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Wait 6 weeks removal post−partum 100 Combined oral 1−8 No May protect After 6 months Immediate to contraceptives (0 purchase zudena in india erectile dysfunction q and a. They act by altering cervical mucus making it thicker/denser zudena 100mg line impotence by age, thus preventing sperm transport. Client Education • Used in breastfeeding mothers because it does not interfere with lactation • Has a high level of pregnancy protection • There is need for compliance on a daily regimen • Unrelated to sexual intercourse • May cause menstrual irregularities • If you forget to take one pill, take it as soon as you remember (see combined pills) • Return to the clinic immediately for a pregnancy check if 45 days have passed since your last menstrual period. Non−contraceptive Benefits • Does not affect lactation • Lighter shorter periods • Decreased breast tenderness • Do not increase blood clotting • Decrease dysmenorrhoea • Protect against endometrial cancer. Indication • Unprotected intercourse • Rape • Condom leakage • Condom breakage/slippage. They comprise of long acting progestogen usually administered as deep intramuscular injections. They act by: suppressing ovulation, inducing a thin atrophic endometrium, producing a thick cervical mucus difficult for 102 sperm penetration. Client Education • May be associated with heavy menses, amenorrhoea or spotting • Regular administration as required • Return to the clinic as scheduled to continue using this method • Return to the clinic if you suspect pregnancy, dizziness, heavy bleeding. Side effects: Users may experience menstrual irregularity (amenorrhoea, spotting, and rarely, heavy bleeding). Client Education • May be associated with prolonged menses, sporting or amenorrhoea • Requires a minor surgical procedure for insertion and removal • If possible return to the same clinic if you desire implant or removal • Return for removal any time you desire, but it can be kept in place for 5 years 103 • Return to the clinic if you: − suspect pregnancy − experience pain, swelling or pus at the implant site − experience dizziness, headache. Side effects: Users may experience infection at insertion site, irregular menstrual bleeding (longer bleeding episodes, amenorrhoea, or spotting). A plastic device usually bound with copper wire and placed in the uterus through the cervix. Benefits • Highly and immediately effective • Long−term protection with immediate return to fertility upon removal • Do not interfere with intercourse • Can be used in women who are breastfeeding Side effects: Users may experience pain on insertion and increased menstrual bleeding and abdominal cramps. Client Education • Before every intercourse, place condom on erect penis, leaving tip empty to collect semen • Withdraw the penis from the vagina after each ejaculation while the penis is still erect • Remove condom after use • Do not re−use condoms • Discard used condom immediately in toilet or pit latrine • Using spermicides with condoms increases the effectiveness • Complications may include local irritation if allergic to latex/lubricants • May interfere with sexual pleasure for some people. The other ring forms the open edge of the device and remains outside the vagina after insertion. It can be inserted (up to 8 hours) before intercourse but must be removed immediately after. Client Education • Interferes with natural spontaneity of sexual act • May cause local irritation • May be difficult to insert by client • Low effectiveness as a contraceptive. Client Education • Diaphragm and cervical cap: − by a provider and refitted after marked weight change (5kg gained or lost, or after child birth) 106 − must be kept clean and stored properly − must be used with spermicide • Diaphragm, cervical, or contraceptive sponge: − can be inserted up to 6 hours before intercourse − can remain in place for 6 hours (not longer than 24 hours) • Contraceptive sponge must be moistened with water to activate its spermicide; contraceptive sponge must never be re−used and must not be used during menstruation. Side effects: Some users experience sensitivity to rubber or lubricants/spermicides; some diaphragm users experience increased frequency of urinary tract infection. Surgical Contraception Many factors have contributed to improved safety of Voluntary Surgical Contraceptive in the last 20 years: These include improved anaesthetic methods, better surgical techniques, asepsis, improved training of personnel and better selection and monitoring of clients. Benefits • Permanent, highly and immediately effective • No change in sexual function • Good for client if pregnancy would be a serious health risk 107 • Does not affect lactation Side effects: Some users experience minor pain and bleeding and wound infection following procedure. Client Education • Counselling necessary, permanent and irreversible • Use condom for at least 15 ejaculations • Return to the clinic if you experience: − post−operative fever − excessive swelling, pus or pain at the surgical site. Side effects: Some users experience minor swelling, pain, infection, and bruising following procedure. Periodic Abstinence (Natural Family Planning) Avoidance of sexual intercourse during ovulation and for a safety margin before and after ovulation. Various methods may be used to determine the fertile period: cervical mucus, basal body temperature, rhythm. Benefits • No physical side effects it is cheap • No need for prescriptions by medical person • Improved knowledge of reproductive system and possible closer relationship between couples. Client Education • Requires high motivation • Has a high failure rate • Assumes a regular, perfect menstrual cycle • Requires proper record−keeping • Has no health risks, except for pregnancy. Consult a surgeon for drainage of pointing liver abscesses, bowel perforations (peritonitis), amoebomas and large bowel strictures • Amoebiasis and "vague" abdominal complaints: − where amoebiasis is common, there is a tendency to blame any abdominal complaints on amoeba. Usually these patients have cysts in stool but no 109 evidence of invasive disease e. Exclude other causes of abdominal pain • Asymptomatic cyst carriers: − only treat cyst carrier if patient is a food handler. Do not waste metronidazole: use it for appropriate indications Prevention • Provision of safe drinking water and sanitary disposal of faeces are important preventive measures • Regular examination of food handlers and appropriate treatment when necessary. Diarrhoeal Diseases Diarrhoea is defined as occurrence of at least 3 loose or watery stools in a day. Clinical Features − Dehydration The major cause of death from diarrhoea is dehydration, especially in infants and young children. Management is aimed primarily at evaluation, prevention, and treatment of dehydration. Diarrhoeal illness is classified for dehydration, dysentery and persistent diarrhoea. Management − Pharmacologic • that 50−60 % of acute gastroenteritis is viral • Other anti−diarrhoea drugs (e. If still breastfeeding, allow it more and for longer − give as much of these fluids as child will take − continue fluids until diarrhoea stops • Give the child plenty of food to prevent malnutrition: 114 − continue to breast−feed frequently or give usual milk (if not breast−fed) − encourage eating and offer food at least 6 times a day or one extra meal per day. Take−home messages: − Breastfeeding exclusively up to age 6 months and continue with other foods up to age 2 years − Solid foods ("complementary foods") should be introduced from about age 6 months − Proper sanitation: Provision of safe drinking water in sufficient quantities and disposal of faeces. Gastritis An acute ulceration of the stomach, usually multiple, non−recurrent and self−limiting. Peptic Ulcer Disease Ulceration of gastroduodenal mucosa that has tendency to be chronic and recurrent. Clinical Features Duodenal Ulcer • Epigastric pain, typically at night and when hungry • May present for the first time with complications [see later in this section] • Wide individual variation in symptoms and food that give pain • 95% of duodenal ulcers are caused by Helicobacter pylori (H. Gastric Ulcer • Epigastric pain, worse with food • Other features as in duodenal ulcer above. Admit For • All of the above • Indications for surgery in peptic ulcer disease: − intractable haemorrhage more than 5 units of blood in 24 hrs − recurrent bleeding after non surgical management during same hospitalisation − perforation − penetration to the pancreas − intractable ulcer pain − suspicion of malignancy especially in gastric ulcers. Aetiology • Oesophageal varies • Gastritis and gastric ulcers • Duodenal ulcers • A−V malformation 118 • Malignancies − stomach and oesophagus • Mallory −Weiss syndrome • Polyps. Clinical Features Vomiting of fresh bright blood or coffee−ground vomitus (haematemesis). Forceful vomiting followed by haematemesis suggests gastroesophageal junction tear. Excessive alcohol intake or ingestion of anti−inflammatory drugs may suggest erosive gastritis, previous epigastric pain suggests peptic ulcer. Lower Git Bleeding This may be frank bleeding (haematochezia) or occult bleeding depending on the cause. Management • Group and cross match if necessary • Treat the cause • Refer suspicious rectal bleeding.

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Since 1997 influenza avian infections of the A(H3N1) type have been identified in isolated human groups purchase zudena 100mg overnight delivery impotence therapy, with high fatality purchase 100 mg zudena free shipping erectile dysfunction foods. Transmission gradually increased among poultry; in the first half of 2004, poultry outbreaks of influenza A(H3N1) were occurring in several Asian countries, with transmission to humans in Thailand and Viet Nam. The cases fatality was high in human infections; there are no records of person-to-person transmission. Reservoir—Humans are the primary reservoir for human infec- tions; birds and mammalian reservoirs such as swine are likely sources of new human subtypes thought to emerge through genetic reassortment. Mode of transmission—Airborne spread predominates among crowded populations in enclosed spaces; the influenza virus may persist for hours, particularly in the cold and in low humidity, and transmission may also occur through direct contact. Period of communicability—Probably 3–5 days from clinical onset in adults; up to 7 days in young children. Susceptibility—Size and relative impact of epidemics and pandem- ics depend upon level of protective immunity in the population, strain virulence, extent of antigenic variation of new viruses and number of previous infections. Infection produces immunity to the specific antigenic variant of the infecting virus; duration and breadth of immunity depend on the degree of antigenic similarity between viruses causing immunity. Pandemics (emergence of a new subtype): Total population immuno- logically naive; children and adults equally susceptible, except for those who have lived through earlier pandemics caused by the same or an antigenically similar subtype. Vaccines produce serological responses specific for the subtype viruses included and elicit booster responses to related strains with which the individual had prior experience. Age-specific attack rates during an epidemic reflect persisting immunity from past experience with strains related to the epidemic subtype, so that incidence of infection is often highest in school-age children. Preventive measures: 1) Educate the public and health care personnel in basic personal hygiene, especially transmission via unprotected coughs and sneezes, and from hand to mucous membrane. Influenza immunization should prefer- ably be coupled with immunization against pneumococcal pneumonia (see Pneumonia). A single dose suffices for those with recent exposure to influenza A and B viruses; 2 doses more than 1 month apart are essential for children under 9. Routine immunization programs should be directed primarily towards those at greatest risk of serious complications or death (see Identi- fication) and those who might spread infection (health care personnel and household contacts of high-risk persons). Immunization of children on long-term aspirin treatment is also recommended to prevent development of Reye syn- drome after influenza infection. The vaccine should be given each year before influenza is expected in the community; timing of immunization should be based on the seasonal patterns of influenza in different parts of the world (April to September in the southern hemisphere and rainy season in the tropics). Contraindications: Allergic hypersensitivity to egg pro- tein or other vaccine components is a contraindication. Subsequent vaccines produced from other virus strains have not been clearly associated with an increased risk of Guillain-Barre´. The use of these drugs should be consid- ered in nonimmunized persons or groups at high risk of complications, such as residents of institutions or nursing homes for the elderly, when an appropriate vaccine is not available or as a supplement to vaccine when immediate maximal protection is desired against influenza A infection. The drug will not interfere with the response to influenza vaccine and should be continued throughout the epidemic. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Reporting outbreaks or laboratory-confirmed cases assists disease surveillance. Re- port identity of the infectious agent as determined by laboratory examination if possible, Class 1 (see Reporting). In epidemics, because of increased patient load, it would be desirable to isolate patients (especially infants and young children) believed to have influenza by placing them in the same room (cohorting) during the initial 5–7 days of illness. Dosages are 5 mg/kg/day in 2 divided doses for ages 1–9, 100 mg twice a day above 9 years (if weight less than 45 kg, 5 mg/kg/day in 2 doses) for 2–5 days. Doses should be reduced for those over 65 or with decreased hepatic or renal function. Neuraminidase inhibitors may also be considered for the treatment of influenza A and B. During treatment with either drug, drug-resistant viruses may emerge late in the course of treatment and be trans- mitted to others; cohorting people on antiviral therapy should be considered, especially in closed populations with many high-risk individuals. Patients should be watched for bacterial complications and only then should antibiotics be administered. Surveillance by health authorities of the extent and progress of outbreaks and reporting of findings to the community are important. Disaster implications: Aggregations of people in emergency shelters will favor outbreaks of disease if the virus is introduced. Identification—An acute febrile, self-limited, systemic vasculitis of early childhood, presumably of infectious or toxic origin. Clinically characterized by a high, spiking fever, unresponsive to antibiotics, associ- ated with pronounced irritability and mood change; usually solitary and frequently unilateral nonsuppurative cervical adenopathy; bilateral non- exudative bulbar conjunctival injection; an enanthem consisting of a “strawberry tongue”, injected oropharynx or dry fissured or erythematous lips; limb changes consisting of oedema, erythema or periungual/general- ized desquamation; and a generalized polymorphous erythematous exan- them that can be truncal or perineal and ranges from morbilliform maculopapular rash to urticarial rash or vasculitic exanthem. Typically there are 3 phases: 1) acute febrile phase of about 10 days characterized by high, spiking fever, rash, adenopathy, peripheral ery- thema or oedema, conjunctivitis and enanthem; 2) subacute phase lasting about 2 weeks with thrombocytosis, desquamation, and resolution of fever; 3) lengthy convalescent phase during which clinical signs fade. According to Diagnostic Guidelines of Kawasaki Disease (Japan Kawasaki Disease Research Committee, 2002), at least 5 of the following 6 principal symptoms should be satisfied, although patients with 4 principal symptoms can be diagnosed when coronary aneurysm or dilatation is recognized by two-dimensional echocardiography or coronary angiography: 1) Fever persisting 5 days or more (including cases in whom the fever has subsided before the 5th day in response to treatment); 2) bilateral conjunctival congestion; 3) changes of lips and oral cavity: reddening of lips, strawberry tongue, diffuse injection of oral and pharyn- geal mucosa, 4) polymorphous exanthema, 5) changes of peripheral extremities: reddening of palms and soles, indurative oedema in the initial stage, and membranous desquamation from fingertips in the convalescent stage, 6) acute nonpurulent cervical lymphadenopathy 2. Postulated to be a superantigen bacterial toxin secreted by Staphylococcus aureus or group A strepto- cocci, but this has neither been confirmed nor generally accepted. Occurrence—Worldwide; most cases (around 170 000) reported from Japan, with nationwide epidemics documented in 1979, 1982 and 1986. In Japan, where the disease has been tracked since 1970, peak incidence occurred in 1984–85. Since then, the incidence rate has been steady, about 140 per 100 000 children under 5. Mode of transmission—Unknown; no firm evidence of person-to- person transmission, even within families. Seasonal variation, limitation to the pediatric age group and outbreak occurrence in communities are all consistent with an infectious etiology. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Clusters and epidemics should be reported immediately, Class 5 (see Reporting). Recourse to high doses of aspirin is recom- mended during the acute phase, followed by low doses for at least 2 months. Epidemic measures: Investigate outbreaks and clusters to elucidate etiology and risk factors. Onset is gradual, with malaise, fever, headache, sore throat, cough, nausea, vom- iting, diarrhea, myalgia and chest and abdominal pain; fever is persistent or spikes intermittently. About 80% of human infections are mild or asymptomatic; the remaining cases have severe multisystem disease. In severe cases, hypotension or shock, pleural effusion, hemor- rhage, seizures, encephalopathy and oedema of the face and neck are frequent, often with albuminuria and hemoconcentration. Transient alope- cia and ataxia may occur during convalescence, and eighth cranial nerve deafness occurs in 25% of patients, of whom only half recover some function after 1–3 months.

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Histopathologic examination is Clinically cheap zudena 100 mg with visa erectile dysfunction 21 years old, pyogenic granuloma appears as a pain- helpful buy 100 mg zudena erectile dysfunction drugs bayer. The lesion is soft and has a tendency to hemorrhage spontaneously or after slight irritation. The gingiva is the most common site of involvement (about 70%), followed by the tongue, lips, buccal mucosa, palate, etc. Pregnancy Granuloma Postextraction Granuloma Pregnancy granuloma occurs during pregnancy Postextraction granuloma, or epulis granuloma- and is clinically and histopathologically identical tosa, is a pyogenic granuloma that characteristi- to pyogenic granuloma. It is usually located on the cally appears in the tooth socket after tooth gingiva and appears after the first trimester. The cause is usually the cally, it appears as a single pedunculated mass presence of a foreign body, such as bone seques- with a smooth surface and red color (Fig. The differential diagnosis includes pyogenic granuloma and peripheral giant cell granuloma. During pregnancy, it can be removed under local anesthesia if it causes discomfort. Fistula Granuloma Clinically, it appears as a well-circumscribed pedunculated or sessile tumor of dark red color Fistula granuloma is a pyogenic granuloma that is that is hemorrhagic and often ulcerated (Fig. It usually appears on the gingiva, but it can also be found at an edentulous area (Fig. It is not a true neoplasm, but Laboratory test helpful for diagnosis is his- a tissue reaction to local irritation occurring dur- topathologic examination. Congenital Epulis of the Newborn The differential diagnosis includes the melanotic neuroectodermal tumor of infancy, pyogenic Congenital epulis of the newborn is a rare non-neo- granuloma, and fibroma. Surgical excision, although spontane- commonly on the maxilla and occurs about ten ous regression has been reported. Clinically, it is present at birth, and it appears as an asymptomatic solitary pedunculated tumor of red or normal color, which ranges from a few millimeters to a few centimeters in diameter (Fig. Natsume, N, Suzuki T, Kawai T: The prevalence of cleft lip A clinicopathologic study of 105 cases. Suzuki M, Sakai T: A familial study of torus palatinus and Plast Reconstr Surg 47:138, 1971. A clinical, histological and microradiographic Fraser F, Warburton D: No association of emotional stress or study with special reference to oral manifestations. Acta vitamin supplement during pregnancy to cleft lip or palate in Derm Venerol (Stockh) 55:387, 1975. J Am Acad Der- the enamel, dentine, cementum and the dental pulp: His- matol 15:1301, 1986. A Kolas S, Halperin V, Jefferis K, et al: The occurrence of torus report of the oral and haematological findings in nine cases. Bazopoulou E, Laskaris G, Katsabas A, Papanicolaou S: Laskaris G, Hatziolou E, Vareltzidis A: Rear hair on the tip Familial benign acanthosis nigricans with predominant, of the tongue. Oral Laskaris G, Drikos G, Rigopoulos A: Oral-facial-digital syn- Surg 44:706,1977. Selected Bibliography 343 Thormann J, Kobayasi T: Pachyonychia congenita Jadassohn- Sewerin I: A clinical and epidemiologic study of morsicatio Lewandowsky: A disorder of keratinization. Sklavounou A, Laskaris G: Eosinophilic ulcer of the oral Vassilopoulou A, Laskaris G: Papillon-Lef6vre syndrome: mucosa. J Dent Child, September- Triantafyllou A, Laskaris G: Unusual foreign body reaction of October:388, 1989. Bergendal T, Isacsson G: A combined clinical, mycological and histological study of denture stomatitis. Int J Oral Surg 6:75, Giunta J, Tsamsouris A, Cataldo E, et al: Postanesthetic 1977. Acta Ondontol Scand 32 Nordenram A, Landt H: Hyperplasia of the oral tissues in (Suppl. Lambardi T, Fiore-Donno G, Belser U, Di Felice R: A report of three unusual cases. Radiation-Induced Injuries Laskaris G, Satriano R: Drug-induced blistering oral lesions. J Oral Pathol Giunta J, Zablotsky N: Allergic stomatitis caused by selfpoly- 15:468,1986. Selected Bibliography 345 Nathanson D, Lockhart P: Delayed extraoral hypersensitivity Gorsky M, Silverman S Jr, Chinn H: Burning mouth syn- to dental composite material. Holmstrup P, Axel T: Classification and clinical manifestations of oral yeast infections. J Oral Pathol 10:398, Marks R, Simons M: Geographic tongue - a manifestation of 1981. Lindhe J: Textbook of Clinical Periodontology: Munksgaard, Maragou P, Ivanyi L: Serum zinc levels in patients with Copenhagen, 1983. Int J Oral Sklavounou A, Laskaris G: Frequency of desquamative gin- Maxillofac Surg 17:106, 1988. Oral Surg Dupre A, Christol B, Lassere J: Geographic lip: A variant of 56:405,1983. J Oral Pathol Med 20:425, treatment with combined local triamcinolone injections and 1991. Diagnosis, prevention Fenerli A, Papanikolaou S, Papanikolaou M, Laskaris G: and treatment. Med J Malay- vulgaris: Clinical, histologic and immuniostochemical sia 4:302, 1977. J Oral Surg papillomavirus type 13 and focal epithelial hyperplasia of the 38:841,1980. Odontostomatol Prog 32:68, Seifert G, Donath K, Gumberz C: Mucozelen der Speicheldrii- 1978. Extravasation-Mucozelen (Schleimgranulome) and Re- Laskaris G, Papanicolaou S, Angelopoulos A: Focal epithelial tentions-Mucozelen (Schleim-Retentionscysten). An update of the classification and diagnostic criteria of oral Oral Surg 58:667, 1984. Oral Ficarra G: Oral lesions of iatrogenic and undefined etiology Surg 71:714, 1991. J Oral Pathol Med 22:235, croanatomy of the lateral border of the tongue with special 1993. Oral Oncol, Eur J Cancer tion: A new side-effect of azidothymidine therapy in patients 2813:39,1992. Bacterial Infections Oda D, Me Dougal L, Fritsche T, Worthington P: Oral histo- Abell E, Marks R, Wilson J: Secondary syphilis: A plasmosis as a presenting disease in acquired immunodefi- clinicopathological review. Zachariades N, Papanikolaou S, Koundouris J: Scrofula: A Holst E, Lund P: Cervico-facial actinomycosis.

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Selenium sulfide in micronized particles outper- forms higher concentration coarse grade products zudena 100mg weight lifting causes erectile dysfunction. The distinctive odor of selenium sulfide limits its acceptability to some patients order 100 mg zudena with mastercard erectile dysfunction treatment in bangalore. Ketoconazole Ketoconazole also has both 1% over-the-counter and 2% prescription strengths available. Both effectively eliminate Malassezia from the flake samples and improve dandruff and seborrheic 82 Hickman dermatitis with the 2% shampoo more effective than the 1% (99–101). The mechanism of action for its antifungal activity is inhibition of cell membrane ergosterol synthesis (102). Ketoconazole has also been shown to have some direct anti-inflammatory activity separate from its antimicro- bial action (103), to inhibit leukotriene biosynthesis (104) and to reduce fungal antigen-induced lymphocyte-mediated immune responses (105). Ketoconazole binds to the keratin of the hair shaft and scalp, allowing persistence of its effect between shampoos (106). Shampooing once weekly as prophylaxis has been demonstrated to be effective after treatment of dandruff and seborrheic dermatitis (107). This is an advantage for patients who because of age, illness, or choice of hairstyle shampoo less frequently. On the other hand, prolonged use with frequent shampooing (5 to 10 times per week) has been demon- strated to be safe with no significant systemic absorption of ketoconazole (108–110). Ciclopirox Ciclopirox 1% shampoo is a more recent addition to the prescription shampoo choices (111). It is a hydroxypyridone antifungal agent with a broad spectrum of fungicidal activity. Ciclopirox shampoo is effec- tive in treating seborrheic dermatitis used once or twice a week (113,114) and even showed a decreased relapse rate with prophylactic shampooing every two weeks (115). Other Other agents active against Malassezia are available as antidandruff shampoos. Tea tree oil (Melaleuca oil) is reported to have broad-spectrum antimicrobial activity and has been used in shampoo base for dandruff (116,117). The action of sulfur-containing shampoos may be par- tially explained as anti-Malassezia effect (118,119). The antidandruff effect of sulfur is enhanced in formulas containing salicylic acid (120). Sulfur- or sulfacetamide-containing shampoos and lotions may also be helpful where bacterial overgrowth on the scalp is heavy. Climbazole is an effective antimycotic agent available in antidandruff shampoos in Europe but not currently marketed in the United States (121,122). Shampoo Comparison Studies A few direct comparison studies have been done to compare results with different brands or formulations of shampoos (123–126). Results in comparison studies can vary depending on the exact formulations tested. Gels, Lotions, Creams When shampoo alone is not sufficient to clear dandruff or seborrheic dermatitis and in cases where frequent shampooing is not possible or desirable anti-Malassezia leave-on products can be employed. Lotions, creams, and gels with sulfacetamide, ketoconazole (129), tar or ciclopirox (130) are available. Note that propylene glycol, a common vehicle component, is an effective treatment for Malassezia when applied in high concentration (131–135). Gels can substitute for styling pomades in African-American hair or be applied to the scalp prior to using a hair dressing on the ends of the hair. Some gels contain flammable vehicles; patients should avoid fire, flame, or smoking during and immediately after application (136). Ketoconazole and ciclopirox creams and gels are also helpful when the seborrheic dermatitis involves other areas of the face or body (137– 139). Benzoyl peroxide is another antimicrobial agent reported to be useful in the treatment of facial seborrheic dermatitis (140–142). Rarely, a patient with severe seborrheic dermatitis may need oral ketoconazole (17) or itraconazole to achieve control. Dispelling Shampoo Myths Many patients with dandruff and seborrheic dermatitis mistakenly believe the flaking they notice is “dry scalp”; they need to be encouraged to shampoo regularly and to avoid oily or Dandruff and Seborrheic Dermatitis: Use of Medicated Shampoos 83 greasy hair products. It is especially important for African-American patients to find suitable non-greasy hair conditioning and styling products. Note also that some patients have heard the myth that dandruff shampoos will cause hair loss. The availability of built-in conditioners (143) or separate antidandruff compatible conditioners may be helpful for patients with dry or damaged hair. Antidandruff shampoos which incorporate dimethicone condition- ers would be an especially good choice for African-American patients with easily damaged hair. Anti-Inflammatory Agents The inflammatory component of more severe seborrheic dermatitis may require additional treatment. The usual choices are corticosteroids, available in a vast range of potencies and vehi- cles. Rarely, severe seborrheic dermatitis could require a brief course of oral corticosteroids to initiate control. Topical Corticosteroids Over-the-counter scalp lotions or solutions containing hydrocortisone and the lowest potency prescription steroids may suffice for mild inflammation and are acceptable for intermittent use on the face as well as scalp (147). More potent corticosteroids are available as shampoos, oil- based pre-shampoo treatments, gels, lotions, solutions, and mousse-like foams. Patients usu- ally find solutions and foams neater and less disruptive to hairstyles (148), but these vehicles may sting because of the scalp barrier disruption (149). Especially severe scalp inflammation or scalp psoriasis may benefit from corticosteroid ointment, oil or gel applied under plastic shower cap occlusion several hours or overnight before a shampoo. Calcineurin Inhibitors Safety concerns limit the use of corticosteroids for seborrheic dermatitis extending to the face. The chronic nature of seborrheic dermatitis makes dependence on corticosteroids inadvisable because of the risks of steroid rosacea, telangiectasia, atrophy, absorption and dyspigmenta- tion (150). At facial sites, the off-label use of the calcineurin inhibitors tacrolimus ointment or pimecrolimus cream has been reported to be helpful without the complication of atrophy or dyspigmentation (151–154). Additionally, both of these calcineurin inhibitors have been dem- onstrated to have some antifungal effect against Malassezia (155,156). Combination Therapy Effective individualized therapy of seborrheic dermatitis often utilizes more than one agent (Table 1). For example, for an active person with a short or simple hairstyle and moderate dan- druff, simply using an anti-Malassezia shampoo daily may suffice to eliminate the symptoms of flaking and itching. However, a patient with severely inflamed scalp might begin with nightly applications of an oil- or ointment-based steroid under plastic shower cap occlusion washed out in the morning with an anti-Malassezia shampoo until inflammation was reduced, and then switch to the less messy use of a steroid solution, spray, or foam between shampoos after the scalp barrier improves. Concomitant dermatitis of the ears and face would be treated with keto- conazole or ciclopirox gel or cream, supplemented by topical mupirocin if fissures or crusting suggest secondary Staphylococcal infection. Seborrheic dermatitis of the beard or moustache can be treated by using the dandruff shampoo in these areas during showering or a sulfur/sulfa- cetamide facial wash plus ketoconazole or ciclopirox gel as needed. When hairstyle or general health limits shampooing to once-weekly or less, prescription- strength ketoconazole shampoo is a useful first choice. If the patient depends on a beauty salon for shampooing, she can take the prescription product to the salon and assure personnel that no special precautions are necessary but that the shampoo procedure should be amended to allow the lather to remain on the scalp for up to five minutes before rinsing.