Common Skin Conditions in Children and Adolescents: Acne.

Acne is a chronic, recurrent inflammatory condition of the pilosebaceous unit. It affects approximately 85% of adolescents and creates significant psychosocial and financial burdens. The pathogenesis involves altered follicular growth and differentiation, microbial colonization with Cutibacterium acnes, increased sebum production influenced by androgen levels, and inflammation. Evidence-based risk factors include family history and body mass index. Diagnosis of acne is clinical, according to patient age and acne morphology and severity. Setting treatment expectations is an important aspect of management. For mild acne, benzoyl peroxide is an effective first-line drug as monotherapy or in combination with a topical retinoid and/or topical antibiotic. Oral tetracyclines are first-line drugs as part of a multipart treatment regimen for moderate to severe acne for patients older than 8 years. Oral isotretinoin is the first-line drug for moderate to severe inflammatory acne. Because of its teratogenic effects, its prescribing is monitored through the iPLEDGE Risk Evaluation and Mitigation Strategy (REMS) program. Prescribing oral or topical antibiotics as monotherapy for acne is not recommended, as this may increase microbial resistance. Combined oral contraceptives and spironolactone are used as adjunctive therapies in female adolescents. Patients with skin of color, pregnant patients, and transgender or gender diverse patients warrant special considerations in acne management.

Common Skin Conditions in Children and Adolescents: Bacterial Infections.

Bacterial skin infections represent a significant health care burden. Cellulitis and erysipelas are rapidly spreading, painful, superficial skin infections, usually caused by streptococci or Staphylococcus aureus. Folliculitis is an infection of hair follicles mostly caused by S aureus. Simple folliculitis typically is self-limited. Topical benzoyl peroxide is a first-line nonantibiotic treatment. Mupirocin and clindamycin are topical antibiotic options. For treatment-resistant cases, oral cephalexin or dicloxacillin is an appropriate option. Impetigo is a common, self-limited infection in children. Bullous impetigo is caused by S aureus, and nonbullous impetigo is caused by beta-hemolytic streptococci, S aureus, or both. In most cases, topical mupirocin or retapamulin (Altabax) is effective. Oral antibiotics should be considered for household outbreaks or patients with multiple lesions. Abscesses are red, painful collections of purulence in the dermis and deeper tissues caused by S aureus or polymicrobial infections. Furuncles are abscesses of a hair follicle, whereas carbuncles involve several hair follicles. In recurrent cases of these lesions, culture of the exudate is recommended. Abscess, furuncle, and carbuncle management consists of incision and drainage. Oral antibiotics are not necessary in most cases but should be prescribed for patients with severe immunocompromise or systemic signs of infection. In bacterial skin infections, methicillin-resistant S aureus coverage should be considered for patients with infections that have not improved with treatment.

Common Skin Conditions in Children and Adolescents: Nonbacterial Infections.

Tinea infections are caused by dermatophytes, except for tinea versicolor, which is caused by yeasts in the Malassezia genus. If available, potassium hydroxide preparation should be performed to confirm diagnosis of tinea capitis or onychomycosis. In some cases, fungal culture, UV light examination, or periodic acid-Schiff stain can be helpful. Topical drugs are effective for tinea corporis, tinea cruris, and tinea pedis. Tinea incognito is an atypical presentation that usually requires systemic treatment. Management of tinea capitis always requires oral drugs. Oral drugs are preferred for onychomycosis treatment but should not be prescribed without confirmation of fungal infection. Localized cases of tinea versicolor can be managed with topical drugs, but oral drugs might be needed for severe, widespread, or recurrent cases. Warts are superficial human papillomavirus infections. Common treatments include irritant, destructive (eg, cryotherapy), immune stimulant (eg, intralesional Candida antigen), and debridement and excision methods. Scabies infestation results in intensely itchy papules, nodules, or vesicles. Mites and burrows on the skin are pathognomonic but difficult to identify. Dermoscopy, particularly with UV light, can make identification easier. Topical permethrin and oral ivermectin are two of the most commonly used treatments. All household and close contacts should be treated regardless of the presence or absence of symptoms.

Common Skin Conditions in Children and Adolescents: Atopic and Seborrheic Dermatitis.

Atopic dermatitis (AD) is a chronic, recurring, inflammatory skin condition. Xerosis, pruritus, and rash make the clinical diagnosis. Adequate skin care and regular emollient use are key in management. Topical corticosteroids are the first-line treatment for AD flare-ups. Wet wrap therapy can improve AD severity and extent. Topical calcineurin inhibitors are second-line treatments. Emollient use, topical corticosteroids and calcineurin inhibitors, and bleach baths can help prevent flare-ups. Patients with refractory AD that might require immunomodulatory treatments, such as dupilumab (Dupixent), Janus kinase inhibitors, or phototherapy, should be referred to a dermatologist. Seborrheic dermatitis (SD) is a common, chronic, relapsing, inflammatory condition that involves sebaceous skin areas. Infection with Malassezia species and the inflammatory response to it are the probable etiologies. The clinical diagnosis is made by the presence of hallmark greasy, yellow scales on the scalp or face. Infantile SD most commonly involves the scalp and forehead and typically is self-limited. In infants, application of emollients followed by hair brushing and shampooing may be effective. In infants and children, if the condition does not improve with this treatment, topical ketoconazole shampoo, gel, or lotion is safe and effective. Refractory cases of SD can be managed with topical corticosteroids and calcineurin inhibitors.

Pruritic rash and nocturnal itching.

UV light illuminated the patient's diagnosis.

Trigger point injections and dry needling can be effective in treating long COVID syndrome-related myalgia: a case report.

INTRODUCTION: Myofascial pain is a complex health condition that affects the majority of the general population. Myalgia has been recognized as a symptom of long COVID syndrome. The treatment for long COVID syndrome-related myalgia lacks research. Dry needling is a technique that involves the insertion of a needle into the tissue of, or overlaying, a pain point. Wet needling is the addition of an injection of an analgesic substance such as lidocaine while performing needling. Both dry and wet needling have are practiced as treatment modalities for myofascial pain. Limited literature exists to define long COVID syndrome-related myalgia and its relation to myofascial pain, or to examine the utility of needling techniques for this pain. We report a case of dry and wet needling as effective treatments for long COVID-related myofascial pain. CASE PRESENTATION: A 59-year-old, previously healthy Hispanic male with no comorbid conditions was diagnosed with COVID-19 pneumonia. The patient suffered moderate disease without hypoxia and was never hospitalized. Three months later, the patient continued to suffer from symptoms such as exertional dyspnea, "brain fog," and myalgia. An extensive multisystem workup revealed normal cardiac, pulmonary, and end organ functions. The patient was then diagnosed with long COVID syndrome. The nature and chronicity of the patient's myalgia meet the criteria for myofascial pain. Both wet and dry needling were used to treat the patient's myofascial pain, with good short- and long-term therapeutic effects. CONCLUSIONS: COVID-19 infection has been shown to exacerbate preexisting myofascial pain syndrome. Our case report indicates that long COVID syndrome-related myalgia is likely a form of new-onset myofascial pain. Additionally, both wet and dry needling can be utilized as an effective treatment modality for this pain syndrome, with short- and long-term benefits.

Impact on the fitness of N95 masks with extended use/limited reuse and dry heat decontamination.

Substandard use of N95 masks, sometimes combined with dry heat decontamination, lacks safety data. We evaluated the impact of these practices on the fitness of N95 masks. This is a non-human subject research conducted from July to October 2020. 155 masks were used by 12 healthcare workers during 10-hour shifts. Masks were collected at the end of the shift and if the number of donnings/doffings was less than five ('modified extended use', ME) or whenever this number reached five ('limited reuse', LR), per the recommendation of the Centers for Disease Control and Prevention. Masks that passed an Occupational Safety and Health Administration qualitative fit test underwent a cycle (30 min, 75°C) of dry heat decontamination. After use, 84% (95% CI 77% to 90%) of the masks fit the users, 85% (95% CI 73% to 93%) in ME and 83% (95% CI 73% to 90%) in LR. After dry heat, 86% of the fitted masks (95% CI 78% to 91%) still fit, 93% (95% CI 80% to 98%) in ME and 82% (95% CI 70% to 89%) in LR. If a fit test was not done before decontamination, 72% (95% CI 64% to 79%) of the masks would fit, 79% (95% CI 66% to 88%) in ME and 68% (95% CI 57% to 77%) in LR. Common substandard use preserves fitness of N95 masks up to 85%. One cycle of dry heat decontamination preserves fitness of N95 masks up to 93% when donned/doffed less than five times and fitness is ensured before decontamination. If a fit test is not performed beforehand, dry heat decontamination cannot preserve the fitness of used N95 masks above 80%.

Improving the Attitudes to Homeless Persons in a Family Medicine Residency.

INTRODUCTION: Family medicine providers are at the forefront of serving homeless persons. It is important to prepare family medicine residents for this responsibility during residency. In the current study, we aimed to assess the effect of a series of enrichment activities on the attitudes toward homeless persons held by residents, faculty, and staff in a rural family medicine residency program. METHODS: The residency program implemented a 6-month enrichment activities series that provided various educational experiences and aimed to improve the participants' knowledge of and attitudes toward homeless persons. Participants completed 2 anonymous online surveys before and after the enrichment series: (1) the Health Professional's Attitude Toward the Homeless Inventory (HPATHI) and (2) a short survey assessing the understanding of local issues that affected homeless persons. Two-tailed Student t tests were used to compare the survey results. RESULTS: Of the 48 eligible participants, 42 (88%) completed the surveys before enrichment activities and 41 (85%) completed the surveys afterward. Engagement in the enrichment series was associated with a significant improvement in attitudes supporting social advocacy, but it did not affect self-reported levels of cynicism or personal advocacy. Participant knowledge of local homelessness issues improved, but the difference was not statistically significant. CONCLUSIONS: The longitudinal enrichment activities series, which was implemented in a rural family medicine residency program and aimed to provide experiences working with homeless individuals, was effective in improving attitudes supporting social advocacy among participants.

Understanding the molecular properties and metabolism of top prescribed drugs.

Molecular properties such as the molecular weight, hydrophobicity parameter logP, and the total polar surface area (TPSA) have been used extensively in modern drug discovery. We investigated these properties and ADMET scores of the top 200 therapeutic drugs by the U.S. retail sales (2010) and classified them according to the clinical indications and/or routes of administration. This list of drugs provides ample information of these molecular descriptors for successfully approved drugs. The mean logP for oral drugs is 2.5 while the logP for injectable drugs seems to be smaller. Among different types of clinical indications, drugs used for anti-HIV, and antibiotics tend to have lower logP. The molecular weights of anti-HIV drugs, antihypertensives and antibiotics appear to be larger. The ADMET scores, derived from a combination of molecular weights and logP, are consistent for oral drugs, with a mean score of 1.5 and a standard deviation of 1.0. Many clinical drugs that violate Lipinski's rule of five criteria can still exhibit ADMET scores that are very close to the mean value for oral drugs (1.5) and lie within the acceptable standard deviation. The molecular properties of MW, logP, and TPSA appear to vary according to their clinical indications. Many drugs form salts or cocrystals with acids or solvents that increase their solubility. Our data show that addition of hydrochloride is the most common method to increase solubility of drug ingredients. Cytochrome P450 isozymes 3A4, 2D6, 2C9, 2C8 and 3C5 are the top five proteins that metabolize the 200 most prescribed drugs. Drugs metabolized by 3A4 appear to have larger molecular weights and those metabolized by 2D6 have lower molecular weights. CYP2C8-metabolized drugs appear to be most hydrophilic, with the smallest logP and the largest polar surface areas.