DOCSLIB.ORG

Atopic Eczema with Detail on How to Apply Wet Wraps

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Atopic Eczema with Detail on How to Apply Wet Wraps Atopic Eczema with detail on how to apply wet wraps Dr Carol Hlela Consultant Dermatologist Head of Unit, Department of Dermatology, Paediatrics Red Cross Children’s Hospital, UCT Red Cross War Memorial Children’s Hospital The many “FACIES” of Atopic Eczema Very dry skin-may be an early manifestation of AE Prophylactic Moisturisation • Full body application of moisturisers for 6-8 months beginning in the first month of life for high risk infants showed a cumulative reduced incidence of AD J Allergy Clin Immunology.2014 Oct; (134(4):818-23 J Allergy Clin Immunology.2014 Oct; (134(4):824-830.e6. The many “FACIES” of Atopic Eczema The many “FACIES” of Atopic Eczema Infant phase(birth to 2 years) • face, scalp, extensors of limbs • cheeks, spares perioral and perinasa • chin, cheilitis • spares nappy area AE distribution evolve over months/years You can objectively confirm AE, using the UK working party criteria You can objectively confirm AE, by searching for Signs (stigmata) of cutaneous atopy The many “FACIES” of Atopic Eczema The many “FACIES” of Atopic Eczema Management principles – AE (to control the disease) Education Soap substitutes Optimal topical care (emollients) Specific therapy: corticosteroids / calcinuerin inhibitors Antihistamines systemic therapy –e.g. Azathioprine, Methotrexate ultraviolet light therapy Education in AE • Work with patients and parents as a team. – Education – Written instructions – Address steroid phobia Avoiding triggers • Soaps ( use emollient wash products) • Bubble baths • Woolen or rough fabric clothes • Fragrances • Aggressive antiseptics • Shampoos with high content sodium lauryl sulphate • ?cats • Sweat (use wet wraps) • Dry climates (increase frequency of moisturizing) Atopic Eczema - a chronic skin disease Bathing Practice • Bath/ shower once a day in warm (not hot) water • Avoid soap • Use a soap substitute such as aqueous cream – bath oils, liquid paraffin • Pat dry Moisturisers Basis of management Should be used continuously even when skin is clear • ?Ideal moisturiser: unperfumed, low pH • Guided by patients needs and preferences – Emulsifying ointment or cetomacrogol or Vaseline – Avoid aqueous cream • Applied frequently, after bathing and swimming • Within 3 min of a luke warm bath or shower • Prescribed in large quantities (250g/wk) Topical corticosteroids Mainstay of pharmacological treatment vast majority respond very rapidly to adequate topical steroid treatment But: -need adequate quantities -need correct potency (mid to high potent) -steroid phobia -applied for maximum 2 weeks, before side effects occur Prescribing topical steroids -Vehicle: Ointment – dry eczema Lotion- wet eczema or scalp Creams – wet eczema or eczema in folds Gel - scalp and wet eczema Quantity Do not under-prescribe! Prescribing topical steroids • Once daily as effective as twice daily • Acute flare: – Intermittent use 7-14 days with emollient only “steroid holidays” – Short bursts may be needed for flares – Start potent , wean down • Maintenance: – Least potent that controls disease – “weekend therapy” Topical calcineurin inhibitors • Not cause skin atrophy • Pimecrolimus 1% (Elidel) is approved for mild AD, less effective than betamethasone • Tacrolimus (0.03%) is superior • May be useful for face, periorbital and intertriginous areas Adjuvant therapy-in AE NICE UK GUIDELINES The many “FACIES” of Atopic Eczema Benefits- Wet wrap therapy • Ancient practice - in Babylon and Egypt • To cool skin, anti-inflammatory, itch reduction • For severe , refractory AD • Safe and effective • Biggest barrier: it’s time consuming Side effects- Wet wrap therapy • Increased infectious complications- folliculitis, impetigo, herpes • Skin atrophy, striae, easy bruising, hypopigmentation, telangiectasia, steroid acne, steroid rosacea, hirsutism, contact dermatitis • Rare: suppression of HPA axis, growth retardation, cataracts, glaucoma, tachyphylaxis, Cushing's Conclusions • there are many facies of atopic eczema • intervene appropriately depending on the stage of AE • the vast majority will respond to optimal topical care – Emollients – Topical corticosteroids/TCIs • moderate-severe AE require WWT -acute intervention • WWT should be considered as a treatment option ahead of systemic immunosuppressives.
Load more

Recommended publications
  • Designing a Campaign on Topical Steroids Misuse
    Ministry Of Higher Education University Of Al-Qadysiah And Scientific Research College Of Pharmacy Designing a Campaign On Topical steroids misuse By: Hussein A. Abdulwahab Ali H. Abd Zaid Supervised By: Dr. Hussein A. Sahib 1 بسمميحرلا نمحرلا هللا ۞ َوقُ ْم َر ِّة ِز ْدَِي ِع ْه ًًب ۞ صدق هللا العظيم 2 List of subjects : Dedication 4 Aim 4 Chapter one : introduction 5 Potency 8 Adverse effects 10 Study on topical steroids 18 Chapter tow : methodology 19 Chapter three : 22 Conclusion discussion recommendations References 25 3 Dedication : We dedicate this work to our families and to the Iraqi army Aim : Is to make a campaign that raise awareness on topical steroids’ misuse and side effects 4 Chapter One Introduction 5 1.1 Introduction 1.1.1 Corticosteroids: Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids , are involved in a wide range of physiologic processes, including stress response, immune response, and regulation of inflammation, carbohydrate metabolism, protein catabolism, blood electrolyte levels, and behavior.[1] Some common naturally occurring steroid hormones are cortisol (C21H30O5), corticosterone (C21H30O4), cortisone (C21H28O5) and aldosterone (C21H28O5). (Note that aldosterone and cortisone share the same chemical formula but the structures are different.) The main corticosteroids produced by the adrenal cortex are cortisol and aldosterone. [2] 1.1.2 Topical steroids: The introduction of topical corticosteroids (TC) by Sulzberger and Witten in 1952 is considered to be the most significant landmark in the history of therapy of dermatological disorders.[3] This historical event was gradually, followed by the introduction of a large number of newer TC molecules of varying potency rendering the therapy of various inflammatory cutaneous disorders more effective and less time consuming.
    [Show full text]
  • Pathological Investigation of Rosacea with Particular Regard Of
    CORE Metadata, citation and similar papers at core.ac.uk Provided by White Rose E-theses Online A Clinico-Pathological Investigation of Rosacea with Particular Regard to Systemic Diseases Dr. Mustafa Hassan Marai Submitted in accordance with the requirements for the degree of Doctor of Medicine The University of Leeds School of Medicine May 2015 “I can confirm that the work submitted is my own and that appropriate credit has been given where reference has been made to the work of others” “This copy has been supplied on the understanding that it is copyright material and that no quotation from the thesis may be published without proper acknowledgement” May 2015 The University of Leeds Dr. Mustafa Hassan Marai “The right of Dr Mustafa Hassan Marai to be identified as Author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988” Acknowledgement Firstly, I would like to thank all the patients who participate in my rosacea study, giving their time and providing me with all of the important information about their disease. This is helped me to collect all of my study data which resulted in my important outcome of my study. Secondly, I would like to thank my supervisor Dr Mark Goodfield, consultant Dermatologist, for his continuous support and help through out my research study. His flexibility, understanding and his quick response to my enquiries always helped me to relive my stress and give me more strength to solve the difficulties during my research. Also, I would like to thank Dr Elizabeth Hensor, Data Analyst at Leeds Institute of Molecular Medicine, Section of Musculoskeletal Medicine, University of Leeds for her understanding the purpose of my study and her help in analysing my study data.
    [Show full text]
  • Folliculitis-It's More Than Acne!
    Paul K. Shitabata, M.D. Dermatopathology Institute Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 SAPHO Syndrome Synovitis Acne Pustulosis Hyperostosis Osteitis Thursday, May 23, 13 Acne Conglobata Severe form of acne characterized by burrowing and interconnecting abscesses and irregular scars Chest, shoulders, back, buttocks, upper arms, thighs, and face Sudden deterioration of existing active papular or pustular acne Recrudescence of quiescent acne Thursday, May 23, 13 Chloracne Toxic chemicals exposure (dioxins) Few months after swallowing, inhaling or touching Occupational exposure, enviromental poisoning Ukrainian President Victor Yushchenko Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Histopathology Folliculitis with varying degrees of the following depending upon the stage and temporal progression Telangiectasia Sebaceous hyperplasia Fibrosis Granulomas Thursday, May 23, 13 Disease Associaons of Acne Rosacea Steroid rosacea HIV-1 Pyoderma faciale Perioral dermatitis Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Histopathology Hair shaft infiltrated by fungal yeast and hyphae May have epidermal involvement Suspect with acute suppurative folliculitis Woods lamp negative PAS/GMS to confirm T. tonsurans most common Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May 23, 13 Thursday, May
    [Show full text]
  • Steroid-Induced Rosacealike Dermatitis: Case Report and Review of the Literature
    CONTINUING MEDICAL EDUCATION Steroid-Induced Rosacealike Dermatitis: Case Report and Review of the Literature Amy Y-Y Chen, MD; Matthew J. Zirwas, MD RELEASE DATE: April 2009 TERMINATION DATE: April 2010 The estimated time to complete this activity is 1 hour. GOAL To understand steroid-induced rosacealike dermatitis (SIRD) to better manage patients with the condition LEARNING OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Explain the clinical features of SIRD, including the 3 subtypes. 2. Evaluate the multifactorial pathogenesis of SIRD. 3. Recognize the importance of a detailed patient history and physical examination to diagnose SIRD. INTENDED AUDIENCE This CME activity is designed for dermatologists and generalists. CME Test and Instructions on page 195. This article has been peer reviewed and approved Einstein College of Medicine is accredited by by Michael Fisher, MD, Professor of Medicine, the ACCME to provide continuing medical edu- Albert Einstein College of Medicine. Review date: cation for physicians. March 2009. Albert Einstein College of Medicine designates This activity has been planned and imple- this educational activity for a maximum of 1 AMA mented in accordance with the Essential Areas PRA Category 1 Credit TM. Physicians should only and Policies of the Accreditation Council for claim credit commensurate with the extent of their Continuing Medical Education through the participation in the activity. joint sponsorship of Albert Einstein College of This activity has been planned and produced in Medicine and Quadrant HealthCom, Inc. Albert accordance with ACCME Essentials. Dr. Chen owns stock in Merck & Co, Inc. Dr. Zirwas is a consultant for Coria Laboratories, Ltd, and is on the speakers bureau for Astellas Pharma, Inc, and Coria Laboratories, Ltd.
    [Show full text]
  • The Effect of Oral Methylprednisolone Pulse on Blood Sugar
    THE EFFECT OF ORAL METHYLPREDNISOLONE PULSE ON BLOOD SUGAR DISSERTATION SUBMITTED IN FULFILLMENT OF THE REGULATIONS FOR THE AWARD OF M.D. DERMATOLOGY, VENEREOLOGY & LEPROSY DEPARTMENT OF DERMATOLOGY, VENEREOLOGY & LEPROSY PSG INSTITUTE OF MEDICAL SCIENCES & RESEARCH THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY GUINDY, CHENNAI, TAMILNADU, INDIA APRIL – 2011 THE EFFECT OF ORAL METHYLPREDNISOLONE PULSE ON BLOOD SUGAR DISSERTATION SUBMITTED IN FULFILLMENT OF THE REGULATIONS FOR THE AWARD OF M.D. DERMATOLOGY, VENEREOLOGY & LEPROSY GUIDE DR. C.R.SRINIVAS, MD., DEPARTMENT OF DERMATOLOGY, VENEREOLOGY & LEPROSY PSG INSTITUTE OF MEDICAL SCIENCES & RESEARCH THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY GUINDY, CHENNAI, TAMILNADU, INDIA APRIL – 2011 Certificate CERTIFICATE This is to certify that the thesis entitled “THE EFFECT OF ORAL METHYLPREDNISOLONE PULSE ON BLOOD SUGAR" is a bonafide work of Dr M. Barathi done under my direct guidance and supervision in the Department of Dermatology, Venereology and Leprosy, PSG Institute of Medical Sciences and Research, Coimbatore in fulfillment of the regulations of Dr .MGR Medical university for the award of MD degree in Dermatology, Venereology and Leprosy. GUIDE & HOD PRINCIPAL DECLARATION I hereby declare that this dissertation entitled "THE EFFECT OF ORAL METHYLPREDNISOLONE PULSE ON BLOOD SUGAR" was prepared by me under the direct guidance and supervision of Prof. Dr. C.R.SRINIVAS MD., PSG Hospitals, Coimbatore. The dissertation is submitted to the Dr. M.G.R. Medical University in partial fulfillment of the University regulations for the award of MD degree in Dermatology, Venereology and Leprosy. This dissertation has not been submitted for the award of any Degree or Diploma.
    [Show full text]
  • Rosacea: Classification and Treatment
    JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 90 March 1997 Rosacea: classification and treatment Thomas Jansen MD Gerd Plewig MD J R Soc Med 1997;90:144-150 Rosacea is a chronic skin disorder affecting the facial formation in pre-existing rosacea. Rosacea was once convexities, characterized by frequent flushing, persistent regarded as a seborrhoeic disease. Seborrhoea is, however, erythema, and telangiectases. During episodes of inflamma- not always present12. Unlike acne vulgaris, rosacea is not tion additional features are swelling, papules and pustules. primarily a disease of sebaceous follicles. The disease was originally called acne rosacea, a misleading The pathogenesis of rosacea thus remains obscure. What term that unfortunately persists1. is certain, however, is that rosacea patients are constitu- Rosacea is a common disease, especially in fair-skinned tionally predisposed to blushing and flushing. The basic people of Celtic and northern European heritage; it has abnormality seems to be a microcirculatory disturbance of been called the curse of the Celts. It is rare in American and the function of the facial angular veins13. Statistical African blacks2. Women are more often affected than men, associations between rosacea-related flushing and migraine but they seldom suffer the gross tissue and sebaceous gland suggest a shared disorder of vascular regulation14 but there hyperplasia of rhinophyma. Onset is usually between ages is no direct evidence that rosacea is primarily a vascular 30 and 50. In a recent epidemiological study the prevalence disorder. The response of the facial vessels to adrenaline, was 10%, most of the patients having only a red face3. In histamine and acetylcholine is normal,15 and the vessels do young patients especially, there may be a history of acne and not seem abnormally fragile16 so the main abnormality is the conditions may coexist.
    [Show full text]
  • Mallory Prelims 27/1/05 1:16 Pm Page I
    Mallory Prelims 27/1/05 1:16 pm Page i Illustrated Manual of Pediatric Dermatology Mallory Prelims 27/1/05 1:16 pm Page ii Mallory Prelims 27/1/05 1:16 pm Page iii Illustrated Manual of Pediatric Dermatology Diagnosis and Management Susan Bayliss Mallory MD Professor of Internal Medicine/Division of Dermatology and Department of Pediatrics Washington University School of Medicine Director, Pediatric Dermatology St. Louis Children’s Hospital St. Louis, Missouri, USA Alanna Bree MD St. Louis University Director, Pediatric Dermatology Cardinal Glennon Children’s Hospital St. Louis, Missouri, USA Peggy Chern MD Department of Internal Medicine/Division of Dermatology and Department of Pediatrics Washington University School of Medicine St. Louis, Missouri, USA Mallory Prelims 27/1/05 1:16 pm Page iv © 2005 Taylor & Francis, an imprint of the Taylor & Francis Group First published in the United Kingdom in 2005 by Taylor & Francis, an imprint of the Taylor & Francis Group, 2 Park Square, Milton Park Abingdon, Oxon OX14 4RN, UK Tel: +44 (0) 20 7017 6000 Fax: +44 (0) 20 7017 6699 Website: www.tandf.co.uk All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.
    [Show full text]
  • Glucocorticoids Enhance Toll-Like Receptor 2 Expression in Human
    ORIGINAL ARTICLE Glucocorticoids Enhance Toll-Like Receptor 2 Expression in Human Keratinocytes Stimulated with Propionibacterium acnes or Proinflammatory Cytokines Michio Shibata1, Masako Katsuyama1, Tomoko Onodera1, Ritsuko Ehama1, Junichi Hosoi1 and Hachiro Tagami2 Toll-like receptors (TLRs) on keratinocytes are important cell surface receptors involved in the innate and acquired immune response to invading microorganisms. In acne vulgaris, TLR2 activation by Propionibacterium acnes (P. acnes) may induce skin inflammation via induction of various proinflammatory molecules that stimulate the invasion of inflammatory cells. Although corticosteroids themselves exert immunosuppressive or anti-inflammatory effects, it is well known clinically that systemic or topical glucocorticoid treatment provokes an acneiform reaction. Nevertheless, the effect of steroids on TLR2 expression in human keratinocytes remains unknown. Here, we found that the addition of glucocorticoids, such as dexamethasone and cortisol, to cultured human keratinocytes increased their TLR2 gene expression. Moreover, these glucocorticoids markedly enhanced TLR2 gene expression, which was further stimulated by P. acnes, tumor necrosis factor-a, and IL-1a. Gene expression of mitogen-activated protein kinase (MAPK) phosphatase-1 was also increased by the addition of dexamethasone. By using several inhibitors and activators, we found that TLR2 gene induction by glucocorticoids was mediated by the suppression of p38 MAPK activity following induction of MAPK phosphatase-1. These
    [Show full text]
  • A Systematic Review of Topical Corticosteroid Withdrawal (``Steroid Addiction'') in Patients with Atopic Dermatitis
    REVIEW A systematic review of topical corticosteroid withdrawal (‘‘steroid addiction’’) in patients with atopic dermatitis and other dermatoses Tamar Hajar, MD,a Yael A. Leshem, MD,a Jon M. Hanifin, MD,a Susan T. Nedorost, MD,b Peter A. Lio, MD,c Amy S. Paller, MD,c Julie Block, BA,d and Eric L. Simpson, MD, MCR,a (the National Eczema Association Task Force) Portland, Oregon; Cleveland, Ohio; Chicago, Illinois; and San Rafael, California Background: The National Eczema Association has received increasing numbers of patient inquiries regarding ‘‘steroid addiction syndrome,’’ coinciding with the growing presence of social media dedicated to this topic. Although many of the side effects of topical corticosteroids (TCS) are addressed in guidelines, TCS addiction is not. Objective: We sought to assess the current evidence regarding addiction/withdrawal. Methods: We performed a systematic review of the current literature. Results: Our initial search yielded 294 results with 34 studies meeting inclusion criteria. TCS withdrawal was reported mostly on the face and genital area (99.3%) of women (81.0%) primarily in the setting of long-term inappropriate use of potent TCS. Burning and stinging were the most frequently reported symptoms (65.5%) with erythema being the most common sign (92.3%). TCS withdrawal syndrome can be divided into papulopustular and erythematoedematous subtypes, with the latter presenting with more burning and edema. Limitations: Low quality of evidence, variability in the extent of data, and the lack of studies with rigorous steroid addiction methodology are limitations. Conclusions: TCS withdrawal is likely a distinct clinical adverse effect of TCS misuse. Patients and providers should be aware of its clinical presentation and risk factors.
    [Show full text]
  • Adverse-Reactions-To-Topical-Steroid
    82 Clinical Dermatology Systemic Absorption BOX 2-2 Adverse Reactions to Topical Steroids The possibility of producing systemic side effects from absorption of topical steroids is of concern to all physi- • Rosacea, perioral dermatitis, acne cians who prescribe these agents. Topical corticosteroids • Skin atrophy with telangiectasia, stellate pseudoscars can cause iatrogenic Cushing disease and adrenal sup- (arms), purpura, striae (from anatomic occlusion, e.g., pression. Populations at greater risk are infants and young groin) children, patients with an impaired cutaneous barrier, and • Tinea incognito, impetigo incognito, scabies incognito patients in whom highly potent corticosteroids are ap- • Ocular hypertension, glaucoma, cataracts plied over large areas or under occlusion. The risk of sys- • Allergic contact dermatitis temic absorption can be reduced by using pulse applica- • Systemic absorption tion of more potent corticosteroids (weekends only or 2 • Burning, itching, irritation, dryness caused by vehicle (e.g., propylene glycol) weeks on/1 week off), by using medication “holidays,” by • Miliaria and folliculitus following occlusion with plastic using the minimally effective strength and dose of medi- dressing cation, and by using steroid-sparing agents. • Skin blanching from acute vasoconstriction • Rebound phenomenon (e.g., psoriasis becomes worse after treatment is stopped) • Nonhealing leg ulcers; steroids applied to any leg ulcer retard healing process • Hypopigmentation • Hypertrichosis of face tential to produce a number of adverse reactions. Once these are understood, the most appropriate strength ste- roid can be prescribed confidently. Reported adverse re- actions to topical steroids are listed in Box 2-2. A brief description of some of the more important adverse reac- tions is presented in the following pages.
    [Show full text]
  • Steroid Rosacea in Prepubertal Children
    ARTICLE Steroid Rosacea in Prepubertal Children William L. Weston, MD; Joseph G. Morelli, MD Objective: To examine clinical associations, family his- tisone preparations. Only 3% of children had used su- tory of rosacea, and response to treatment in prepuber- perpotent (class 1) topical corticosteroids. The mean age tal children with steroid rosacea. at onset was 7.04 years (range, 6 months to 13 years). Twenty-nine children were younger than 3 years. A fam- Design: Retrospective case-series evaluation of chil- ily history of rosacea was found for 20% of the children. dren younger than 13 years with steroid rosacea seen over After abruptly stopping topical steroid use and starting an 8-year period (1991-1998). treatment with oral erythromycin, 86% of children had complete clearing within 4 weeks and 100% by 8 weeks. Setting: Ambulatory care university hospital. Clearing within 3 weeks was observed in 22% of chil- dren. Patients: Referral patients from pediatricians serving a population of 3.4 million. Conclusions: Abrupt discontinuation of topical corti- costeroids and institution of oral antibiotics resulted in Interventions: Abrupt cessation of topical corticoste- clearing within 4 weeks. This finding does not support roid use and initiation of treatment with oral erythro- the concept that prepubertal children with steroid rosa- mycin stearate for 4 weeks. cea need to continue low-strength steroids in a gradual withdrawal strategy. This conclusion is supported by the Main Outcome Measures: Age at onset, class of topi- finding that 54% developed the steroid rosacea while be- cal corticosteroid used, family history of rosacea, loca- ing treated with the lowest-strength (class 7) topical cor- tion of lesions, treatment, and weeks to clearing.
    [Show full text]
  • Jennifer a Cafardi the Manual of Dermatology 2012
    The Manual of Dermatology Jennifer A. Cafardi The Manual of Dermatology Jennifer A. Cafardi, MD, FAAD Assistant Professor of Dermatology University of Alabama at Birmingham Birmingham, Alabama, USA [email protected] ISBN 978-1-4614-0937-3 e-ISBN 978-1-4614-0938-0 DOI 10.1007/978-1-4614-0938-0 Springer New York Dordrecht Heidelberg London Library of Congress Control Number: 2011940426 © Springer Science+Business Media, LLC 2012 All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York, NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identifi ed as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Notice Dermatology is an evolving fi eld of medicine.
    [Show full text]