Skin conditions: new drugs for managing skin disorders.

New drugs are available for managing several common skin disorders. For psoriasis, topical corticosteroids remain the first-line therapy, but topical vitamin D3 analogs, such as calcipotriene, now have a role. They are as effective as medium-potency topical steroids but without steroid side effects, though they can induce hypercalcemia if the dose exceeds 100 g/week. For more severe cases, methotrexate has been widely used, but other drugs now also are prescribed. They include calcineurin inhibitors, such as cyclosporine, and more recently, biologic agents, such as tumor necrosis factor inhibitors. For children and pregnant women, in whom the previously discussed drugs are not appropriate, narrowband UV-B light often is the first-line treatment. For eczema, patients requiring steroid-sparing topical drugs can be treated with calcineurin inhibitors (ie, pimecrolimus or tacrolimus); between the 2, tacrolimus is the first choice for adults and children older than 2 years. When systemic management is needed, oral calcineurin inhibitors (eg, cyclosporine) are appropriate, though oral steroids often are needed for severe cases. The need for systemic management can sometimes be delayed with use of diluted bleach baths. For acne vulgaris, standard treatments with topical benzoyl peroxide and topical or systemic antibiotics are used widely, as are oral contraceptives, but oral isotretinoin is the most effective treatment.

Skin conditions: emerging drug-resistant skin infections and infestations.

Methicillin-resistant Staphylococcus aureus (MRSA) skin infections are increasingly common. Automated microbiology systems are now available to detect MRSA and to determine antibiotic resistance patterns. Abscesses should be drained and antibiotics administered, with systemic antibiotics used to manage more severe infections. Until sensitivities are known and depending on local resistance rates, clindamycin is an option for empiric management of stable patients without bacteremia. For patients who are more ill, linezolid and vancomycin are alternatives, the latter being first-line treatment for children hospitalized with MRSA skin infections. Drug resistance also occurs in head lice management. Although topical permethrin is still the first-line drug management, its effectiveness has decreased due to permethrin-resistant strains. Patients who do not benefit from 2 applications of permethrin can be treated with topical malathion or topical ivermectin. Though not approved by the Food and Drug Administration (FDA) for treating head lice, oral ivermectin is sometimes used for difficult-to-treat cases. Permethrin is also the first-line management for scabies, though there is a concern that permethrin-resistant scabies may soon occur. For patients with scabies who do not benefit from topical treatment, oral ivermectin is recommended by the Centers for Disease Control and Prevention, although it is not approved by the FDA for this purpose.

Skin conditions: benign nodular skin lesions.

Benign subcutaneous lesions are a common reason that patients visit family physicians. Lipomas are the most common of these lesions; they most often occur on the trunk and proximal extremities. Recent data show that as many as half of the fat cells in lipomas are atypical. Ultrasound is used increasingly to confirm lipoma diagnosis, but deep lesions should be evaluated with magnetic resonance imaging study or computed tomography scan to exclude involvement of underlying structures and/or liposarcoma. Small lesions can sometimes be managed with serial injections of midpotency steroids. Larger lesions (larger than 5 cm), those compressing other structures, or those suspicious for malignancy should be excised using standard surgical excision or, when possible, the newer minimal-scar segmental extraction technique. Ganglion cysts are another common lesion, the presence of which often is confirmed with ultrasound if the diagnosis is not clinically apparent. Management includes splinting, aspiration, and/or injection of steroids, with or without hyaluronidase. Epidermal inclusion cysts, also called sebaceous cysts, typically are asymptomatic unless they become infected. Ultrasound can aid in diagnosis. The only definitive management is surgical excision with complete removal of the cyst wall or capsule, using minimal-scar segmental extraction or conventional surgical removal.

Skin conditions: common skin rashes in infants.

Infants exhibit many skin rashes. Erythema toxicum neonatorum presents as erythematous macules, papules, and pustules on the face, trunk, and extremities; it typically resolves spontaneously within 1 week. Neonatal acne presents as comedones or erythematous papules on the face, scalp, chest, and back. Infantile acne is similar but starts after the neonatal period. Both conditions typically resolve spontaneously; failure to resolve within 1 year warrants evaluation for androgen excess. Neonatal cephalic pustulosis is an acne variant caused by hypersensitivity to Malassezia furfur. It is typically self-limited, but severe cases are managed with topical ketoconazole. Miliaria and milia are caused by sweat retention and present as tiny vesicles or papules; they resolve spontaneously. Contact diaper dermatitis is managed by keeping the diaper area clean and with open air exposure. Diaper dermatitis due to Candida albicans is managed with topical antifungals. Seborrheic dermatitis causes scaling on the scalp. Management involves shampooing and removing scales with a soft brush after applying mineral oil or petrolatum; severe cases are managed with tar or ketoconazole shampoo. Atopic dermatitis is related to food allergy in approximately one-third of children. Food allergy can be confirmed with oral food challenges or skin prick tests. Management includes elimination of irritants and triggers and use of low-potency topical steroids.

Falling through the cracks: gaps in depression treatment among older Mexican-origin and white men.

OBJECTIVES: This study aims (i) to compare depression frequency and self-reported depression treatment in Mexican-origin and white men; (ii) to examine ethnic differences in self-reported prior depression diagnosis and types of treatment; and (iii) to determine whether Mexican-origin men (both English and Spanish language preferring) are less likely than white men to report receiving depression treatment after controlling for potential confounders. METHODS: This is a cross-sectional, observational study of Mexican-origin and white men (60 years old and over) presenting for primary care visits at six outpatient clinics in California's Central Valley. Clinical depression was assessed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), module for past-year major depression and questions for chronic depression. Past year, self-reported prior depression diagnosis and treatment (i.e., medication, psychotherapy, mental health referral) were assessed through a structured questionnaire. RESULTS: The frequency of past-year clinical depression was similar for both ethnic groups, yet Mexican-origin men were significantly less likely than whites to report receiving a prior diagnosis of depression or prior depression treatment. Compared with whites, the odds of untreated depression in Mexican-origin men was 4.35 (95% CI 1.35-14.08) for those interviewed in English and 10.40 (95% CI 2.11-51.25) for those interviewed in Spanish. For both ethnic groups, the majority (i.e., approximately two-thirds) of men receiving depression treatment also met criteria for past-year clinical depression. CONCLUSIONS: Mexican-origin older men in primary care suffer from significant gaps in depression care (i.e., diagnosis and treatment) compared with whites. Delivering effective depression treatment (i.e., so that depression remits) remains elusive for both ethnic groups.

El intento de suicidio en el cuarto de urgencia del C.H.M., C.S.S. y su relación con el suicidio en la República de Panamá / Attemped suicide in the emergency room of C.H.M., C.S.S. and its relation with the suicide in the República de Panamá

En esta investigación se ponen en evidencia los intentos de suicidio en el Complejo Hospitalario Metropolitano, se realiza una comparación entre los diversos estudios publicados en Panamá, hechos con pacientes del Cuarto de Urgencia del Hospital Santo Tomás, estableciendo una correlación con la incidencia de suicidio en la República de Panamá y se revisa en forma general la literatura y las experiencias al respecto en otras latitudes. Se incluyen 194 pacientes que acudieron al Cuarto de Urgencia durante el período de enero a diciembre de 1984, sienso evaluados por los residentes de Psiquiatría y registrados en forma diaria en un libro especial donde se consignaban: edad, sexo, método del intento, residencia habitual, causa, ocupación, diagnóstico e intentos previos y destino para su tratamiento posterior. Se logró valorar el riesgo del intento y del suicidio, concluyéndose que el grupo de edad donde ocurren más suicidios es el de los 15 a 24 años (28%) con mayor número de intentos de suicidio entre los 20 y los 24 años (30%), siendo varones (84%) los que más se suicidan y las mujeres (74%) las que más intentan suicidarse, ocupando San Miguelito (39.6%) el primer lugar de procedencia de los pacientes que intentaban suicidarse y la provincia de Chiriquí (19%) en donde ocurre el mayor número de suicidios, mencionándose los conflictos familiares y económicos como las principales causas del intento, utilizándose los fármacos y substancias tóxicas como el medio más frecuentemente usado para tal finalidad. Como objeto primordial se desea llamar la atención de los trabajadores de la Salud Mental hacia la importancia de brindar una atención intensiva en forma interdisciplinaria, por medio del programa de Intervención en Crisis, a este grupo de pacientes, que ocupa el segundo lugar entre las causas de Urgencias Psiquiátricas en el C.H.M.C.S.S.

El hipertiroidismo y la psicosis orgánica transitoria / Hyperthyroidism and organic transient psychosis

Presentamos un caso clínico de una paciente sin antecedentes psiquiátricos ni endocrinológicos, que tuvo alteraciones psíquicas secundarias a un hipertiroidismo y cuyo manejo en la fase inicial fue complejo y se efectuó en la Sala de Psiquiatría. El objeto principal de este trabajo fue realizar una revisión general de las manifestaciones psíquicas de una enfermedad endocrinológica como lo es el Hipertiroidismo

Atención psiquiátrica en el cuarto de urgencia del Complejo Hospitalario Metropolitano de la Caja de Seguro Social / Psychiatric care in an emergency room of the Complejo Hospitalario Metropolitano de la Caja de Seguro Social

El presente trabajo tiene como objetivo primordial poner en evidencia la variada patología psiquiátrica que presentaron novecientos setenta y dos (972) pacientes atendidos por los médicos residentes de Psiquiatría durante el período comprendido entre el 1 de junio de 1983 y el 31 de mayo de 1984. Se puso en evidencia que los trastornos psicóticos del tipo de la Esquizofrenia, fueron la principal causa de atención, trescientos ocho (308) casos. Los intentos de suicidio ocuparon el segundo lugar, ciento veintiseis (126) pacientes, mientras que los problemas asociados con el abuso de drogas no fueron notorios (1%). Hubo predominio de mujeres en el grupo estudiado, con mayor frecuencia de atención a pacientes de edades jóvenes (10 a 29 años). El mayor porcentaje de pacientes (41.6%) fue referido a la Consulta Externa de Psiquiatría, 38.7% de los pacientes fueron admitidos a la Sala de Observaciones del Cuarto de Urgencias y 4.2% de los pacientes fueron trasladados a otras instituciones