American family physician
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Skin conditions during pregnancy fall into three categories: benign hormone-related changes, preexisting skin conditions, and pregnancy-specific disorders. Benign hormonal skin changes (e.g., hyperpigmentation, striae gravidarum, hair and nail changes, vascular changes) are common during pregnancy and often improve or resolve postpartum. Topical therapies, including tretinoin, hydroquinone, and corticosteroids, can be helpful in the postpartum treatment of melasma. ⋯ Low- to midpotency topical corticosteroids are generally considered safe during pregnancy, whereas extensive use of high-potency corticosteroids may be associated with low birth weight. Pregnancy-specific skin conditions include atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis, intrahepatic cholestasis of pregnancy, and pustular psoriasis of pregnancy. Conditions that may cause adverse fetal outcomes and require consideration of antenatal fetal surveillance include intrahepatic cholestasis of pregnancy, pemphigoid gestationis, and pustular psoriasis of pregnancy.
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Acute otitis externa is an inflammatory condition that affects the external ear canal. It is usually of rapid onset and is generally caused by bacterial infection. The primary bacterial infections are Pseudomonas aeruginosa and Staphylococcus aureus. ⋯ Oral antibiotics are indicated only if evidence of cellulitis occurs outside of the ear canal or if associated conditions such as immunocompromise, diabetes mellitus, or conditions that would not allow for the use of topical treatment are found. Duration of topical treatment is usually seven to 10 days. Keys to prevention include avoiding injury to the ear canal and keeping it free of water.
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Trigger points producing myofascial pain syndromes are common in primary care. Located within skeletal muscle, trigger points are taut, band-like nodules capable of producing pain and disability. Some evidence from clinical trials supports massage, physical therapy, and osteopathic manual medicine as first-line less invasive treatment strategies. ⋯ No single pharmacologic agent used in trigger point injections has been proven superior to another, nor has any single agent been proven superior to placebo. Trigger point injections, therefore, should be reserved for patients whose myofascial pain has been refractory to other measures, and family physicians should first employ less invasive treatment strategies. Trigger point management is only one part of a comprehensive, multimodal, and team-based approach to patients with myofascial pain.
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Fibromyalgia is a chronic, centralized pain syndrome characterized by disordered processing of painful stimuli. Fibromyalgia is diagnosed more frequently in women and occurs globally, affecting 2% of people in the United States. Patients with fibromyalgia have diffuse chronic pain, poor sleep, fatigue, cognitive dysfunction, and mood disturbances. ⋯ Patient education, exercise, and cognitive behavior therapy can improve pain and function. Duloxetine, milnacipran, pregabalin, and amitriptyline are potentially effective medications for fibromyalgia. Nonsteroidal anti-inflammatory drugs and opioids have not demonstrated benefits for fibromyalgia and have significant limitations.