Mark Corson

By E. Pavel. Saint Thomas Aquinas College. 2018.

Downloaded “Human Immunodeficiency Virus Infection Is Rare from September 22 generic aristocort 4 mg mastercard, 2002 purchase aristocort 10 mg free shipping. Downloaded September 5 discount 4mg aristocort free shipping, “Human Papillomavirus Testing Highly Valuable in Cer- 2002. Western Medical Journal 173 (2000): 296 The Encyclopedia of Sexually Transmitted Diseases 292–293. Allergy and Infectious Diseases, National Institutes of org/special/std/support/educate/stdpid. Downloaded on Transfusion Transmitted Infection in Recipients of November 1, 2001. National Institute of Allergy and Infectious Diseases, “Prophylaxis of Venereal Disease. Journal of the American Medical Association sure of Mucous Membrane to Contaminated 286 (2001). News item from British Medical Journal (December 5, “Surgeon General’s Call to Action to Promote Sexual 2001). Journal of the “What You Need to Know about This Dangerous Sexually American Medical Association 286, no. United States: Epidemiologic, Diagnostic, and Clinical Wodarz, Dominik, and Nowak, Martin A. See Centers for bacterial vaginosis 14 Burroughs Wellcome 6 sexual assault and Disease Control and genital warts 65 Bush, George W. See carcinoma in situ and fear of ostracism Child Care Health duty to warn 38 civil liberties 26, 150. Crohn’s disease 178 dental dam 35, 162 opportunistic infection Helms Amendment 72 cryotherapy 32, 62–64 Department of Health and reduction 82 needle access 152 cryptococcal meningitis Human Services, U. See enzyme Intervention Research 36 187–188 immunoassay and Support Dobkin, Jay F. See body fluids gangrene 198 episodic herpes therapy tubal pregnancy 213 fluorescent treponemal gardening genital herpes 54, 57, false-negative 46, 51 antibody-absorption test. See Journal of the infectious 117 opportunistic infection interstitial pneumonia 122 American Medical Infectious Disease Society reduction 82 intervention 122. See mycobacterium discrimination 36 prevention messages lobal pneumonia 174 avium complex disease medication guidelines 139 177 Loisel, Douglas 113 macrobiotic diet 159 meditation 139–140 mood disorders 142–143. See Medicaid 138 bacterial vaginosis 14 also animals, working 52 meningitis 141 cause 169 with podofilox (Condylox) 62, patterns of condom use chlamydia and xiv Phair, John P. See protease inhibitor in 197 213–214 Index 321 Preven 144 prodrome Public Health Service, U. See rest and n assay Chlamydia trachomatis patients 72 relaxation risk control 189 25 stress 200–202 reporting and education 41 gay bowel syndrome surveillance data 202 confidentiality 185–187 genital herpes 52 49 Public Health Practice mandatory reporting sexually transmitted proctocolitis 49, 178 Program Office 93 136 disease 197 322 The Encyclopedia of Sexually Transmitted Diseases risky behavior 189. See sexually swollen glands 202 rate of new infections, social services 199 transmitted disease symptoms U. See adolescents third-party payers 120, failure to seek xv Chlamydia trachomatis tenofir 106 121 gene therapy 49 25 tertiary syphilis 203, 205, Thorne, C. See World Health lesions 158 genital warts 64 vibrators 193 Organization urban legends. See myths vaginal intercourse 222 Vietnam 23 withdrawal 180–181 Ureaplasma urealyticum Chlamydia trachomatis viral culture 51, 223 women. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857;e-mail: bookorders@who. The designations employed and the presentation of the material in this publication do not imply the expression ofanyopinionwhatsoever on thepartoftheWorldHealth Organization concerning thelegal statusofanycountry,territory,cityorareaorofitsauthorities,orconcerningthedelimitationofitsfrontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. This publication contains the collective views of an international group of experts and does not necessarily represent the decisions or the stated policy of the World Health Organization or of the Food and Agriculture Organization of the United Nations. Population nutrient intake goals for preventing diet-related chronic diseases 54 5. Amine, Dean, High Institute of Public Health, Alexandria University, Alexandria, Egypt Dr N. Baba, Chairperson, Department of Nutrition and Food Sciences, American University of Beirut, Beirut, Lebanon Dr M. Belhadj, Professor of Internal Medicine and Diabetologia, Centre Hospitalier Universitaire, Oran, Algeria Dr M. Deurenberg-Yap, Director, Research and Information Management, Health Promotion Board, Singapore (Co-Rapporteur) Dr A. Djazayery, Professor of Nutrition, Department of Nutrition and Biochemistry, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran Dr T. Forrester, Director, Tropical Medicine Research Institute, The University of the West Indies, Kingston, Jamaica Dr D.

This can be used 12 days after expo- woman who gets herpes for the first time while sure and gives accurate results 10mg aristocort visa. Also generic aristocort 15 mg otc, she may run the risk of when those infected do not know that the virus premature delivery and considerable problems for is active purchase aristocort 4 mg without a prescription. Half of babies infected with herpes die or individual can get herpes without even recogniz- suffer neurological damage; a baby who is born ing the first episode because of the possibility of with herpes can experience encephalitis (brain “silent” transmission. When genital herpes is in the active stage, there Acyclovir can improve the outcome of babies may or may not be visible lesions. Several labora- with neonatal herpes if they are treated immedi- tory tests may be required to differentiate herpes ately. Complications During the last trimester, refraining from inter- A herpes-infected woman who sheds herpesvirus course is wise. Thus, since having a first time during her second trimester will undoubtedly episode during pregnancy presents a much greater have an abdominal delivery (cesarean section) risk of transmission to the newborn and a greater whether or not she has signs of active herpes, risk of intrauterine infection of the fetus, it is because a mother having her first outbreak of her- important that pregnant women prevent contrac- pes simplex virus near or at the time of the baby’s tion of herpes. In cases of recurrence of this disease, the time of delivery usually requires a cesarean section. However, in women with genital herpes, infection A physician who detects herpes lesions in or of an infant is rare. Though very rare, herpes infec- near the birth canal during labor performs a tions in newborns are life-threatening. Herpes can cesarean section to ward off danger of infection to be transmitted to infants during delivery if the baby the baby. When labor is beginning, it is important to has active herpes signs or symptoms in or near the ask the doctor to check carefully for signs of geni- birth canal at the time of delivery. Vaginal delivery is acceptable for nal birth can be expected if the woman begins women with herpes who have no prodromal signs labor with no symptoms of herpes. Even with a nancy, a longtime herpes sufferer transmits protec- cesarean section, the infant is not 100 percent safe tive antibodies to her fetus. An easy often experience herpes simplex virus episodes target is the soft skin of the genitals, vagina, anus, that are very severe and long-lasting. Herpes can even reactivate without producing visible sores, although the virus may still be shed- Prodrome ding around the original infection site, in genital The signal of a new recurrence of herpes is called a secretions, or from lesions that are barely notice- prodrome, which feels like itching or tingling in able. Although this shedding may last only a day the genital area, a backache, leg pains, or another and may not cause any discomfort, the infected type of sensation. Both types are transmit- A prodrome is often a precursor of skin lesions ted through direct contact: kissing and sexual con- soon to appear—although that is not always what tact (oral, vaginal, anal, or skin-to-skin contact). What it does mean invariably is that her- is extremely important for sexually active individ- pes is in its active phase. Symptoms of recurrent uals to understand that genital herpes can be trans- episodes tend to be milder than those of the first mitted even if the infected partner has no sores or episode and last about a week. It should be emphasized that people with oral herpes can transmit the infection to the Prevention genital area of a partner during oral–genital sex. A Before and during an outbreak, herpes is conta- third route of transmission is through a herpes- gious. It is most contagious when the virus is repli- infected individual who transmits the disease with cating externally before an outbreak and during an no concern for his or her victims. The not attribute their symptoms to genital herpes at patient who takes the drug before lesions appear the time of transmission. During an active herpes makes more significant gains, and, in some cases, episode, people with genital herpes should take early preventive medication forestalls formation of steps to speed healing and to prevent spread of the lesions altogether. The patient protection, but no one should count on these to takes a small dose of antiviral medication daily for provide 100 percent protection because viral long periods. Typically, those on suppressive ther- shedding, and thus exposure, can occur when a apy dramatically reduce their symptom recurrence, herpes lesion (sometimes invisible to the naked and in about one-fourth, there are no recurrences eye) is not totally covered by the condom. Often, the physician treating the herpes suf- partner has genital herpes, abstain from sex when ferer stops suppressive therapy once a year to symptoms are present and use latex condoms assess the need for the medication. Recent research suggests yet another advantage An individual with herpes sores on the lips can of suppressive therapy—a 95 percent reduction in spread herpes to the lips of another person through days per year of viral shedding and risk of trans- kisses. For that reason, many cases of genital transmission can be completely prevented by use herpes are caused by herpes type 1. A patient who takes Treatment either drug can reduce the duration and severity of For herpes, there is no quick fix, nor is there a symptoms during a first episode and speed healing cure. Medications called antiviral drugs can, how- during recurrences and prodrome (when there are ever, attack the virus and give those afflicted with warning signs and symptoms). They work espe- this disease some relief, helping to reduce the cially well when initiated within 24 hours of onset duration and severity of symptoms. Research shows that daily five times a day for a first episode and usually 400 use of antiviral therapy dramatically lessens the mg is taken three times a day for treatment of rate of asymptomatic viral shedding, as well as recurrences. Controlling outbreaks only rarely associated with any serious adverse and minimizing discomfort are two goals of antivi- effects. The severity of a first episode of gen- shown no rise in birth defects or other problems in ital herpes can be dramatically minimized by the more than 10 years. Similar safety is reported in use of an initial 10-day course of medication that the newer entries on the market—valacyclovir helps sores to heal faster, reduces swollen glands, (Valtrex) and famciclovir (Famvir). For chronic suppression, Valtrex is sign of an outbreak; this serves to shorten dura- taken once daily. Famciclovir (Famvir) lasts longer genital herpes 55 in the body than acyclovir, and the herpes patient should be reported to the registry (800-722-9292, takes only twice-daily doses. Oral acyclovir may be taken by a woman who Recurrences has her first episode of genital herpes during preg- It has been seen that people having six or more nancy.

Radiol ence of chondrocalcinosis allow a specific diagnosis to Clin North Am 42(1):169-184 be made discount 10 mg aristocort fast delivery. A femoral fracture heals in one week in In children cheap 4mg aristocort with mastercard, the skeleton undergoes multiple changes with the newborn discount 4mg aristocort with amex, four weeks in the 5-year-old, eight weeks in age. These age-related transformations determine the pat- the 10-year-old, three months in the adolescent, and more terns of injury or disease and their imaging findings. The unossified epiphysis can sepa- Normal Age-Related Variants and Related rate from the smooth metaphysis and, on radiographs, an Diseases apparent dislocation of the hip and shoulder can actually be a separation. The physis or growth plate, initially a flat Radiographs disk between epiphysis and metaphysis, becomes progres- sively undulated after puberty and ultimately closes. The Normal variants are often bilateral, but reassuring symmetry pattern of physeal injuries is thus more complex in older is not always present. The apophyses also tend to be avulsed at the base, es, only the lateral condyle in 44%, and only the medi- where the apophyseal cartilage meets the parent bone. Accessory centers of ossifica- thin, porous bony cortex of the newborn is transformed to tion are more conspicuous in the posterior femoral dense lamellar bone beginning in the diaphysis; metaphy- condyles. The tibial tubercle ossifies between 8 and 12 seal fractures usually occur at the point of transition be- years in girls and 9 and 14 years in boys [2] and is nor- tween the two types of bone. Osgood-Schlatter disease is character- bow rather than break, and the fractures frequently involve ized by local pain and inflammation, and by imaging only one cortex. The injured radius and ulna often fracture evidence of edema anterior to the tubercle and patellar incompletely, and the pelvis of a child is elastic and often tendon. The loosely attached periosteum girls at 4-6 years of age, and in boys at 4-9 years of of growing bones separates easily from the bone during a age, and is uneven, asymmetric, fragmented and scle- fracture; the intact periosteum is essential for the rapid rotic (Fig. The perichondrium, on the other with disuse of the foot or after a month of not bearing hand, is tightly attached to the metaphyseal bone. Sever’s disease (calcaneal apophysitis) can metaphyseal fractures of battered children the perichon- be diagnosed if there is soft tissue swelling on radi- drium retains a rim of juxtaphyseal cortex which is seen ographs or cross-sectional images or increased scinti- as a bucket handle or a corner fracture on radiographs. A pseudofracture produced by one end of the child’s skeleton, and it is unusual to have ligamentous in- physeal disc projecting over the other is easily recog- nized in the proximal humerus, but can be confused with a lateral condylar fracture in the distal humerus. Normal irregularity of ossifi- cation in 4-year-old girl with knee pain and effusion after trauma. Normal calcaneal ossification and distal tibial undula- volving the distal tibial physis 18 tion in a 9-year-old boy. There is an irregular- rosis and irregularity of the apophysis, which is related to weight ity in the metaphysis (arrow) cor- bearing (arrow). The juxtaphyseal metaphysis of weight- distal femoral insertion of the medial head of the gas- bearing bones can be sclerotic between 2 and 6 years of trocnemius muscle, where it can resemble a neoplasm age [5]. This can be seen in neonates under stress, vicinity of the physis are left behind, falsely appearing and in children with leukemia or methotrexate osteopa- to migrate towards the diaphysis (Fig. The navicular is the last tarsal bone to os- tions are prone to repeated minor avulsive injury. There are normally two ossification centers, but cortex becomes irregular, particularly in the posterior multiple irregular, dense centers can develop, and fuse 150 D. Aseptic necrosis of the navicular Scintigraphy (Kohler’s disease) affects older children, and is associ- ated with pain [9]. Tc-99m diphosphonate uptake is high in long bone phy- ses and in physeal equivalents of the flat bones [16, 17]. Skeletal structures that have not yet ossified have hematopoietic to fatty marrow, strongly influence the no Tc-99m diphosphonate uptake. The physis is of high signal intensi- Imaging Strategies ty on most pulse sequences (Fig. With physeal clo- sure, the cartilage loses signal intensity and ultimately In pediatric musculoskeletal imaging, the first imaging disappears [12]. Because of its high water content, normal haps the use of ultrasonography during the first six month hematopoietic marrow is of low signal intensity on of life for evaluation of developmental dysplasia of the T1-weighted images, intermediate signal intensity on hip, where radiographs are of little value. It is important to know the relative strengths hematopoietic to fatty marrow begins in the epiphyses and indications of each modality in the evaluation of pe- and diaphysis, and then advances into metaphyses. Unlike meniscal tears, which are usually multiplanar and three-dimensional (3D) reconstructions vertical in children [14], intrameniscal nutrient ves- are considered (Fig. In acetabular fractures, 3D reconstruc- tions demonstrate the relationships between fragments better. If a low mAs technique is used, the total ovarian dose can be as low as 112 mrad (1. Frontal and posterior oblique 3D surface renderings of the spine of a 3-month-old girl with a severe defect of the bony thorax. It is also malities of vertebral segmentation, and the location of the very useful in pelvic osteomyelitis, where bony geometry conus medullaris (normally at L2 level, more caudal if the is complex and soft tissue involvement is often the most cord is tethered). Septic arthritis and femoral head ischemia in an 11-year-old boy who had osteomyelitis of the ischium. Tibial torsion is determined by the angle between a physeal widening and sometimes transphyseal bridging. External tibial torsion determined by tients in whom impaired sensation and continued motion physical examination is normally 4° at birth, and 14° at result in repeated physeal damage [49]. A 3D fat-suppressed spoiled gradient-recalled Sonography is the main study in infants younger than 6 echo sequence provides most, if not all, of the informa- months with a question of hip dysplasia because it al- tion required to assess growth arrest [52, 53]. In Coventry, T1-weighted images also depict skip lesions and metas- England, screening of more than 14 000 newborns de- tases or multifocal disease in the contralateral extremity tected a 6% incidence of sonographic abnormalities.

In addition aristocort 40 mg low price, it eliminates foci of microbial proliferation buy aristocort 4mg low price, which may be a source of transient bacteremia cheap aristocort 10mg otc. We recommend complete early excision of clearly full- thickness wounds within 48 hours of the injury, and coverage of the wound with autograft or allograft skin when autograft skin is not available. Within days, this treatment will provide a stable antimicrobial barrier to the development of wound infections. Barret and Herndon described a study in which they enrolled 20 subjects, 12 of whom underwent early excision (within 48 hours of injury) and 8 of whom underwent delayed excision (>6 days after injury). Quantitative cultures from the wound excision showed that early excision subjects had less 5 than 10 bacteria/g of tissue, while those who underwent delayed excision had greater than 10 organisms, and three of these patients (37. In another study from the same center, it was found that delayed excision was associated with a higher incidence of wound contamination, invasive wound infection, and sepsis with bacteremia compared with the early group when the rest of the hospitalization was considered (12). These two studies show that the best control of the burn wound is obtained with early excision. Before or after excision, control of microorganism growth is obtained by the use of topical antibiotics. Salves are generally applied directly to the wound and left exposed or covered with cotton dressings, and soaks are generally poured into cotton dressings on the wound. Salves may be applied once or twice a day, but may lose effectiveness between dressing changes. More frequent dressing Infections in Burns in Critical Care 361 Table 1 Topical Antimicrobials Commonly Used in Burn Care Salves Advantages Disadvantages Silver sulfadiazine l Broad-spectrum l Transient leucopenia (Silvadene 1%) l Relatively painless on application l Does not penetrate eschar l May tattoo dermis with black flecks Mafenide acetate l Broad-spectrum l Transient pain upon application to (Sulfamylon 11%) l Penetration of eschar partial thickness burns l May cause an allergic rash l Carbonic anhydrase inhibition Polymyxin B/neomycin/ l Wide spectrum l Antimicrobial coverage less bacitracin l Painless on application than alternatives l Colorless allowing direct inspection of the wound Mupirocin (Bactroban) l Broad-spectrum (especially l Expensive Staphylococcus species) Nystatin l Broad antifungal coverage l May inactivate other antimicrobials (Sulfamylon) Soaks Silver nitrate (0. Soaks will remain effective because antibiotic solution can be added without removing the dressing, however, the underlying wound and skin can become macerated. No single agent is completely effective, and each has advantages and disadvantages. It has a broad spectrum of activity from its silver and sulfa moieties covering gram-positives, most gram-negatives, and some fungal forms. It is relatively painless upon application, has a high patient acceptance, and is easy to use. Occasionally, patients will complain of some burning sensation after it is applied, and a substantial number of patients will develop a transient leukopenia three to five days following its continued use. This leukopenia is generally harmless, and resolves with or without cessation of treatment. Control of the microbial density in the burn wound by topical therapy not only decreases the occurrence of burn wound infection per se but also permits burn wound excision to be carried out with marked reduction of intraoperative bacteremia and endotoxemia. These two conditions formerly compromised the effectiveness of burn wound excision performed on other than the day of injury. Disadvantages include transient pain following application to skin with sensation, 362 Wolf et al. It also can cause an allergic skin rash and has carbonic anhydrase inhibitory characteristics that can result in a metabolic acidosis when applied over large surfaces. For these reasons, mafenide acetate is typically reserved for small full-thickness injuries, wounds with obvious bacterial overgrowth, or in those full-thickness wounds that cannot be rapidly excised, such as in patients with concomitant devastating head injuries. Petroleum-based antimicrobial ointments with polymyxin B, neomycin, and bacitracin are clear on application, painless, and allow for easy wound observation. These agents are commonly used for treatment of facial burns, graft sites, healing donor sites, and small, partial- thickness burns. Mupirocin is another petroleum-based ointment that has improved activity against gram-positive bacteria, particularly methicillin-resistant Staphylococcus aureus and selected gram-negative bacteria. Nystatin, either in a salve or powder form, can be applied to wounds to control fungal growth. Nystatin-containing ointments can be combined with other topical agents to decrease colonization of both bacteria and fungus. The exception is the combination of nystatin and mafenide acetate because each will inactivate the other. Silver nitrate has the advantage of painless application, and almost complete antimicrobial coverage. The disadvantages include its staining of surfaces to a dull gray or black when the solution dries. This can become problematic in deciphering wound depth during burn excisions and in keeping the patient and surroundings clean of the black staining with exposure to light. The solution is hypotonic as well, and continuous use can cause electrolyte leaching, with rare methemoglobinemia as another complication. Dakin’s is a basic solution with effectiveness against most microbes; however, it also has cytotoxic effects on the patients wounds, thus inhibiting healing. Low concentrations of sodium hypochlorite have less cytotoxic effects while maintaining the antimicrobial effects in vitro. In addition, hypochlorite ion is inactivated by contact with protein, so the solution must be continually changed either with frequent application of new solution or continuous irrigation. The same is true for acetic acid solutions; however, this solution may be more effective against Pseudomonas, although this may only be a discoloration of pyocyanine released by this organism without effect on its viability. Mafenide acetate soaks have the same characteristics of the mafenide acetate salve but are not recommended for primary treatment of intact eschar. It must be stated that all topical agents inhibit epithelialization of the wound to some extent, presumably due to toxicity of the agents to keratinocytes and/or fibroblasts, polymorphonuclear cells, and macrophages.

O Normal pigmentation O Lentigo O Amalgam tattoo O Lentigo maligna O Heavy-metal deposition O Pigmented nevi O Drug-induced pigmentation O Nevus of Ota O Smoker’s melanosis O Melanoma O Black hairy tongue O Addison disease O Ephelis O Peutz–Jeghers syndrome Laskaris 40 mg aristocort otc, Pocket Atlas of Oral Diseases © 2006 Thieme All rights reserved purchase aristocort 15 mg with visa. Usage subject to terms and conditions of license 82 Black and Brown Lesions Normal Pigmentation Definition and etiology Increased melanin production and deposition in the oral mucosa may often be a physiological finding buy discount aristocort 40mg on-line, particularly in dark-skinned individuals. Clinical features This type of pigmentation is persistent and symmet- rical, and clinically presents as asymptomatic black or brown areas of varying size. The gingiva are most commonly affected, followed by the buccal mucosa, palate, and lips (Fig. The pigmentation is more prominent in areas of pressure or friction, and usually becomes more intense with increasing age. Differential diagnosis Addison disease, smoker’s melanosis, drug-in- duced pigmentation, pigmented nevi, melanoma, amalgam tattoo. Clinical features The condition presents as a well-defined irregular or diffuse flat area, with a bluish-black discoloration of varying size (Fig. The most common sites of involvement are the gingiva, alveolar mucosa, and buccal mucosa. Differential diagnosis Pigmented nevi, lentigo, freckles, melanoma, normal pigmentation, other metal tattoo. Usage subject to terms and conditions of license 84 Black and Brown Lesions Heavy-Metal Deposition Definition and etiology Heavy-metal deposition is a rare oral condi- tion caused by ingestion or exposure to bismuth, lead, silver, mercury, and other heavy metals. Clinical features Clinically, the most common pattern (bismuth, lead) is a bluish line along the marginal gingiva, or similar spots within the gingival papillae (Fig. Drug-Induced Pigmentation Definition Drug-induced oral pigmentation is a relatively common condition, caused by increased melanin production or drug metabolite deposition. Etiology Antimalarials, tranquilizers, minocycline, azidothymidine, ke- toconazole, phenolphthalein, and others are the most common drugs that induce pigmentation. Clinical features The clinical picture varies, and the condition may appear as irregular brown or black macules or plaques, or diffuse mela- nosis (Fig. The buccal mucosa, tongue, palate, and gingiva are the most commonly affected sites. Differential diagnosis Normal pigmentation, Addison disease, Peutz– Jeghers syndrome. Usage subject to terms and conditions of license 86 Black and Brown Lesions Smoker’s Melanosis Definition Smoker’s melanosis, or smoking-associated melanosis, is a benign abnormal melanin pigmentation of the oral mucosa. Clinical features Clinically, it appears as multiple brown pigmented areas, usually located on the anterior labial gingiva of the mandible (Fig. Pigmentation of the buccal mucosa and palate has been asso- ciated with pipe smoking. Differential diagnosis Normal pigmentation, drug-induced pigmenta- tion, pigmented nevi, melanoma, Addison disease. Cessation of smoking is usually associated with a return of normal mucosal pigmentation. Usage subject to terms and conditions of license 88 Black and Brown Lesions Ephelis Definition Ephelides, or freckles, are discrete brown macules, com- monly seen on sun-exposed skin and rarely in the mouth. Clinical features Clinically, the lesions appear as solitary and well- demarcated asymptomatic round brown macules, less than 5 mm in diameter (Fig. Differential diagnosis Lentigo, pigmented nevi, melanoma, drug-as- sociated pigmentation, Peutz–Jeghers syndrome, Albright syndrome. Treatment No treatment is required, except for aesthetic or diagnostic considerations. Clinical features The condition presents as small round flat spots, brown or dark brown in color, usually less than 0. Differential diagnosis Ephelis, pigmented nevi, melanoma, Peutz– Jeghers syndrome. Usage subject to terms and conditions of license 90 Black and Brown Lesions Lentigo Maligna Definition Lentigo maligna, or Hutchinson’s freckle, is a premalignant lesion of melanocytes that probably represents in-situ melanoma. Clinically, it appears as a slowly expanding black or brown plaque, with irregular borders (Fig. The lips, buccal mucosa, palate, and floor of the mouth are the common sites affected. Pigmented Nevi Definition Pigmented cellular nevi are benign malformations of me- lanocytes and “nevus cells,” common in the skin and rare in the oral mucosa. Clinical features Based on histological criteria, oral pigmented nevi are classified into four types: intramucosal, junctional, compound, and blue. Clinically, the lesion appears as an asymptomatic, well-demarcated, flat or slightly elevated, brown, black, or blue spot or plaque (Fig. Usage subject to terms and conditions of license 92 Black and Brown Lesions Nevus of Ota Definition Nevus of Ota, or oculodermal melanocytosis, is a hamar- tomatous disorder of the melanocytes that predominantly involves the skin of the face and eyes, and mucous membranes. Characteristically, the lesions follow the distribution of the first and second branches of the trigeminal nerve. Hyperpigmentation is due to melanin-pro- ducing melanocytes in the dermis that have failed to reach the epidermis or epitheliumduring fetal life. Clinical features The skin lesions present as multiple mottled black or brown macules varying in size from 1 mm to several millimeters (Fig. The oral lesion presents as asymptomatic blue or blue-black dots or patches that usually involve the palate and buccal mucosa (Fig. Hyperpigmentation of ipsilateral sclera is a common sign, while involvement of the cornea, iris, fundus, oculi, and retina is rare. Other sites such as nasal mucosa, pharynx, and tympanum may be less com- monly affected. The disorder usually appears in early childhood before the age of 1 year and around puberty. Usage subject to terms and conditions of license 94 Black and Brown Lesions Melanoma Definition Melanoma is a malignant neoplasm originating either de novo frommelanocytes, or froma benign melanocytic lesion.