By X. Peer. University of Central Florida.

Sagittal T2-weighted images show the different degrees of disk de- generation according to the classification system proposed by Pfirrmann et al 250mg flagyl visa. Currently purchase 500mg flagyl otc, the most widely accepted terms are: normal, bulging, protrusion, extrusion and sequestration [6]. A disk is considered normal when it does not reach beyond the border of the adjacent vertebral bodies. Bulging is defined as circumferential, symmetric disk extension around the posterior vertebral border. Protrusion is defined as focal or asymmetric extension of the disk beyond the vertebral border, with the disk origin broader than any other dimen- sion of the protrusion. Extrusion is defined as a more ex- treme extension of the disk beyond the vertebral border, Fig. T2-weighted images in with the base against the disk of origin narrower than the di- the sagittal and axial planes ameter of the extruding material and a connection between demonstrate disk extrusion at the L4/5 disk level with com- the material and the disk of origin (Fig. Sequestration is pression of the right-sided L5 defined as a free disk fragment that is distinct from the par- nerve root ent disk and has intermediate signal intensity on T1-weight- ed images but increased signal intensity on T2-weighed im- ages (Fig. The above-mentioned classification system for disk abnormalities does not use the term disk herniation, which is defined as displacement of disk material beyond a b the normal margins of the intervertebral disk space [6]. The herniated material may include nucleus pulposus, cartilage, fragmented apophyseal bone, or fragmented anular tissue. Some authors use the term disk herniation to collectively designate protrusions and extrusions. Intervertebral disk herniation or Schmorl’s node repre- senst an intervertebral displacement of nuclear material through a break in the vertebral endplate. Occasionally, it may present as a well-delineated cystic lesion within the vertebral body, the so-called giant cystic Schmorl’s node [7]. Intravertebral disk displacement may be associated with any disease process that weakens or disrupts the Fig. Sagittal T1- and T2-weighted images demonstrate a se- endplate or subchondral bone, including intervertebral questrated disk at the L3/4 level. In addition, high-signal-intensity osteochondrosis, Scheuermann disease, trauma, hyper- zones are visible at L3/4, L4/5 and L5/S1 disk levels 134 D. Spondylosis Deformans and Degenerative Chronic Schmorl’s node is asymptomatic and most com- Facet Disease monly occurs in the thoracolumar region. Acute Schmorl’s node may cause pain and the surrounding ver- The most obvious changes in degenerative diseases of the tebral bone marrow may show diffuse marrow edema [9]. The outgrowths are called pain, it is not only important to report the morphology, lo- osteophytes or spondylosis deformans. Osteophytes arise cation, and size of the disk abnormality, but also to describe in the setting of disk degeneration when Sharpey fibers the relationship between the disk and the nerve root. According to this classification sys- ly, particularly in the lateral recesses of the spinal canal tem, the relationship between the disk and the nerve root is or in the intervertebral foramen. Although the grading joints are true synovial joints, with hyaline articular car- system is primarily based on the assessment of axial images, tilage, a synovial membrane and a joint capsule. Facet sagittal images are also useful, in particular to detect com- joint osteoarthritis does not differ from degenerative promise of the nerve root within the neuroforamina. There is commonly tears (synonym: anular fissure) are separations between a proliferative response involving the formation of osteo- anular fibers, avulsion of fibers from their vertebral-body phytes and sclerosis of subchondral bone. In addition, insertions, or breaks through fibers involving one or subchondral cysts and synovial inflammation may be pre- many layers of the anular lamellae. Other forms of ac- a b quired central stenosis include iatrogenic stenosis, trau- matic stenosis, and miscellaneous causes of stenosis (e. Cervical Spinal Stenosis In the cervical spine, central canal stenosis is caused by osteophytosis and ligamentous thickening. In the cervical spine, the width of the spinal canal is often quan- titatively assessed on radiographs since such measure- ments are predictive for the presence of spinal canal stenosis. In addition, anterolisthesis at the same level is noted and the anteroposterior diameter of the vertebral body. If the area of the dural sac is below 75 mm2, the likelihood of a stenosis is high. The lateral recess is bordered posteriorly by the su- perior articular facet, laterally by the pedicle and anteri- orly by the vertebral body and disk. Lumbar lateral recess stenosis occurs when a hypertrophic superior facet en- croaches on the recess, often in combination with nar- rowing due to a bulging disk and osteophyte. Foraminal stenosis occurs when a hypertrophic facet, vertebral-body osteophyte, or bulging disk narrows the neural foramen Fig. A 68-year-old woman with clinical symptoms of cervical and encroaches on the nerve roots. On conventional lateral radiographs the dis- Magnetic resonance imaging has extensively been used in tance between the posterior surface of the vertebral body the identification of abnormal conditions of the lumbar and the spinolaminar line can be measured. A spinal cord spine and has become the gold standard in evaluation of compression may be diagnosed if this distance is 10 mm spinal pathology. However, particularly in studying pa- or less, whereas if this distance is 13 mm or more then tients with low back pain, there is often a discrepancy be- spinal canal stenosis is unlikely.

Echocardiography in infants and children cheap 200mg flagyl mastercard, performed to diagnose or follow con- genital or acquired heart disease that affects this age group buy flagyl 400mg lowest price, is technically very different from adult echocardiography and requires specific equipment and exper- tise usually not found in typical adult echocardiography laboratories. This has been recognized by accreditation agencies that have developed specific requirements for quality control of pediatric studies. In addition, children under the age of three are often too uncooperative for a complete, comprehensive echocardiography, which can take up to 30–45 min, therefore in many cases sedation is required and should only be done in a laboratory with pediatric cardiologists on-site to optimize acquisi- tion and interpretation of the study. The pediatrician is often faced with the question of when an echocardiogram should be ordered directly versus requesting a cardiologist consultation at first. There are many indications for echocardiography that are appropriately ordered directly by the generalist, and only if abnormalities are found, would a consultation with the cardiologist be important. In other cases, consultation as the first strategy is more efficient and usually leads to more appropriate testing (Tables 4. An extensive list of situations suitable for echocardiography is included in these guidelines. The following is an outline of situations in which echocardiogra- phy is a valuable and helpful tool to the practitioner. In the neonatal period, echocardiography is indicated in the evaluation of sus- pected patent ductus arteriosus (Fig. It should also be used for screening for cardiac defects in patient with known or suspected chromosomal or other genetic syndrome with cardiac involve- ment (Fig. In uncomplicated cases, an initial echocardiogram should be done at diagnosis, at 2 weeks, and at 6–8 weeks after onset of disease. If the echocardiogram is normal at 6–8 weeks, a follow-up study 1 year later is optional. If abnormalities are detected on any of the echocardiographic studies, additional studies will usually be ordered by the cardiologist, with frequency and length of Fig. Color Doppler echocardio- graphy: parasternal short axis view color Doppler shows direction of blood flow. Typically, the setting is such that red color indicates flow towards the probe, while blue is blood flow away from the probe. The illustration on the left hand shows cardiac anatomy, red and blue color- ing reflects well oxygenated and poorly oxygenated blood in different cardiac chambers. This coloring scheme should not be confused with the red and blue coloring of color Doppler follow-up determined by the severity of the abnormalities. It is important to note that it is difficult to obtain high quality coronary imaging on a fussy infant or young child, which may necessitate the use of sedatives to enable completion of echocardiography. In addition, for any infant or child with ³5 days of fever and only 2–3 classic clinical criteria, or elevated inflammatory markers but <3 supplemental lab criteria, an echocardiogram can be used to help make the pre- sumptive diagnosis. In patients with systemic hypertension, the first echocardiogram should include a full anatomy study to rule out aortic coarctation, as well as an assessment of left ventricu- lar wall thickness and function. Subsequent yearly follow-up examinations should be done to look for abnormal increases in left ventricular mass or changes in function. The diagnosis and follow-up of pulmonary hypertension includes the use of echocardiography. In cases of obstructive sleep apnea, the extent to which hypoventilation has affected the heart can be assessed through measurement of Fig. On the other hand, the motion of ventricular walls in the patient in (b) is flat reflecting limited ventricular wall motion 4 Pediatric Echocardiography 61 Fig. The illustration on the left hand shows cardiac anatomy, red and blue coloring reflects well oxygenated and poorly oxygenated blood in different heart chambers. This coloring scheme should not be confused with the red and blue coloring of color Doppler right ventricular pressure (using tricuspid valve Doppler or interventricular septal position), wall thickness, and function. Patients with sickle cell disease and increased pulmonary artery pressure as estimated by echocardiography have higher mortality. Cardiomegaly or other abnormal cardiovascular findings noted on X-ray, espe- cially if associated with other signs or symptoms of potential heart disease should prompt echocardiography. If possible, pericardial effusion is suspected, especially in the setting of hemodynamic compromise possibly representing cardiac tampon- ade, emergency echocardiography is indicated and may be used to assist in pericar- diocentesis (Fig. Patients suspected of having connective tissue disease such as Marfan syndrome or Ehlers–Danlos syndrome should have echocardiography. Specifically, echocar- diogram is used to evaluate the aortic root in individuals with suspected Marfan syndrome and to evaluate for Mitral Valve prolapse. Echocardiography is indicated for surveillance in various genetic disorders (Table 4. Patients diagnosed with Tuberous Sclerosis should undergo echocar- diography to evaluate for rhabdomyomas.

Fromthe skin lesions 250 mg flagyl otc, the virus can be autoinoculated into the oral mucosa buy 250mg flagyl, usually on the vermilion border and the lip mucosa, com- missures, and tongue. Clinically, it appears as a painless, small, sessile, and well-defined exophytic growth with a cauliflower surface and whit- ish color (Figs. Differential diagnosis Papilloma, condyloma acuminatum, verruci- formxanthoma, focal epithelial hyperplasia. Usage subject to terms and conditions of license 206 Papillary Lesions Verruciform Xanthoma Definition Verruciformxanthoma is a rare hyperplastic disorder of the oral mucosa. Typically, it appears as a well-demarcated, painless, sessile, slightly elevated lesion. Differential diagnosis Papilloma, verruca vulgaris, condyloma acumi- natum, sialadenoma papilliferum, verrucous carcinoma. Typically, it presents as an exophytic, whitish mass with a papillary or verruciformsurface (Fig. Along with the clinical fea- tures, biopsy and histopathological examination should be performed to rule out other papillary growths. Verrucous carcinoma is well-differ- entiated, slow-growing, rarely metastasizes, and has a good prognosis. Usage subject to terms and conditions of license 208 Papillary Lesions Squamous-Cell Carcinoma Squamous-cell carcinoma has a wide range of clinical presentations (see also pp. It has a papillary or verruciformsurface and a red, whitish, or normal color (Fig. The surface is usually ulcerated, and the base of the lesion is indurated on palpation. The buccal mucosa, tongue, floor of the mouth, and gingiva are the most common regions affected by this clinical form of carcinoma. Verrucous Leukoplakia Verrucous leukoplakia is a rare clinical formof leukoplakia with a greater risk of malignant transformation (see also p. Clinically, it presents as an irregular, white, exophytic plaque with a papillary surface (Figs. Verrucous leukoplakia occurs more frequently in women (the female to male ratio is about 4 : 1). Usage subject to terms and conditions of license 210 Papillary Lesions Focal Epithelial Hyperplasia Definition Focal epithelial hyperplasia, or Heck disease, is a benign hyperplastic lesion of the oral squamous epithelium. Clinical features The disease frequently occurs among the Eskimos, North American Indians, South Africans, and, rarely, in other ethnic groups. The condition is characterized clinically by multiple painless, sessile, slightly elevated, soft nodules or plaques 1–10 mm in diameter (Figs. The lesions may occasionally have a slightly papillary surface, and they have a whitish or normal color. The buccal mucosa, lips, tongue, and gingiva are the sites more frequently involved. Differential diagnosis Multiple condylomata acuminata and verruca vulgaris, multiple papillomas, focal dermal hypoplasia syndrome, Cow- den disease. Epulis Fissuratum Definition Epulis fissuratum, or denture fibrous hyperplasia, is a rela- tively common hyperplasia of the fibrous connective tissue. Usage subject to terms and conditions of license 212 Papillary Lesions Clinical features The lesion presents as multiple or single inflamed and elongated papillary folds, usually in the mucolabial or mucobuccal grooves (Fig. Differential diagnosis Neurofibromatosis, fibroma, fibroepithelial polyp, squamous-cell carcinoma. Usage subject to terms and conditions of license 214 Papillary Lesions Crohn Disease Definition Crohn disease or regional ileitis is a chronic inflammatory disease that primarily affects the ileum and other parts of the gastro- intestinal tract. Clinical features The disease usually affects young individuals, and presents clinically with abdominal pain, nausea, diarrhea, weight loss, low-grade fever, and rectal bleeding. Extra-abdominal involvement in- cludes arthritis, spondylitis, uveitis, and oral manifestations. Oral lesions occur in 10–20% of patients and are characterized by nodular swelling, which may be ulcerated. Diffuse raised nodules resulting in a cobble- stone appearance of the mucosa or mucosal tag lesions may occur (Fig. Granulomatous lip swelling, angular cheilitis, gingival swel- ling, and atypical ulcerations may be seen. Differential diagnosis Orofacial granulomatosis, epulis fissuratum, pyogenic granuloma. Usage subject to terms and conditions of license 216 Papillary Lesions Acanthosis Nigricans, Malignant Definition Acanthosis nigricans is a rare disorder involving the skin and mucosae, characterized by papillary lesions and brownish alteration of the skin. Clinical features The disorder is classified into two major types: the benign form(genetic or acquired) and the malignant form, which is associated with an internal malignancy, particularly adenocarcinoma. Oral manifestations are more common in the malignant form and are characterized by papillomatous growths that most often involve the lips, tongue, and gingiva (Fig.

This system also allows greater recovery of Streptococcus pneumoniae and simplifies the subculture process discount 250mg flagyl free shipping, resulting in decreased labour purchase 400mg flagyl with mastercard, contamination and cost. Pseudomonas, coagulase negative Staphylococcus, Staphylococcus aureus, Bacillus, Escherichia coli, Klebsiella, Serratia, Acinetobacter, Alcaligenes, Neisseria and Candida show diminished growth in unvented vacuum-exhausted bottles, while significantly more isolates of Corynebacterium, Haemophilus, Flavobacterium, Moraxella, Bacteroides and Peptostreptococcus are recovered from unvented bottles. Routine subculturing of biphasic bottles is unnecessary, but unvented bottles should routinely be subcultured at 6-17 h and again at 48 h. In this case, also, agitation of the vented bottle significantly decreases the detection time and increases the number of positive blood cultures detected. Repeat subculture of known positive blood cultures is costly and ineffective in detecting polymicrobial bacteremias. Isolation rates can be significantly increased by use of lysis-centrifugation, eg, DuPont Isolator. This gives > 10% higher isolation rates than conventional 2 bottle systems (especially Staphylococcus aureus, fungi and mycobacteria, although the additional of oleic acid to conventional systems increases the yield of the latter to an equivalent extent), but recovery of Streptococcus pneumoniae is less good than with conventional systems and the contamination rate is 12% higher. This method is also useful for viral isolation and should always be used in investigating fungemia. Isolation rates also depend on the volume of blood cultured, average yields from 30 mL of blood being 61% greater than that from 10 mL of blood. The Bactec automated system provides similar isolation rates to conventional methods (except for Streptococcus pneumoniae; also, Coccidioides immitis produces visible growth but a negative growth index) and is cost effective for volumes in excess of about 6000 specimens per year. Cost per bottle is only about 40% of that for Isolator and biphasic Diagnosis and Management of Infectious Diseases Page 407 Collection, Processing and Handling of Specimens systems, while labour involved is about equal to the biphasic. Antimicrobials present in blood can frequently be removed by use of Bactec 16B medium (which does not always work for ticarcillin or moxalactam) or Marion’s antimicrobial removal device (which may not work for moxalactam, cefotaxime or cefoperazone). However, studies have not convincingly shown that this translates into a higher yield of positives. On the other hand, the membrane filtration technique of Sullivan, Sutter and Finegold yields twice as many positives as the best conventional system from patients on antimicrobial therapy. Gram staining should be the first step in investigating any positive blood culture. Gram positive cocci will almost always be staphylococci, streptococci or anaerobic cocci. Neisseria, Haemophilus, Bacteroides and Gram positive bacilli can also usually be identified from microscopy. If diphtheroids are seen, it may be worth while doing a hanging drop preparation to look for the distinctive tumbling motility of Listeria monocytogenes. It is frequently possible to obtain a quick identification of Escherichia coli by spinning down a portion of the culture fluid and performing an indole test on the supernate. Arboviruses, simplexvirus virus, lymphocytic choriomeningitis virus and rabies virus may also be cultured, but this is not routinely done. Contamination and drying of routine smears and cultures for bacteria (including mycobacteria) and fungi must be avoided. A decubitus swab provides little clinical information and a tissue biopsy or needle aspirate is always to be preferred. For otitis externa, vigorous swabbing is required, because surface swabbing may miss streptococcal cellulitis. For anaerobes, the specimen collection method must preclude contamination by anaerobic flora of mucocutaneous surfaces. Even with transport medium, delays of > 1 h in transit of wound swabs, sputa, tracheal aspirates and urine can cause alterations to the microbial flora and loss of clinically significant species. Trichomonas vaginalis will remain viable for  24 h on dacron swabs transported in Amies medium. For genital lesions, a swab and slide of transudate from the base of the lesion is the preferred specimen. Swabs for viral culture must be collected directly into viral transport medium (Virocult (Medical Wire) is the most efficient system). Stuart’s transport medium rapidly inactivates most viruses, and calcium alginate swabs should not be used. Human cytomegalovirus and simplexvirus virus are routinely isolated from cervical, urethral and vaginal swabs; molluscum contagiosum virus and human papillomavirus are not cultivable. Adenovirus, coxsackievirus A, human cytomegalovirus, simplexvirus, human enterovirus 70 and Newcastle disease virus are routinely isolated from conjunctival swabs. Adenovirus, human cytomegalovirus, enterovirus, simplexvirus, influenza virus, measles virus, mumps virus and parainfluenza virus are routinely isolated from throat swabs; respiratory syncytial virus may also be isolated by non-routine methods. Adenovirus, Enterovirus, measles virus and human rubella virus are routinely isolated from swabs taken from the base of maculopapular rash lesions, while Diagnosis and Management of Infectious Diseases Page 408 Collection, Processing and Handling of Specimens coxsackievirus A, echovirus, simplexvirus and human herpesvirus 3 are similarly isolated from vesicular rashes (vesicle aspirate in viral transport medium preferred for varicella-zoster). Exudates, cellular scrapings and washings should be collected into buffered tryptose phosphate broth with gelatine or Hank’s balanced salt solution with gelatine.

The limitations of these studies are that they use data on sugar availability and not actual intake order flagyl 250mg with visa, they do not measure frequency of sugars intake buy flagyl 500mg overnight delivery, and they assume that level of intake is equal throughout the population. Also, the values are for sucrose, yet many countries obtain a considerable amount of their total sugars from other sugars. Caution needs to be applied when extrapolating the results of animal studies to humans because of differences in tooth morphology, plaque bacterial ecology, salivary flow and composition, and the form in which the diet is provided (usually powdered form in animal experiments). Nonetheless, animal studies have enabled the effect on caries of defined types, frequencies and amounts of carbohydrates to be studied. Plaque pH studies measure plaque acid production, but the acidogeni- city of a foodstuff cannot be taken as a direct measurement of its cariogenic potential. Plaque pH studies take no account of protective factors in foods, salivary flow and the effects of other components of the diet. Many of the plaque pH studies that show falls in pH below the critical value of 5. This electrode is recognized as being hypersensitive and non-discriminating, tending to give an ‘‘all or nothing’’ response to all carbohydrates (150). Research has consistently shown that when annual sugar consumption exceeds 15 kg per person per year (or 40 g per person per day) dental caries increase with increasing sugar intake. When sugar consumption is below 10 kg per person per year (around 27 g per person per day), levels of dental caries are very low (26, 28, 29, 51, 151--158). Tables 14--17 summarize the evidence relating to diet, nutrition and dental diseases. Population goals enable the oral health risks of populations to be assessed and health promotion goals monitored. The best available evidence indicates that the level of dental caries is low in countries where the consumption of free sugars is below 15--20 kg per person per year. This is equivalent to a daily intake of 40--55 g per person and the values equate to 6--10% of energy intake. It is of particular importance that countries which currently have low consumption of free sugars (<15--20 kg per person per year) do not increase consumption levels. For countries with high consumption levels it is recommended that national health authorities and decision-makers formulate country- specific and community-specific goals for reduction in the amount of free sugars, aiming towards the recommended maximum of no more than 10% of energy intake. In addition to population targets given in terms of the amount of free sugars, targets for the frequency of free sugars consumption are also important. The frequency of consumption of foods and/or drinks containing free sugars should be limited to a maximum of four times per day. Many countries that are currently undergoing nutrition transition do not have adequate exposure to fluoride. There should be promotion of adequate fluoride exposure via appropriate vehicles, for example, affordable toothpaste, water, salt and milk. It is the responsibility of national health authorities to ensure implementation of feasible fluoride programmes for their country. Research into the outcome of alternative community fluoride programmes should be encouraged. In order to minimize the occurrence of dental erosion, the amount and frequency of intake of soft drinks and juices should be limited. Elimination of undernutrition prevents enamel hypoplasia and the other potential effects of undernutrition on oral health (e. Intake of non-starch polysaccharide (dietary fibre) in edentulous and dentatepersons: an observational study. Surveys coordinated by the British Association for the Study of Community Dentistry in 1995/96. Changes in caries prevalence amongst 6- and 12-year-old children in Friesland, 1973--1988. Evidence of dental caries decline among children in an East European country (Hungary). Oral health --- diet and other factors: the Report of the British Nutrition Foundation’s Task Force. Epidemiological and clinical dental findings in relation to intake of carbohydrates. A field study of dental caries, periodontal disease and enamel defects in Tristan da Cunha. Comparison of dietary habits and dental health of subjects with hereditary fructose intolerance and control subjects. The effect of different levels of carbohydrate intake on caries activity in 436 individuals observed for 5 years. Final report on the effect of sucrose, fructose and xylitol diets on the caries incidence in man. Variation in caries prevalence related to combinations of dietary and oral hygiene habits and chewing fluoride tablets in 4-year-old children. Modificationofoccurrenceofcariesinchildren by toothbrushing and sugar exposure in fluoridated and non-fluoridated area. Oral health status and oral health behaviour of 12-year-old urban schoolchildren in the People’s Republic of China.

Old age There is a growing acreage of elderly skin because of the staggering increase in the proportion of the population over the age of 60 years cheap flagyl 250mg line. The increase in longevity since the beginning of the twentieth century is approximately equal to that seen in the human race in the previous 5000 years 500 mg flagyl overnight delivery. We certainly need to know more about the ageing process and its effects on the skin. Whatever the explanation, at present there is very little that can be done to stem the tide of the passing years, other than carefully choosing long-lived parents! There are enormous variations in the rates at which different individuals age, as well as major differences in the rates at which individual organs and systems age within one individual. The degree of thinning is variable, but, between the ages of 20 and 80, dermal thickness on the flexor aspect of the forearm changes in men from a mean of 1. The epidermis thins from four to five cells thick at age 20 to approximately three cells thick at age 80. The individual ker- atinocytes also shrink with age, although the horn cells at the surface inexplicably increase in area. Interestingly, the stratum corneum does not appear to change sub- stantially in thickness during ageing. This applies also to the hair (see page 268), but not always to the sebaceous glands, as on the face they may, paradoxically, enlarge, which is sometimes clinically evident in the condition of sebaceous gland hyperplasia (see page 188). The dermal connective tissue loses much of its proteoglycan ground substance and the collagen fibres become mainly tough, insoluble and heavily cross-linked biochemically. Pigment cells become fewer in number and smaller, and Langerhans cells are also less in evidence in the skin of the elderly. Functional changes Wound healing is slower and may be less complete in the elderly. The aged also respond less vigorously to chemical and physical trauma – the erythema and swelling are less marked and slower to develop. Delayed hypersensitivity is depressed and this also applies to other components of the immune response. Sweat gland responses to heating decrease, and the rate of sebum secretion also decreases, although this is less marked than many other functions in the elderly. Sensory discrimination decreases in the elderly, but, unfortunately, not the sen- sations of itch or pain! However, there are many disorders that are more common in the aged, and others that have a differ- ent natural history and appearance. Dry and itchy skin As the skin ages, it becomes drier and tends to become itchier. This tendency is heightened by: ● low relative humidity ● frequent hot bathing and vigorous towelling ● low ambient temperature. The itchiness can be disabling and it is important to try to reduce the desiccat- ing stimuli to which the skin is exposed. The generous use of emollients as top- ical applications as cleansing agents and of bath additives is mandatory. Although itchiness due to dry skin in the elderly is quite common, it has to be remembered that scabies and the other causes of generalized pruritus also occur in this age group and should be diligently sought. In most cases, no cause is found for the development of eczema, particularly in elderly people, in whom it can spread rapidly and become extremely disabling. Atopic dermatitis is uncommon in the elderly and is as trying and uncomfortable as at other times of life when it does occur. Discoid eczema is a form of constitutional eczema that is more common in the elderly. Eczema craquelée is an eczematous disorder that is virtually specific to the skin of the elderly, occurring against a background of generalized xerosis, or drying of the skin surface. Photosensitive eczema is more common in elderly men and is often very per- sistent, causing great difficulties in its management. Minor degrees of seborrhoeic dermatitis are very common in the elderly and occasionally the disorder can spread to become generalized. However, emollients are even more important and there should be greater readiness to use systemic remedies, including cyclosporin, azathioprine and corticosteroids. After being in hospital for 4 days, his chest improved with the use of antibiotics, but he began to develop an odd, itchy, ‘crazy paving’ pattern of rash on his shins. This eczema craquelée was due to the increased washing and decreased humidity in the hospital. Skin tumours Skin tumours are a frequent reason for the elderly consulting a physician. Seborrhoeic warts are found in virtually everyone over the age of 60 years and, although benign, often result in minor symptoms and some cosmetic embarrass- ment. They can easily be removed by curettage and cautery, but when present in large numbers, can present an insoluble problem.