PCOS/PCOD/Polycystic Ovarian Syndrome

Polycystic Ovarian Syndrome or PCOS is a hormonal endocrine disorder of ovary in women in all over the world. Other name for PCOS is Stein-Leventhal Syndrome. As the name indicates multiple cysts in the ovary is called polycystic ovary syndrome, and the size of ovaries in women with PCOS are 2 to 5 times the normal size.
Undiagnosed and untreated PCOD is a leading cause of female infertility. PCOS affects 4 to 6% of women, the full-blown syndrome of hyperandrogenism, chronic anovulation and polycystic ovaries. Because of wide variety of clinical symptoms and biochemical features exact definition of Polycystic Ovary Syndrome is least understood and can be confusing. According to Rotterdam criteria definition of PCOS contains two out of three following criteria:
1. Oligomenorrhea or Anovulation
2. Hyperandrogenism (clinical/biochemical)
3. Polycystic ovaries with exclusion of other etiologies.

Hormonal and biochemical changes are responsible for PCOS symptoms. There may be abnormality in the four active compartments: a) ovary, b) hypothalamus-pituitary compartment, c) peripheral fat or d) adrenal glands. Abnormality in ovarian compartment is responsible for hyperandrogenism in PCOS. Ovaries in women with PCOS are 2 to 5 times the normal size.

Hormonal changes in PCOS
1. Hyperandrogenism – Increased level of total and free testosterone.
High intraovarian androgen concentration inhibits follicle maturation results in inactive granulosa cells with minimal aromatase activity for conversion to estrogens.
2. Increased LH without increase in FSH leads to Increase LH/FSH ratio.

Clinical symptoms

1. Menstrual dysfunction – From amenorrhea to oligo menorrhea. Menarche tends to be delayed, irregular menstrual cycles or 4 to 6 menstrual periods per year.
2. Acne – Severe acne in teenage years is very common finding of PCOS.
3. Obesity – About 50 % women with PCOS found obese. Obesity in PCOS linked to insulin resistance, diabetes mellitus and increased risk of cardiovascular disease in later life.
4. Hirsutism – Excess hair growth on the face and body.
5. Alopecia – Hair loss and male pattern baldness.
6. Acanthosis nigricans – Hyperpigmentation of the skin.
7. InfertilityInfertility is the common problem in PCOS women.

How to Diagnose?

1. Symptoms and clinical features are most important in early diagnosis. Patient gives history of irregular menstruation, acne, excess facial hair growth and weight gain (high BMI). During reproductive age women may have history of infertility.

2. Laboratory tests – Blood tests to know the level of some hormones, Blood sugar, Insulin and IGF 1, cholesterol and triglycerides level in PCOS women.
Criteria for metabolic syndrome in PCOS women
• Abdominal obesity (waist circumference >88 cm or 35 inches)
• Triglycerides >150 mg/dl
• HDL-C <50 mg/dl
• Blood pressure > 130/85
• Fasting blood sugar of 110-126 mg/dl and 2-hour glucose from oral glucose tolerance test of 140-199 mg/dl

3. Ultrasonography – Ultrasonographic examination is a useful method for early detection of PCOS and follow-up. Generally, ovarian size is increased. The most important ultrasonographic finding is a bilaterally increased number of microcysts measuring 0.5 to 0.8 cm with generally more than five microcysts in each ovary.

Management

The management of PCOS depends upon clinical symptoms and presenting problems.

Menstrual irregularities
1. Weight loss – In obese women weight loss should be the first line of treatment. A reduction in body weight of 5-10 per cent will cause a 30 per cent reduction in visceral fat, which is often sufficient to restore ovulation and reduce markers of metabolic disease.
2. Oral contraceptives – Often OCPs can have the benefits of contraception, protection against endometrial cancer and improve skin manifestations such as acne and hirsutism.

Acne
Mild acne can be treated topically with keratinolytics such as azelaic acid, retinoids or with antibacterials erythromycin 2 % gel or clindamycin 1 % lotion. Severe forms can be treated by oral antibiotics or isotretinoin.
But in PCOS antiandrogens are most effective because acne occurs as a result of hyperstimulation of sebaceous glands by androgens. Cyproterone acetate, Spironolactone Flutamide and Finasteride have antiandrogenic properties. Cyperoterone acetate can be combined with OCPs.

Hirsutism
Hirsutism can be treated by physical therapy such as bleaching, shaving, plucking, depilatory creams or electrolysis and laser. Combined Oral contraceptive is useful for prevention of excess hair growth.

Alopecia
Psychological supports and hairstyling are the treatment for alopecia. Drugs such as minoxidil, cyproterone acetate, spironolactone has limited role.

Infertility
Main cause of infertility in PCOS is anovulation. So methods of inducing ovulation are reduction of insulin concentrations, FSH (follicular stimulating hormone) stimulation and reduction in LH (luteinizing hormone) concentration.

Weight loss
Weight loss is the mainstay therapy for induction of ovulation. Weight loss improves endocrine profile and the likelihood of ovulation and a healthy pregnancy. Diet plan and exercises should be encouraged.

Clomiphene citrate
Clomiphene citrate 50 mg orally for 5 days is a common method to induce ovulation. Serial transvaginal ultrasound is used to look for follicles or urinary LH test can also be done to know fertile period.

Metformin
For treating hyperinsulinemia in PCOS women Metformin 500 mg 8 hourly is an effective treatment.
In patients who do not ovulate with clomiphene citrate and metformin, doctor can advise for laparoscopic ovarian drilling or parenteral gonadotrophic therapy.

Laparoscopic ovarian drilling
Laparoscopic ovarian drilling is a simple procedure whereby several punctures are made in one or both the polycystic ovaries.

Gonadotropin therapy
Gonadotrophin therapy is indicated for women with anovulatory PCOS who have been treated with antiestrogens, either if they have failed to ovulate or if they have a response to clomiphene that is likely to reduce their chance of conception. Patients are started with very low dose gonadotrophin (FSH) and the dose is gradually increased. When the leading follicle reaches 14 mm, the FSH threshold dose is reduced by half.
In some patients, invitrofertilisation (IVF) or even intracytoplasmic sperm injection (ICSI) may be the only option for pregnancy.

Complications

PCOS patients are increased risk of developing chronic diseases which are directly linked to obesity in PCOS.
Non-insulin dependent Diabetes mellitus (NIDDM)
Cardiovascular diseases such as hypertension and coronary heart disease
Endometrial cancer
Infertility
Depression and anxiety

Because of the risk of chronic disorders, PCOS patients are advised to continue follow-up every 6 months.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Content source – Jeffcoate’s Principles of Gynaecology 7th edition

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GERD / Heartburn /Regurgitation/Indigestion

What is GERD?
Gastroesophageal reflux disorder is reflux or regurgitation of acid content or bitter fluid from the stomach to the esophagus. Most common words used for GERD are heartburn, indigestion, acid reflux and acid regurgitation. It can affect individual’s quality of life so do not ignore if you are having this problem.

Symptoms of GERD
GERD presents with acid content or bitter taste in mouth usually after meals, on lying down or with bending, straining or heavy lifting. GERD often accompanied with other symptoms such as;
• Heartburn or burning sensation or heaviness around middle of the chest or upper abdomen
• Nausea
• Vomiting
• Halitosis or bad breath
• Difficulty in swallowing or pain during swallowing.
• Dry, long-lasting cough with sore throat.
• Wearing away of your teeth/erosion of enamel of your teeth.

Causes of GERD
GERD means acid content coming back up to the esophagus or food pipe. Actually when we swallow food it comes from esophagus to stomach. At the lower end of esophagus there is a band of muscles called as lower esophageal sphincter (LES) which plays an important role in preventing acid reflux from the stomach means it acts as a barrier between lower part of esophagus and stomach. When lower esophageal sphincter relaxes it allows food to enter in to the stomach and then it closes to prevent food particles and acidic content to flow back in to the esophagus, but if there is weakness in the muscles of lower esophageal sphincter it may relax at inappropriate time when actually it should not and causing stomach contents to rise up in to the esophagus. Factors like distention of the stomach, delayed emptying of the stomach, large sliding hiatal hernia, or too much acid in the stomach can also make it easier for acid reflux to occur.

Risk factors of GERD
1. Obesity – Increased weight may cause increase pressure on the abdomen and may causes relaxation of LES at inappropriate time.
2. Pregnancy – In pregnancy due to high progesterone level motility of entire gastrointestinal tract decreases and LES relaxation leads to acid regurgitation and heartburn.
3. Smoking – smoking and passive smoking also relaxes LES leads to acid regurgitation.
4. Certain medications- antihistamines, analgesics, antidepressants, Calcium channel blockers used to treat high BP, Asthma medications eg bronchodilators and theophylline, sedatives, antibiotics and estrogen replacements.
5. Sedentary lifestyle – People who work as sitting for long, do not do any physical activity and late night work or not sleeping in the night increases acid content of stomach.
6. Wrong dietary habits – Oily and spicy food, junk food, chocolates, peppermints and alcoholic beverages increases acid content of stomach and weakens LES.
7. Low gap between meal and sleep – Ideal time gap between meal and sleep (going to bed) should be at least 3 hours but reduced time gap or going to bed just after meal decreases digestion process and increases acid content of stomach.
8. Hiatus hernia – Hiatus hernia is a condition in which the opening in your diaphragm lets the upper part of the stomach move up into your chest, which lowers the pressure in the esophageal sphincter.

Even when the LES and the diaphragm are intact and functioning normally, reflux can still occur. The LES may relax after having large meals leading to distension of the upper part of the stomach. When that happens there is not enough pressure at the LES to prevent reflux. In some patients the LES is too weak or cannot mount enough pressure to prevent reflux during periods of increased pressure within the abdomen.

When you need to go to the doctor
If you are having acid reflux or heartburn twice in week for few weeks, accompanied by other symptoms like nausea, vomiting, abdominal pain, bad breath, chronic dry cough, sore throat then you should take an appointment with your doctor.

Diagnosis
1. Signs and symptoms, medical history, medication history, family history, lifestyle and dietary habits, and physical examination are important to diagnose GERD.

If patient has chronic heartburn, symptoms are not improving, trouble in swallowing then doctor can order few of these diagnostic tests and may refer the patient to gastroenterologist.

2. Ambulatory 24 hour acid pH probe test – It is a test to monitor the amount of acid in your esophagus. This is the most accurate procedure to detect acid reflux. A gastroenterologist performs this procedure at a hospital or in outpatient care as a part of an upper GI endoscopy. A thin tube with pH sensor passed through the patient’s nose or mouth in to the esophagus which measures how much and how many times stomach regurgitates acid, other part of tube is connected to the computer which records the pH readings. Monitoring is for 24 hours.

Bravo wireless esophageal pH monitoring – This is also for pH monitoring but in this the doctor temporarily attaches a small capsule to the wall of your esophagus during an upper endoscopy. The capsule measures pH levels in the esophagus and transmits information to a receiver. The receiver is about the size of a pager, which you wear on your belt or waistband. You can follow your usual daily routine during monitoring, which usually lasts 48 hours. The receiver has several buttons on it that you will press to record symptoms of GERD such as heartburn. The nurse will tell you what symptoms to record. You will be asked to maintain a diary to record certain events such as when you start and stop eating and drinking, when you lie down, and when you get back up. Before this procedure your doctor will ask to stop all GERD medications if you are taking any. After about 5 to 7 days capsule will fall off and pass through the stool.

3. Upper GI endoscopy and Biopsy –Procedure performed by surgeon or gastroenterologist in the hospital usually under sedation. Endoscope is a thin flexible tube fitted with camera to see inside the organs. Doctor carefully feeds the endoscope in to the upper gastrointestinal tract (esophagus, stomach and duodenum) to examine and if need to take small sample of tissue (biopsy) for further examination.

4. X-ray images of Upper GI – Upper GI series usually performed by X -ray technician at hospital or outpatient center. Patient is asked to drink barium to coat the inner lining of your upper GI tract. With help of barium (contrast) X-ray doctor can detect hiatal hernia, esophageal stricture, ulcers or any other problem.

5. Esophageal manometry – Esophageal manometry measures muscle contractions in your esophagus. A gastroenterologist may order this procedure if you’re thinking about anti-reflux surgery.

Treatment
Depending upon signs and symptoms doctor may recommend naturotherapy, pharmacotherapy or surgery.

Naturotherapy
1. Lifestyle change – If you have sedentary life style, change it and try to walk every day for 30 min and in the sitting job try to walk after each meal and after every 2 hours for 5-10 min.
2. Dietary habits – Avoid caffeine, avoid spicy, fatty and junk food and alcoholic beverages. Increase intake of fibers, fruits and fresh vegetables. Do not overeat. Healthy breakfast is must to prevent acid reflux.
3. Meal time – You should follow a strict pattern of meal time. Last meal of the day should be at or around 7 pm, so that you can have time gap between meal and sleep at least 3 hours. Do not go on the bed just after a meal.
4. Sleeping habits – Always try to go to bed around 9 pm- 10 pm and minimum 6 hours sleep is very important for healthy life. Sleep on a slight angle. Elevate the head of your bed 6 to 8 inches by safely putting blocks under the bedposts.
5. Quit smoking – smoking increases acid production and quitting smoking will prevent from cancer and many diseases.
6. Stop taking over the counter available analgesics and medicines which can increase acid production.
7. Weight loss- if you are overweight or obese try to loose your weight to prevent obesity related disorders.
8. Aloevera – Aloevera soothes the burn or inflammation, so drinking aloevera juice is beneficial in GERD.
9. Banana and apple are natural antacids.
10. Avoid tight-fitting clothes.
Follow healthy lifestyle and Health tips.

Pharmacotherapy
1. Antacids to relieve heartburn and other mild symptoms. Antacids are available over the counter are Maalox, Mylanta, Gelusil, Gaviscon, Rolaids and Tums, may provide quick relief. But antacids alone will not heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or constipation.
2. H2 blockers decrease acid production. H2 blockers are Ranitidine (Zantac 75), Cimetidine (Tagamat HB), Famotidine (Pepcid AC), Nizatidine (Axid AR).
3. PPIs(Proton pump Inhibitors) limit acid secretion in the stomach and resolution of the symptoms with healing of the esophagus. Over the counter available PPIs are Omeprazole (Prilosec),lansoprazole, pantoprazole(protonix), rabeprazole(Acip Hex), esomeprazole (Nexium)
4. Prokinetics help the emptying of stomach faster. On prescription metoclopramide(reglan), Bethanechol (Urecholine)

Surgery
Though most of the time GERD improved and relieved by medications but if symptoms are not improving with medications and lifestyle change, doctor may advice for surgery.

Fundoplication – For long-term reflux prevention Nissen fundoplication is the most common surgery. Surgeon perform this at the hospital under anesthesia by using laparoscope, which is a thin tube fitted with video camera. Fundoplication is a procedure to tightening the lower esophageal sphincter by wrapping the top of the stomach. Hospital stay usually 2-3 days. Return to normal daily activities in 2 weeks.

Using LINX – Linx is a ring-shaped magnetic titanium based device which is used to wrap around lower esophagus and top of stomach to tighten the lower esophageal sphincter. Because of the strong magnetic attraction between titanium beads in the ring it prevents opening during acid reflux.

Complications Of untreated GERD
Respiratory problems – Because of acid reflux in GERD sometimes during sleep acid can go in to the lungs which cause respiratory problems.
Dry and long-lasting cough or sore throat
Chest congestion or fluid in the lungs (Aspiration Pneumonia)
Hoarseness of voice
Wheezing
Laryngitis
Esophagitis – It is inflammation of esophagus because of destruction of normal esophageal lining by acid. If left untreated chronic esophagitis may be cancerous.
Esophageal stricture- In this esophagus becomes narrow.
Barrett’s esophagus – Untreated GERD may sometimes give rise to a serious condition like barrett’s esophagus which is cancerous.

Key point to remember
Heartburn due to GERD and chest pain due to angina (reduced blood supply to the heart) or heart attacks are similar. GERD related heartburn usually after heavy meal or spicy food and gets worse by bending or lying down. Chest pain or discomfort due to angina usually after exertion or emotional stress and not affected by changing in the positions and gets worse after physical activity and does not go away with rest.If you are not sure visit to the doctor without delay.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Source content – The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), International Foundation for Functional Gastrointestinal Disorders aboutgerd.org

Acne or Pimples

Acne or commonly known as pimples are very common skin problem in teenage and late teenage groups, though any age group from newborn to adults or sometimes older people can also have acne, usually women complains about acne but common in men too. Acne has negative effects on selfesteem due to cosmetic reason and it gives scars when goes off.
Acne is a chronic inflammation of pilosebaceous units (hair follicles and accompanying sebsceous glands) due to increased sebum production. Acne may present as various forms include seborrhea, comedones, papules, pustules, nodules, pseudocyst and after that scars when acne goes off.

Pathogenesis
There are four major pathogenic factors in the development of acne
1. Increased sebum production
2. Follicular hyperkeratinization (follicular plugging with sebum and keratinocytes)
3. Propionibacterium acne (P. acne) colonization
4. Release of multiple inflammatory mediators

Factors that may cause acne
Severity of acne depends upon sebum excretion rate which increases in puberty. There are multiple factors which can cause acne.
1. Hormonal factors – Sex hormones androgens, progesterone and testosterone increases sebum production rate. At puberty, level of these hormones increases thus cause acne formation. Estrogen reduces sebum production. But most patients have normal hormone profiles.
2. Genetic factors – sometimes if anyone in family had bad acne that may run in to family.
3. Environmental factors – high humidity, heat and sweating may also cause acne.
4. Stress and depression – Psychological stress and depression may disturb the hormonal level and may cause acne.
5. Lack of sleep – Insufficient sleep also stimulates sebum production and acne formation.
6. Certain cosmetics which contain lanolin, vegetable oils, butyl sterate or lauryl alcohol and oleic acid are another cause of acne.
7. Some products which are irritants on skin or allergic to skin also cause acne.
8. Dietary habits – High intake of dairy products, meat, sugars, junk food also cause acne.
9. Hair dandruffs also cause acne so hair washing frequently advised to prevent acne.
10.Certain medications also provoke acne.

Signs and symptoms
Local symptoms are pain tender and erythema. Acne vulgaris typically affects the areas of skin with the densest population of sebaceous follicles (eg, face, upper chest, back). Acne vulgaris may have a psychological impact on any patient, regardless of the severity or the grade of the disease.
Acne or pimples may be in different forms
Comedones are sebaceous plugs impacted within follicles. Depending on wheather follicle is closed or dilated(open) at skin suface comedones are of two types closed comedone or whiteheads and open comedones also called blackheads.
Plugs are easily extruded from open comedones but are more difficult to remove from closed comedones. Closed comedones are the precursor lesions to inflammatory acne. Whiteheads (closed comedones) are flesh-colored or whitish palpable lesions 1 to 3 mm in diameter; blackheads (open comedones) are similar in appearance but with a dark center.
Papules and pustules are inflammatory acne, usually occurs after propionibacterum acne colonization in closed comedones, these are red lesions around 2-5 mm in diameter, papules are relatively deeper and pustules are superficial.
Nodules or small eruptions which are solid and painful. Cysts are suppurative nodules.
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Acne fulminans – It is rare but severe presentation usually associated with fever, joint pain and swelling. It is usually found on the trunk.
Acne Conglobate – Severe acne, characterized by multiple comedones, nodules, abscess, sinuses, cysts and marked scarring without the presence of systemic symptoms. More commonly present in adult males on the trunk and upper limb.
Acne Excorii- Self inflicted excoriation of skin due to repetitive touching , picking and pricking of preexisting acne lesions. Most commonly presents in teenage girls and people suffering with psychological stress or depression.
Pyoderma faciale (also called rosacea fulminans) – occurs suddenly on the midface of young women. The eruption consists of erythematous plaques and pustules, involving the chin, cheeks, and forehead.
Secondary acne– acne caused by either greasy or irritant cosmetics, exposure to oil and dust or some medications like corticosteroids, anticonvulsants, lithium. Polycystic ovary syndrome, menstrual irregularities and premenstrual period are usually associated with acne.

Diagnosis
Signs and symptoms along with medical history, menstrual history, any medications, psychological stress or depression and environmental history.
Local examinations of acne and scars
Laboratory tests for female menstruating patients to check hormone levels of total and/or free testosterone, dehydroepiandrosterone sulfate, luteinizing hormone (LH), and follicle-stimulating hormone (FSH).

Treatment
It is important to treat acne to reduce the extent of disease, scarring, and psychological distress.

A. Naturotherapy (Natural way of treatment for simple acne and prevention of severe acne).
1. Affected areas should be cleansed daily.
2. Change dietary habits avoid oily food, reduce intake of dairy products and sugar. Food should be rich in fibers and fruits.
3. Drink plenty of water.
4. Full sleep for 6-8 hours.
5. Pranayama (deep breathing exercises) helps to reduce stress and thus acne.
6. Avoid irritant cosmetic products.
Follow healthy lifestyle and health tips.

B. Pharmacotherapy
Consultation with a specialist may be necessary. Treatment should involve educating the patient and tailoring the plan to one that is realistic for the patient. Treatment failure can frequently be attributed to lack of adherence to the plan and also to lack of follow-up.

Topical therapy is useful in mild and moderate acne, as monotherapy, in combination and also as maintenance therapy. Systemic and physical therapy depends upon severity of acne.
1. Benzoyl peroxide – Mild acne usually managed with topical therapy. Initially started with low concentration topical benzoyl peroxide for short duration then gradually increased if tolerated.
2. Topical retinoids – Topical retinoids target the microcomedo–precursor lesion of acne. Tretinoin and isotretinoin are commonly used topical retinoids.
3. Topical antibiotics – Many topical antibiotics formulations are available, either alone or in combination. They inhibit the growth of P. acne and reduce inflammation. Topical antibiotics such as erythromycin and clindamycin are the most popular in the management of acne.
4. Other topical agents – Azelaic acid, Salicylic acid, Lactic acid/Lactate lotion, Tea tree oil 5%, Picolinic acid gel 10%, Dapsone gel 5% can also be used either single agent or in combination therapy.
5. Systemic antibiotics – Oral antibiotics are indicated in mainly moderate-to-severe inflammatory acne. Tetracyclines and derivatives still remain the first choice. Macrolides, co-trimoxazole, and trimethoprim are other alternatives for acne. Gastrointestinal upset and vaginal candidiasis are most common side effects. Doxycycline can be associated with photosensitivity. Minocycline may produce pigment deposition in the skin, mucous membrane, and teeth. Autoimmune hepatitis, systemic lupus erythematosus-like syndrome, and serum sickness-like reactions occur rarely with minocycline.
6. Hormonal therapy – Used in female patients suffering with androgenic alopecia, hirsuitism, seborrhea, and proven ovarian or adrenal hyperandrogenism.
Oral contraceptives – Anti-acne effect of oral contraceptive governed by decreasing level of circulatory androgens through inhibition of luteinizing hormones (LH) and follicle stimulating hormone (FSH).
Spironolactone – functions primarily as a steroidal androgen receptor blocker.
Cyproterone acetate– it is first androgen receptor blocking agent used in combination with ethinyl estradiol to treat acne in females.
Flutamide – used to treat acne in females with hirsuitism.

7. Oral isotretinoin – used to treat modereate to severe acne which in not responsive to conventional therapy.

C. Physical treatment-
Intralesional injections of triamcinolone acetonide may be required for inflamed acne nodules or cysts, which can also be incised and drained, or excised under local anaesthetic.
UVB phototherapy or PDT can occasionally be used in patients with inflammatory acne who are unable to use conventional therapy.

Summary of treatment

• Comedones: Topical tretinoin
• Mild inflammatory acne: Topical antibiotics, benzoyl peroxide, or both
• Moderate acne: Oral antibiotics
• Severe acne: Oral isotretinoin
• Cystic acne: Intralesional triamcinolone
• Oral contraceptives are effective in treating inflammatory and noninflammatory acne in females.

Effective treatments aim to improve the condition and prevent worsening (including later scarring), and to restore emotional well-being and self-esteem. The psychological impact of acne must not be underestimated and should be considered in management decisions.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Content source –  Davidson’s Principles and Practice of Medicine(22ndedition), Indian Journal of Dermatology, http://www.merckmanuals.com, http://www.dermnetnz.org