soles glands, such as the scalp, face, upper with raised edges occur at certain or between the toes (Fig.18). Tinea chest and back. On a greasy back- sites, especially around the mouth. pedis must be differentiated from mac- ground, and yellowish scales Moist, -like plaques occur on the erated soft corns, and occur. Itching is mild or not present. genitalia — condylomata lata.

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dyshidrotic foot eczema. Diagnosis is like streptococcal pharyngi- confirmed through mycological exami- tis can also cause acute urticaria, nation of foot scrapings. Tinea pedis especially in children. This responds responds well to a variety of treat- well to antibiotics. Urticaria which ments, but is often recurrent. Risk fac- becomes recurrent over many weeks tors include shared ablutions, use of and months is termed chronic communal swimming pools, occlusive urticaria. The causes are usually differ- footware, humid environments and ent from those of acute urticaria, and coexistent conditions like varicose in most cases remain unknown. veins or diabetes. Terbinafine cream Presumed causes include chronic bac- (Lamisil) is a popular treatment, terial infection, especially of the teeth, applied once or twice daily for a few tonsils, throat or sinuses, recurrent uri- weeks. Any of the imidazole antifun- nary tract infections, hepatitis B and gal creams like ketoconazole HIV, scratching (dermographism) (Fig. (Nizcreme), econazole (Pevaryl) or 19), pressure, water, cold, sweating (Canesten) can also be or sun exposure, bilharzia and intestin- used. More severe cases are treated al worms, autoimmune diseases, with oral antifungals like ketoconazole haematological malignancy or lym- (Nizoral, Ketazol), phoma, drug and food allergies and (Diflucan, Fluzol, Flucoric), itracona- emotional stress. It is important to note zole (Sporanox) or terbinafine that most cases of chronic urticaria are (Lamisil). is very effective, not allergic. If a cause is found and but high doses are needed. Severe, treated, the urticaria may disappear. neglected tinea pedis can become sec- Symptomatic treatment is still required. ondarily infected with mixed organ- isms, and this responds best to regular soaking of the feet in diluted potassi- um permanganate solution.

Fig. 19. Dermographism.

If no cause is forthcoming the condi- tion is labelled chronic idiopathic Fig. 18. Vesicular tinea pedis. urticaria, and treatment is purely symptomatic and suppressive. URTICARIA Antihistamines remain the mainstay of therapy, and a trial-and-error Urticaria is characterised by transient, approach is recommended until the itchy weals or that tend to last right agent is found. Both older, sedat- less than 24 hours. Mucous membrane ing and newer non-sedating agents involvement, angioedema, can be can be tried, sometimes in combina- potentially dangerous. Weals can tion. Look out for interactions between occur anywhere and are often of antihistamines and other drugs. Oral bizarre or annular shape, healing with corticosteroids are also effective, and no secondary changes. Acute urticaria can be used for short-term control. is usually caused by allergies to food, Unresponsive chronic idiopathic medicine or insect stings, and is best urticaria can be treated with ketotifen, managed in medical emergency units cyclosporin or psoralen plus ultraviolet because of the risk of laryngeal A phototherapy (PUVA). angioedema or anaphylaxis. Bacterial

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