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Mass-participation endurance sporting events have grown in popularity and number over the past several decades. These events vary widely, ranging from small-scale, local, 5-km run-walks whose participants are primarily recreational athletes and non-athletes to major international marathon and triath

CloseIntracardiac and surface ECG tracings during radiofrequency catheter ablation of the right bundle branch in a patient with BBRVTIntracardiac and surface ECG tracings during radiofrequency catheter ablation of the right bundle branch in a patient with BBRVTShown are five surface ECG leads (I, II, aVF, V1, V6) and intracardiac recordings from the His bundle region (HBE2-3,1-2), the right ventricular apex (RVA3-4), and a mapping catheter (USER1) positioned distal to the His catheter along the RV septum. Application of radiofrequency (RF) energy to the tip of the mapping catheter causes two accelerated beats with a typical left bundle branch block (LBBB) morphology (black arrow), likely from heating and activating the right bundle branch. After these beats, complete right bundle branch block (RBBB) is present (red arrow), as evidenced by the change in QRS morphology, particularly in lead V1. Following right bundle branch ablation, the HV interval increased to 105 milliseconds, though no infranodal A-V block was noted. Right bundle branch reentrant tachycardia was no longer inducible. A permanent pacemaker was placed because of the markedly prolonged HV interval.H: His bundle electrogram; A: atrial electrogram; V: ventricular electrogram; ECG: electrocardiogram; RV: right ventricular.Graphic 80017 Version 6.0

In populations with darkly pigmented skin, melanoma occurs most frequently in acral areas, with a particular predilection for the soles of the feet. In Black people, acral melanomas account for around 80 percent of all melanomas [1]. In Japanese individuals, almost one-half of cutaneous melanomas oc

A wide variety of lesions occurs on the vulva. Some of the disorders causing these lesions are limited to the vulva, while others also involve skin or mucocutaneous membranes elsewhere on the body. This topic provides a morphology-based classification system that can help clinicians with the differe

Piedra, the Spanish word for "stone," is a descriptive name for fungal infections that cause small, stone-like concretions on hair. Piedra is divided into two subtypes: white piedra and black piedra.White piedra presents with white to brown nodules on hair shafts on the scalp, axillae, groin, or oth

A wide variety of lesions occurs on the vulva. Some of the disorders causing these lesions are limited to the vulva, while others also involve skin or mucocutaneous membranes elsewhere on the body. This topic provides a morphology-based classification system that can help clinicians with the differe

CloseWGBT threshold for Twin Cities race cancellationWGBT threshold for Twin Cities race cancellationThe black curved line (curve of best fit) represents the number of runners who dropped out of the race plus the number seen in the finish line medical tent per 1000 race finishers. The red line intersecting the curve of best fit is placed just above the data points associated with an MCI—three hospitals forced onto ambulance diversion—and below the data points associated with a major MCI—six hospitals forced onto ambulance diversion and activation of regional EMS transport teams. The numbers in white boxes are the approximate number of runners who developed EHS per 10,000 finishers for a given WGBT range. Zones of relative risk for EHS by WBGT are designated by color: Green (low risk) is <13°C or 55°F; yellow (moderate risk) is 13.5 to 18°C, or 56 to 64°F; red (high risk) is 18.5 to 20°C, or 65 to 68°F; and black, which is not drawn (very high risk; cancel race), is ≥20.5°C or 69°F.TCM: Twin Cities marathon; MCI: minor mass casualty incident; EHS: exertional heat stroke; EMS: emergency medical services; WGBT: wet-bulb globe temperature.Courtesy of William Roberts, MD.Graphic 111147 Version 3.0

In the normal state, sweat is colorless. The term "chromhidrosis," derived from the Greek "chroma" (colored) and "hidros" (sweat), describes the occurrence of colored sweat.True chromhidrosis is a rare condition characterized by the secretion of colored sweat from apocrine or eccrine sweat glands. I

ClosePulse-wave Doppler distinguishes between constrictive pericarditis and chronic obstructive pulmonary diseasePulse-wave Doppler distinguishes between constrictive pericarditis and chronic obstructive pulmonary diseaseIn patients with chronic obstructive pulmonary disease (COPD) the pulse-wave Doppler echocardiogram shows pronounced respiratory variation in superior vena caval (SVC) blood flow velocity (red arrows, panel A), which is not seen in constrictive pericarditis. In contrast, the mitral flow velocity (panel B) shows a similar respiratory variation (E wave, black arrows) in COPD and constrictive pericarditis. Recording SVC blood flow velocity is therefore a simple way to distinguish pulsus paradoxus due to constrictive pericarditis from that due to COPD.S: systole; D: diastole.; ins: inspiration; exp: expiration.Reproduced with permission from: Boonyaratevej, S, Oh, JK, Tajik, AJ, et al. J Am Coll Cardiol 1998; 32:2043. Copyright © 1998 American College of Cardiology.Graphic 53288 Version 2.0

A wide variety of lesions occurs on the vulva. Some of the disorders causing these lesions are limited to the vulva, while others also involve skin or mucocutaneous membranes elsewhere on the body. This topic provides a morphology-based classification system that can help clinicians with the differe

ST- and T-wave changes may represent cardiac pathology or be a normal variant. Interpretation of the findings, therefore, depends on the clinical context and presence of similar findings on prior electrocardiograms.NONSPECIFIC ST-T-WAVE CHANGES — Nonspecific ST-T-wave changes are very comm

CloseSummary of response interventions in the 2015 Nepal earthquakeSummary of response interventions in the 2015 Nepal earthquake Distribution of individual clean delivery kits Description Clean delivery kits including chlorhexidine for prevention of umbilical cord infection among newbornsBeneficiaries 1100 visibly pregnant women in all 31 earthquake-affected districts, except in Kathmandu ValleySetting up of WHO MCKs and medical tents Description 40 MCKs provided by WHO with all necessary equipment for establishing a birthing center and a functional outpatient departmentMore than 350 medical tents provided by UNFPA, UNICEF, and German Development CooperationMCKs were installed in damaged hospitals, primary health centers, and health posts to serve as emergency shelters for the provision of health servicesOther medical tents served as shelters for RH servicesOutcomes More than 100 birthing centers resumed their services under these tentsDeployment of nursing and medical teams with skilled birth-attendance competencies Description 25 nurses qualified as skilled birth attendants (in 24 birthing centers) were deployed as well as 8 senior nurses (to cover 40 birthing centers)This program was supported by UNICEF and implemented through the MIDSONThe nurses volunteered from government hospitals and nursing collegesThey provided extra support and onsite coaching to the regular maternity staff, helped staff cope with the surge of activities, and facilitated institutional deliveries and timely management of complicated pregnancies/deliveries; some nurses also volunteered to join NGOs' emergency programsOne roving obstetrician was deployed to the affected hospitals to initiate/continue C-sections and other medical reproductive health proceduresOutcomes By June 2015: Antenatal care was re-established in all services sites; majority of birthing centers were able to provide delivery services and C-section services were available in 13 of 14 district hospitalsOrganization of outreach reproductive health camps Description The RH camps were mobile in nature, remaining in one site for about 2 to 4 days before moving to the next community; the number of mobile camps ranged from 8 to 14 per district considering its population coverage and needs; it also included on-site local capacity building, enabling referrals to health facilities and a mobile unit for awareness-raising sessions; it was implemented together with DPHOs; information on the scheduled dates for mobile RH camps was disseminated through FCHVs youth groups prior to the camps132 RH camps were conducted in 128 villages, with support from UNFPARH camps were carried out by national health professionalsProvided SRH services free of charge for earthquake-affected people in remote communities in all 14 affected districts[1]Provided life-saving health care support to women and their families, ranging from antenatal and postnatal check-ups, safe delivery, family planning, lab testing facilities (including for HIV), management of STI, psychosocial support, health response to genderbased violence, and referrals; key health messages and information were delivered to women and girlsFree-of-charge transportation of severe cases identified through the camps was ensuredBeneficiaries 104,740 women and adolescent girls reached; UNFPA has estimated that the needs of 1.4 million affected people were coveredDistribution of ERH kits Description 1331 ERH kits provided to tertiary level hospitals, district hospitals, and smaller health facilities in all the 14 most affected districts, through a total of 37 partners; the kits were also used in the outreach RH camps and in the WHO Medical Camp Kits; the additional kits were supplied/replenished depending on the request from MoH, DPHOs, and/or implementing partnersProvided at community, primary health care, and referral hospital levels, ranging from 1 to up to 35 boxes of equipmentKits included contraceptives, drugs, and supplies for STI treatment and clinical delivery assistance, instruments, equipment, and supplies for the management of obstetric complications, including assisted deliveries and C-sections, medical abortion, and postrape treatment kitsMisoprostol was added to the kits where a program aiming to prevent postpartum hemorrhage during home deliveries was already ongoingOutcomes 213 health facilities benefited from the ERH kitsUNFPA has calculated that the needs of an estimated 1.4 million affected population were coveredProvision of psychosocial counseling Description Provision to maternity hospital health workers who needed support, on voluntary basis, for six weeks after the disaster to help them cope with the stress induced by the earthquake and repeated aftershocks and the unprecedented surge in caseload they were handlingSocial mobilizers and health services providers trained on psychosocial counseling were identified and hired in close collaboration with DPHOBeneficiaries Approximately 100 staff (25 percent) of the central referral maternity hospital in Kathmandu WHO: World Health Organization; MCKs: medical camp kits; UNFPA: United Nations Population Fund (formerly United Nations Fund for Population Activities); UNICEF: United Nations Children's Fund (formerly United Nations International Children's Emergency Fund); RH: reproductive health; MIDSON: Midwifery Society of Nepal; NGO: nongovernment organization; DPHOs: district public health offices; FCHVs: female community health volunteers; SRH: sexual and reproductive heath; STI: sexually transmitted infection; ERH: emergency reproductive health; MoH: Ministry of Health.Reference:United Nations Population Fund. Dignity first: UNFPA Nepal 12 month earthquake report April 2016.Reproduced from: Chaudhary P, Vallese G, Thapa M, et al. Humanitarian response to reproductive and sexual health needs in a disaster: the Nepal Earthquake 2015 case study. Reprod Health Matters 2017; 51:25. Available at: https://www.tandfonline.com/doi/full/10.1080/09688080.2017.1405664 (Accessed on February 27, 2018). Reproduced under the terms of the Creative Commons Attribution License.Graphic 116906 Version 1.0

Seeing blood in your child's bowel movements (sometimes known as "rectal bleeding" or "bloody stools") can be frightening. However, this is a common observation in children and, in most cases, is not a sign of a serious problem. A health care provider can help to determine the most likely cause of t

ClosePatient education: Sunburn prevention (Beyond the Basics)Patient education: Sunburn prevention (Beyond the Basics)Authors:Antony R Young, PhDAngela Tewari, MBBS, BSc, MRCP, PhD Section Editors:Robert P Dellavalle, MD, PhD, MSPHCraig A Elmets, MD Deputy Editor:Rosamaria Corona, MD, DScl*terature review current through: Nov 2022. | This topic last updated: Mar 07, 2022.Please read the Disclaimer at the end of this page.OVERVIEW — There are a number of effective ways to prevent sunburn, including staying out of the sun during peak hours, sunscreen, and protective clothing. While these measures are important for everyone, they are especially important for children and people with fair skin, who burn easily and tan poorly.This article discusses ways to prevent sunburn. The treatment of sunburn is discussed separately (see"Patient education: Sunburn (Beyond the Basics)"). More detailed information about sunburn is available by subscription. (See"Sunburn".)AVOID SUN EXPOSURE — It is important to prepare for sun exposure, especially if you plan to be out in the sun for an extended period of time or during the middle of the day, when the sun's rays are strongest (10:00 AM to 4:00 PM during daylight savings time in the continental United States).Even on cloudy days, it is important to protect your skin because ultraviolet (UV) radiation can pass through the clouds and cause sunburn. In addition, UV rays reflect off surfaces like sand, snow, and cement. Snow can have up to 30 percent reflectance and cause severe sunburn without protection. The sun's rays can also penetrate clear water. Using two types of protection (shade or clothing plus sunscreen) is the best way to reduce sun exposure and the risk of sunburn and skin cancer. Seek shade — Areas that are shaded receive less UV radiation, and can reduce your chances of developing a sunburn. Trees, an umbrella, or a structure (eg, a porch or tent) can provide shade. Sunscreen is still recommended while sitting in the shade because your skin is exposed to some UV rays, particularly through reflection off other surfaces.UV index — The UV index was developed to predict the risk of sunburn in your area on a given day based upon the weather conditions. It gives a number between zero and 11+, in which zero indicates a low risk of sun exposure; 10 indicates a very high risk of exposure; and 11+ is an extreme risk of sun exposure. You can find information about the UV index online at www.epa.gov/sunsafety/uv-index-1.Significant importance is attached to ultraviolet A (UVA) as well as ultraviolet B (UVB) to formulate the UV index, so it is really important that we always choose a broadband sunscreen.SUNSCREEN — The active ingredients of sunscreens can be minerals (eg, titanium oxide or zinc oxide) that provide a physical barrier to ultraviolet (UV) radiation, or organic chemicals that absorb UV rays. Sunscreen formulations (gels, lotions, and sprays) typically contain several active ingredients and, often, a mix of physical and chemical agents. The sun protection factor (SPF) is primarily an indicator of how much protection the sunscreen offers against ultraviolet B (UVB; sunburn) rays. You should look for a sunscreen that is labeled as broad-spectrum, meaning it protects against both ultraviolet A (UVA) and UVB rays. However, most people do not apply enough sunscreen to achieve the SPF on the label and can overestimate their level of protection. Applying the sunscreen twice is a good way to achieve better protection.What SPF is best? — Most health care providers, as well as the American Academy of Dermatology, recommend the following:●Use a sunscreen with an SPF of 50 on exposed skin, as studies show you get 20 percent more protection from SPF 50 sunscreen compared with SPF 30 sunscreen. However, if a lower SPF (eg, SPF 30) is better tolerated on the skin, then that is better than not using a sunscreen at all.●Use a sunscreen that protects against both UVA and UVB radiation (broad-spectrum sunscreen). ●You should not use a high SPF just to stay out longer in the sunshine. If you anticipate intense and/or prolonged sun exposure (eg, while at the beach or skiing), you should use a high SPF sunscreen and reapply it frequently.How much sunscreen do I need? — You should apply sunscreen generously to all exposed skin 20 minutes before exposure. Exposed skin is any skin that is not protected from the sun.Good application is needed to achieve the labeled SPF. One approach is the "teaspoon rule," which means a generous teaspoon of sunscreen to each leg, the front and back torso, and a generous half-teaspoon to each arm, face, and neck. Applying less than this amount may reduce the sunscreen's SPF rating.You should reapply sunscreen after sweating, rubbing the skin, drying off with a towel, or swimming. The traditional advice is to reapply sunscreen every two to three hours. However, some evidence suggests that reapplying sunscreen as soon as 20 minutes after going outside may offer greater protection, allowing you to completely cover areas that you might have missed when you first applied sunscreen. You should then reapply every two to three hours.Protect your lips with lip balm containing a SPF of 30 or higher and reapply frequently. Some cosmetic products (eg, liquid foundation, lipstick) and moisturizers contain sun-protective ingredients, although to be truly effective, these products should be labeled as having an SPF of 15 or higher. Many of these products provide little or no UVA protection.Sunscreen and vitamin D — Although UV radiation has many deleterious consequences, wavelengths within the UVB spectrum have the beneficial effect of triggering the production of vitamin D by the skin. This is the main source of vitamin D, which is essential for good bone health. Some studies have shown that although sunscreens protect against UVB, they still allow very good vitamin D synthesis because the UVB dose for this is much lower than the dose for sunburn. Thus, the benefit of sunscreen use against sunburn and skin cancer is not compromised by any significant effects on vitamin D production. Does sunscreen expire? — Manufacturers recommend throwing away sunscreen when it has passed the expiration date listed on the bottle. Generally, there will be a note on how many months the sunscreen is valid for after opening. However, sunscreens can last longer than their recommended date. Use common sense to assess; if the sunscreen doesn't smell correct or if the consistency is not right, then discard. For sunscreen that does not have an expiration date, a typical recommendation is to replace it every season. Expired sunscreen may be less effective, potentially reducing the SPF rating and increasing your risk of sunburn.Clothing — In addition to sunscreen, consider covering exposed skin with a wide-brimmed hat, long-sleeved shirt, and long pants. A hat made of tightly woven material (eg, canvas) can provide shade for the face, ears, and back of the neck. Sunglasses that provide 100 percent UV ray protection can reduce your risk of cataracts (clouding in the eye's lens); wraparound glasses provide the most complete protection.Clothing made from tightly woven, dark fabric tends to provide greater protection than light-colored fabrics, although they may feel more uncomfortable as they absorb more UV, which gets converted to heat. Some manufacturers have sun-protective clothing with SPF. In addition, UV absorbing agents can be applied to clothing in the laundry.Tips for children — Children are at higher risk than adults for becoming sunburned for several reasons. Children are usually unaware of the risks of sunburn and are less likely to use preventive measures (eg, sunscreen, shade). Children may also be more sensitive to the sun, resulting in more DNA damage in response to the same amount of sunshine as adults. Thus, regular sunscreen application is imperative for children. Baby formulas are recommended, as these are more likely to contain physical blockers (eg, titanium dioxide or zinc oxide) that are thought to be safer. Babies under six months should be kept out of direct sunlight, and sunscreen can be applied to any exposed areas of the skin (eg, face and back of hands). The safety of sunscreen has not been tested in infants younger than six months; thus, parents are encouraged to use hats, sunglasses, and shade to protect children from the sun. SUN TANNING — People with naturally brown or black skin have a high level of the pigment melanin in their skin, which provides protection against sunburn and skin cancer. If your skin is light, tanning increases your skin's production of melanin, which can provide very limited protection to your skin against further damage from ultraviolet (UV) radiation. However, the small benefit of tanning (protection from sunburn) does not outweigh the risks (skin cancer, aged skin).Outdoor tanning — A tan is a response to DNA damage in the skin that, if unrepaired, can lead to skin cancer. Tanning also increases the long-term consequences of sun exposure, such as skin cancer and wrinkling. Tanning beds — Most tanning beds emit UV radiation, primarily in the ultraviolet A (UVA) range. Although both UVA and ultraviolet B (UVB) can cause tanning, UVB-induced tans last a little longer. There are reports that it may protect you from further sunburn by only an SPF of 2 to 4. However, it is important to note that tanning beds can cause sunburn and have been linked to an increased risk of melanoma, a potentially deadly form of skin cancer. The use of commercial tanning lamps is banned in Australia and Brazil, and legislation is in place in the United Kingdom, particularly for those with fairer skin types. In the United States, indoor tanning is banned for those under 18 in several states. Tanning beds should not be used by people under the age of 18 years and with exposure restrictions. For those who do use tanning beds, it is particularly important to use protective eyewear when the sunlamp is on because tanning beds can cause cataracts and melanoma of the eye.Sunless tanning — As people become more aware of the risks of skin cancer from sun exposure and tanning beds, sunless tanning products have become increasingly popular. A variety of safe and natural-appearing sunless tanning products are available, including lotions, gels, and sprays.Topical tanning agents, such as dihydroxyacetone, combine with proteins in the skin, making it darker. The staining is temporary, usually lasting less than one week unless you reapply the product, but does not provide any protection from sunburn. Other tanning products — No tanning pills or tanning accelerators taken by mouth have been approved by the US Food and Drug Administration (FDA). These are marketed to darken the skin by either stimulating the body's pigmentation system or distributing the color additives within the skin. However, their safety is questionable and use is not advised.WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Melanoma skin cancer (The Basics) Patient education: Skin cancer (non-melanoma) (The Basics) Patient education: Sunburn (The Basics) Patient education: Actinic keratosis (The Basics) Patient education: Keloids (The Basics) Patient education: Melasma (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Sunburn (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Primary prevention of melanoma Risk factors for the development of melanoma Sunburn Vitiligo: Pathogenesis, clinical features, and diagnosisThe following organizations also provide reliable health information.●American Academy of Dermatology(https://www.aad.org/public/everyday-care/sun-protection)●National Library of Medicine (https://medlineplus.gov/sunexposure.html, available in Spanish)●Center for Disease Control and Prevention       (https://www.cdc.gov/niosh/topics/sunexposure/sunburn.html)●The National Cancer Institute(https://progressreport.cancer.gov/prevention/sunburn)●The Environmental Protection Agency       (https://www.epa.gov/sunsafety)●The Skin Cancer Foundation       (https://www.skincancer.org/)●The National Council on Skin Cancer Prevention       (https://skincancerprevention.org/)[1-10]Moloney FJ, Collins S, Murphy GM. Sunscreens: safety, efficacy and appropriate use. Am J Clin Dermatol 2002; 3:185.Faurschou A, Wulf HC. The relation between sun protection factor and amount of suncreen applied in vivo. Br J Dermatol 2007; 156:716.Stumpf JL. Myths and facts about sunscreen shelf life and SPF. US Pharm 2004; 8:73.Young AR, Claveau J, Rossi AB. Ultraviolet radiation and the skin: Photobiology and sunscreen photoprotection. J Am Acad Dermatol 2017; 76:S100.Jovanovic Z, Schornstein T, Sutor A, et al. Conventional sunscreen application does not lead to sufficient body coverage. Int J Cosmet Sci 2017; 39:550.Schneider J. The teaspoon rule of applying sunscreen. Arch Dermatol 2002; 138:838.Narbutt J, Philipsen PA, Harrison GI, et al. Sunscreen applied at ≥ 2 mg cm-2 during a sunny holiday prevents erythema, a biomarker of ultraviolet radiation-induced DNA damage and suppression of acquired immunity. Br J Dermatol 2019; 180:604.Young AR, Narbutt J, Harrison GI, et al. Optimal sunscreen use, during a sun holiday with a very high ultraviolet index, allows vitamin D synthesis without sunburn. Br J Dermatol 2019; 181:1052.Narbutt J, Philipsen PA, Lesiak A, et al. Children sustain high levels of skin DNA photodamage, with a modest increase of serum 25-hydroxyvitamin D3 , after a summer holiday in Northern Europe. Br J Dermatol 2018; 179:940.Fajuyigbe D, Lwin SM, Diffey BL, et al. Melanin distribution in human epidermis affords localized protection against DNA photodamage and concurs with skin cancer incidence difference in extreme phototypes. FASEB J 2018; 32:3700.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 2724 Version 24.0References1 : Sunscreens: safety, efficacy and appropriate use.2 : The relation between sun protection factor and amount of suncreen applied in vivo.3 : Myths and facts about sunscreen shelf life and SPF4 : Ultraviolet radiation and the skin: Photobiology and sunscreen photoprotection.5 : Conventional sunscreen application does not lead to sufficient body coverage.6 : The teaspoon rule of applying sunscreen.7 : Sunscreen applied at≥2 mg cm-2 during a sunny holiday prevents erythema, a biomarker of ultraviolet radiation-induced DNA damage and suppression of acquired immunity.8 : Optimal sunscreen use, during a sun holiday with a very high ultraviolet index, allows vitamin D synthesis without sunburn.9 : Children sustain high levels of skin DNA photodamage, with a modest increase of serum 25-hydroxyvitamin D3 , after a summer holiday in Northern Europe.10 : Melanin distribution in human epidermis affords localized protection against DNA photodamage and concurs with skin cancer incidence difference in extreme phototypes.

CloseCicatricial (scarring) alopeciasCicatricial (scarring) alopecias   Epidemiology Clinical features on scalp Nonscalp involvement Pathology Lymphocytic primary cicatricial alopecias Discoid lupus erythematosus Onset usually in young adulthood; more common in females than males; may occur independently or in patients with SLE Erythematous, atrophic plaques with follicular plugging present centrally, hyperpigmentation, and/or hypopigmentation Face, ears, and other sites may be affected; a minority of cases are associated with SLE Interface dermatitis, epidermal atrophy, follicular plugging, basem*nt membrane thickening, perifollicular superficial and deep lymphoplasmacytic infiltrate; DIF shows IgG, IgM, and C3 at the BMZ Lichen planopilaris Most common in White and East Indian females Areas of scarring and follicles with erythema and scale; itching and pain may be severe May be accompanied by cutaneous, nail, or mucous membrane lichen planus Lichenoid infiltrate around the isthmus and infundibulum, interface dermatitis, concentric lamellar fibroplasia Frontal fibrosing alopecia Mostly postmenopausal females Perifollicular erythema, follicular hyperkeratosis, band-like frontal alopecia Loss of eyebrows common, papules on face Lichenoid infiltrate around the isthmus and infundibulum, apoptotic keratinocytes in outer root sheath, concentric lamellar fibroplasia Classic pseudopelade of Brocq Most common in middle-aged females Skin-colored scarred plaques resembling "footprints in the snow" N/A Lymphocytic infiltrate around infundibulum, concentric lamellar fibroplasia around follicles in later lesions Central centrifugal cicatricial alopecia Most common in females of African origin Patch of scarring alopecia on crown of scalp that progresses centrifugally N/A Premature desquamation of the inner root sheath, loss of sebaceous glands, variable perifollicular chronic inflammation at isthmus and infundibulum, concentric lamellar fibroplasia Alopecia mucinosa May be associated with mycosis fungoides or CTCL Erythematous or skin-colored indurated plaques with alopecia, follicular papules Eyebrow involvement may be present Mucin deposits in outer root sheath, eventual replacement of follicles by mucin, lymphocytic infiltrate Keratosis folliculars spinulosa decalvans X-linked inheritance of mutation in the MBTPS2 gene; less commonly autosomal dominant transmission Noninflammatory, hyperkeratotic follicular papules and progressive hair loss Eyebrow and eyelash involvement may be present, photophobia Follicular plugging and hypergranulosis, primarily lymphocytic perifollicular infiltrate, fibrosis Neutrophilic primary cicatricial alopecias Dissecting cellulitis of the scalp Most common in young Black males Inflammatory papules, pustules, fluctuant nodules, abscesses; may also have keloidal scarring May be associated with hidradenitis suppurativa and acne conglobata Follicular occlusion, intrafollicular and perifollicular neutrophilic and lymphoplasmacytic infiltrate; follicular perforation, deep abscesses and sinus tracts in later stages Folliculitis decalvans Most common in young and middle-aged adults, particularly males Patches of alopecia, erythematous follicular papules, pustules, follicular hyperkeratosis, tufted folliculitis N/A Interfollicular and perifollicular neutrophilic infiltrate; mixed infiltrate, granulomas, and fibrosis in later lesions Mixed primary cicatricial alopecias Acne keloidalis nuchae Most common in young Black males Dome-shaped papules and pustules on the occipital scalp and nape of the neck; keloids may develop N/A Neutrophilic or lymphoplasmacytic inflammatory infiltrate around the isthmus and infundibulum; granulomatous infiltrate may also be present; marked fibrosis Acne necrotica Usually occurs in adults Umbilicated, pruritic, painful papules that undergo central necrosis and resolve with varioliform scars N/A Infundibular folliculitis with necrosis, lymphocytic or mixed inflammatory infiltrate Erosive pustular dermatosis of the scalp Most common in older adults, particularly females Pustules, erosions, and crusted plaques N/A Nonspecific early findings; older lesions with a chronic mixed inflammatory infiltrate and fibrosis Other Tinea capitis Usually affects children Scaly patches or plaques; kerion may develop Tinea corporis may be present Perifollicular inflammation and fungal elements within or around the hair shaftSLE: systemic lupus erythematosus; DIF: direct immunofluorescence; IgG: immunoglobulin G; IgM: immunoglobulin M; BMZ: basem*nt membrane zone; CTCL: cutaneous T cell lymphoma.Data from:Otberg N, Shapiro J. Hair growth disorders. In: Fitzpatrick's Dermatology in General Medicine, 8th ed, Goldsmith LA, Katz SI, Gilchrest BA, et al. (Eds), McGraw Hill 2012.Childs JM, Sperling LC. Histopathology of scarring and nonscarring hair loss. Dermatol Clin 2013; 31:43.Graphic 88347 Version 5.0

Cutaneous squamous cell carcinoma (cSCC) is a malignant tumor arising from epidermal keratinocytes [1]. In individuals with lightly pigmented skin, it typically develops in areas of photodamaged skin and presents with a wide variety of cutaneous lesions, including papules, plaques, or nodules, that

ClosePatient education: Acute diarrhea in adults (Beyond the Basics)Patient education: Acute diarrhea in adults (Beyond the Basics)Authors:Regina LaRocque, MD, MPHJason B Harris, MD, MPH Section Editor:Stephen B Calderwood, MD Deputy Editor:Elinor L Baron, MD, DTMHLiterature review current through: Nov 2022. | This topic last updated: May 24, 2022.Please read the Disclaimer at the end of this page.DIARRHEA OVERVIEW — Diarrhea is commonly defined as three or more loose or watery stools per day. Nearly everyone will have an episode of diarrhea at some point during their life, with the average adult experiencing it four times per year. Although most cases of diarrhea resolve within a few days without treatment, it's important to know when to seek help.This topic review discusses the causes and treatments of sudden onset (acute) diarrhea in adults in developed countries. A discussion of acute diarrhea in resource-limited countries and returning travelers is not included here. Diarrhea that lasts for more than 14 days (called chronic diarrhea) and acute diarrhea in children are discussed in separate topic reviews. (See"Patient education: Chronic diarrhea in adults (Beyond the Basics)" and"Patient education: Acute diarrhea in children (Beyond the Basics)".) A topic review that discusses antibiotic-associated diarrhea is also available. (See"Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics)".)DIARRHEA CAUSES — Diarrhea can be caused by infections or a variety of other factors. The cause of diarrhea is not identified in most people, especially those who improve without treatment.Diarrhea caused by infections usually results from eating or drinking contaminated food or water. Signs and symptoms of infection usually begin 12 hours to four days after exposure and resolve within three to seven days. (See"Patient education: Foodborne illness (food poisoning) (Beyond the Basics)".)Diarrhea not related to an infection can occur as a side effect of antibiotics or other drugs, food allergies, gastrointestinal diseases such as inflammatory bowel disease, and other diseases. In addition, there are many less common causes of diarrhea. A summary of the various common causes of diarrhea is available in the table (table 1).DIARRHEA SYMPTOMS — A person with diarrhea may be mildly to severely ill. A person who has mild illness may have a few loose bowel movements but otherwise feels well. By contrast, a person with severe diarrhea may have 20 or more bowel movements per day, happening up to every 20 or 30 minutes. In this situation, a significant amount of water and salts can be lost, seriously increasing the risk of dehydration. Diarrhea may be accompanied by fever (temperature greater than 100.4°F or 38°C), abdominal pain, or cramping.DIARRHEA HOME CAREDrink adequate fluids — If you have mild to moderate diarrhea, you can usually be treated at home by drinking extra fluids. The fluids should contain water, salt, and sugar. Oral rehydration solution (ORS), a specific mixture of glucose and sodium, is the best first-line treatment and is available in over-the-counter commercial preparations. Sports drinks (eg, Gatorade) are not optimal for fluid replacement, although they may be sufficient for a person with diarrhea who is not dehydrated and is otherwise healthy. Diluted fruit juices and flavored soft drinks along with salted crackers and broths or soups may also be acceptable.One way to judge hydration is by looking at the color of your urine and monitoring how frequently you urinate. If you urinate infrequently or have urine that is dark yellow, you should drink more fluids. Normally, urine should be light yellow to nearly colorless. If you are well hydrated, you normally pass urine every three to five hours.If you become dehydrated and are unable to take fluids by mouth, a rehydration solution can be given into a vein (intravenous fluids) in a health care provider's office or in the emergency department.Diet — There is no particular food or group of foods that is best while you have diarrhea. However, adequate nutrition is important during an episode of acute diarrhea. If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oats) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.Antidiarrheal medications — Medications to reduce diarrhea are available, and are safe if there is no fever (temperature greater than 100.4°F or 38°C) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements.●Loperamide (Imodium®) is available without a prescription; the dose is two tablets (4 mg) initially, then 1 tablet (2 mg) after each unformed stool. No more than 16 mg is recommended per day. If you take loperamide, be careful to never exceed the dose on the label unless specifically instructed by your doctor. Taking more than the recommended dose has led to serious heart problems in some people.●Diphenoxylate-atropine (Lomotil®) is a prescription medication used to treat diarrhea; its benefit is similar to loperamide, although it can be associated with more bothersome side effects.●Bismuth subsalicylate (Pepto-Bismol®, Kaopectate®) has also been used for treatment of acute diarrhea, although it is not as effective as loperamide. Bismuth subsalicylate may be recommended in certain situations, such as if you have fever and bloody diarrhea. However, women who are pregnant should not take bismuth subsalicylate. The dose of bismuth subsalicylate is 30 mL or two tablets every 30 minutes for up to eight doses.Antibiotics — Antibiotics are not needed in most cases of acute diarrhea, and they can cause further complications if used inappropriately. Antibiotics may be recommended in certain situations, such as if you have the following signs or symptoms:●More than eight loose stools per day ●Fever●Bloody stool●Dehydration●Symptoms that continue for more than one week●A weakened immune system●You require hospitalizationHowever, the decision to use antibiotics must be made carefully after discussing the potential risks and benefits with a health care provider who is familiar with the situation.Preventing spread — Adults with diarrhea should be cautious to avoid spreading infection to family, friends, and co-workers. You are considered infectious for as long as diarrhea continues. Microorganisms causing diarrhea are spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.Hand washing — Hand washing is an effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antibacterial soap and rubbed together for 15 to 30 seconds. Pay special attention to the fingernails, between the fingers, and the wrists. Rinse your hands thoroughly and dry with a single use towel.If a sink is not available, alcohol-based hand rubs are a good alternative for disinfecting hands. Spread the hand rub over the entire surface of your hands, fingers, and wrists until dry. Hand rubs may be used several times. Hand rubs are available as a liquid or wipe in small, portable sizes that are easy to carry in a pocket or handbag. When a sink is available and your hands are visibly dirty, it is best to wash them with soap and water.Clean your hands after changing a diaper, before and after preparing food and eating, after going to the bathroom, after handling garbage or dirty laundry, after touching animals or pets, and after blowing your nose or sneezing.DIARRHEA PREVENTIONFood safety — The following precautions have been recommended for all consumers by the Food Safety and Inspection Services (www.fsis.usda.gov) and the Centers for Disease Control and Prevention.●Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.●Wash raw fruits and vegetables thoroughly before eating.●Keep the refrigerator temperature at 40°F (4.4°C) or lower; the freezer at 0°F (-17.8°C) or lower.●Eat precooked, perishable, or ready-to-eat food as soon as possible.●Keep raw meat, fish, and poultry separate from other food.●Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.●Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160°F (71°C); chicken 170°F (77°C); turkey 180°F (82°C); pork 145°F (63°C) with a three minute rest time.●Seafood should be cooked thoroughly to minimize the risk of food poisoning. Eating raw fish (eg, sushi) poses a risk for a variety of parasitic worms (in addition to the risks associated with organisms carried by food handlers). Freezing kills some, although not all, harmful microorganisms. Raw fish that is labeled "sushi-grade" or "sashimi-grade" has been frozen.●Cook chicken eggs thoroughly, until the yolk is firm.●Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90°F/32°C).Food safety for pregnant women or those with a weakened immune system — The following additional recommendations apply to pregnant women and those who have a weakened immune system:●Do not eat hot dogs, pâtés, luncheon meats, bologna, or other delicatessen meats unless they are reheated until steaming hot; avoid the use of microwave ovens since uneven cooking may occur.●Avoid spilling fluids from raw meat and hot dog packages on other foods, utensils, and food preparation surfaces. In addition, wash your hands after handling hot dogs, luncheon meats, delicatessen meats, and raw meat, chicken, turkey, or seafood or their juices.●Do not eat pre-prepared salads, such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad.●Do not eat soft cheeses such as feta, Brie, and Camembert, blue-veined cheeses, or Mexican-style cheeses such as queso blanco, queso fresco, or Panela, unless they have a label that clearly states that the cheese is made from pasteurized milk.●Do not eat refrigerated pates or meat spreads. Canned or shelf-stable products may be eaten.●Do not eat refrigerated smoked seafood unless it has been cooked. Refrigerated smoked seafood, such as salmon, trout, whitefish, cod, tuna or mackerel, is most often labeled as "nova-style," "lox," "kippered," "smoked," or "jerky." The fish is found in the refrigerator section or sold at deli counters of grocery stores and delicatessens. Canned or shelf-stable smoked seafood may be eaten.Travelers' diarrhea prevention — Recommendations to prevent travelers' diarrhea are available separately. (See"Patient education: General travel advice (Beyond the Basics)".)WHEN TO SEEK HELP FOR DIARRHEA — If your diarrhea is not severe, you do not always need to be seen by a doctor, especially if the diarrhea begins to improve within 48 hours. Self-care measures for this situation are discussed above (see 'Diarrhea home care' above).However, if you have one or more of the following signs or symptoms, you should be evaluated by a health care provider:●Profuse watery diarrhea with signs of dehydration. Early features of dehydration include sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.●Many small stools containing blood and mucus●Bloody or black diarrhea●Temperature ≥38.5°C (101.3°F)●Passage of ≥6 unformed stools per 24 hours or illness that lasts more than 48 hours●Severe abdominal pain/painful passage of stoolIn addition, if you have persistent diarrhea following antibiotics, are older than 65 years, have other medical illness or a weakened immune system, you should also consult your health care provider.SUMMARY●Acute diarrhea is defined as three or more loose or watery stools per day.●Diarrhea can be caused by infections or other factors. Sometimes, the cause of diarrhea is not known. Diarrhea caused by an infection usually begins 12 hours to four days after exposure and resolves within three to seven days.●A person may have mild to severe diarrhea. Some people with diarrhea also have fever (temperature greater than 100.4°F or 38°C), abdominal pain, or cramping.●People with mild diarrhea do not usually need to go to the doctor, especially if the diarrhea begins to improve within 48 hours. If you develop any of the following, you should call your doctor or nurse immediately:•Profuse watery diarrhea with sluggishness, becoming tired easily, dry mouth and tongue, thirst, muscle cramps, dark-colored urine, urinating infrequently, and dizziness or lightheadedness after standing or sitting up. More severe features include abdominal pain, chest pain, confusion, or difficulty remaining alert.•Passage of many small stools containing blood and mucus•Bloody or black diarrhea•Temperature ≥38.5°C (101.3°F)•Passing 6 or more watery stools per 24 hours or illness that lasts more than 48 hours•Severe abdominal pain●In addition, if you have persistent diarrhea after finishing antibiotics, are older than 69, or have other medical illness or a weakened immune system, you should also consult your doctor or nurse.●The most important treatment for diarrhea is to drink fluids that contain water, salt, and sugar, such as oral rehydration solution (ORS). Sports drinks (eg, Gatorade) may be acceptable if you are not dehydrated and are otherwise healthy. Diluted fruit juices and flavored soft drinks along with saltine crackers and broths or soups may also be acceptable.●If you have dark yellow colored urine or do not pass urine frequently, you should drink more fluids. The urine should normally be light yellow to clear colored.●Medications to reduce diarrhea are available without a prescription, and are safe if there is no fever (temperature greater than 100.4°F or 38°C) and the stools are not bloody. These medications do not cure the cause of the diarrhea, but help to reduce the frequency of bowel movements. Common medications include loperamide (Imodium®), diphenoxylate-atropine (Lomotil®), and bismuth subsalicylate (Pepto-Bismol® or Kaopectate®).●If you do not have an appetite, you can drink only liquids for a short period of time. Boiled starches and cereals (eg, potatoes, noodles, rice, wheat, and oat) with salt are recommended if you have watery diarrhea; crackers, bananas, soup, and boiled vegetables may also be eaten.●Antibiotics are not needed for most people with diarrhea.●If you have diarrhea, be careful to avoid spreading the infection to family, friends, and co-workers. You are contagious for as long as diarrhea continues. Infections are usually spread from hand to mouth; hand washing, care with diapering, and staying out of work or school are a few ways to prevent infecting family and other contacts.WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Diarrhea in adolescents and adults (The Basics) Patient education: Diarrhea in children (The Basics) Patient education: Food poisoning (The Basics) Patient education: Lactose intolerance (The Basics) Patient education: C. difficile infection (The Basics) Patient education: Managing loss of appetite and weight loss with cancer (The Basics) Patient education: Dehydration in children (The Basics) Patient education: Ischemic bowel disease (The Basics) Patient education: Cryptosporidiosis (The Basics) Patient education: Salmonella infection (The Basics) Patient education: Travelers' diarrhea (The Basics) Patient education: E. coli diarrhea (The Basics) Patient education: Listeria (The Basics) Patient education: Campylobacter infection (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Chronic diarrhea in adults (Beyond the Basics) Patient education: Acute diarrhea in children (Beyond the Basics) Patient education: Antibiotic-associated diarrhea caused by Clostridioides difficile (Beyond the Basics) Patient education: Foodborne illness (food poisoning) (Beyond the Basics) Patient education: General travel advice (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Approach to the adult with acute diarrhea in resource-rich settings Clinical manifestations, diagnosis, and treatment of Campylobacter infection Clostridioides difficile infection in adults: Clinical manifestations and diagnosis Shigella infection: Clinical manifestations and diagnosis Shiga toxin-producing Escherichia coli: Clinical manifestations, diagnosis, and treatment Clinical manifestations and diagnosis of rotavirus infection Cryptosporidiosis: Epidemiology, clinical manifestations, and diagnosis Pathogenic Escherichia coli associated with diarrhea Causes of acute infectious diarrhea and other foodborne illnesses in resource-rich settings Norovirus Cholera: Clinical features, diagnosis, treatment, and prevention Acute viral gastroenteritis in adultsThe following organizations also provide reliable health information.●National Library of Medicine(www.nlm.nih.gov/medlineplus/healthtopics.html)●National Institute of Digestive and Diabetes and Kidney Diseases(www.niddk.nih.gov/health-information/digestive-diseases/diarrhea)●Center for Disease Control and Prevention(www.cdc.gov)●American College of Gastroenterology(www.acg.gi.org/patients/gihealth/diarrheal.asp)[1-3]Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis 2017; 65:e45.Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. Am J Gastroenterol 2016; 111:602.DuPont HL. Acute infectious diarrhea in immunocompetent adults. N Engl J Med 2014; 370:1532.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 4021 Version 32.0References1 : 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea.2 : ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults.3 : Acute infectious diarrhea in immunocompetent adults.

ClosePatient education: Anemia caused by low iron in adults (Beyond the Basics)Patient education: Anemia caused by low iron in adults (Beyond the Basics)Author:Michael Auerbach, MD, FACP Section Editor:Robert T Means, Jr, MD, MACP Deputy Editor:Jennifer S Tirnauer, MDLiterature review current through: Nov 2022. | This topic last updated: Aug 23, 2022.Please read the Disclaimer at the end of this page.IRON DEFICIENCY ANEMIA OVERVIEW — Anemia can be caused by a number of different conditions, including heavy menstrual periods, pregnancy, cancer, and bleeding in the digestive tract, to name a few. Iron deficiency anemia is a type of anemia that occurs when there is not enough iron to make the hemoglobin in red blood cells. Hemoglobin is the protein in red blood cells that helps carry oxygen to the body's organs and tissues. The main causes of iron deficiency anemia in adults are bleeding and conditions that block iron absorption in the intestines.Iron deficiency anemia can be mild or severe. The condition is common in the United States, especially in females who are still having menstrual periods or are or have been pregnant. It is less common in males. It is even more common in parts of the world where people cannot get sufficient iron from food and in regions where intestinal parasites are common, especially hookworm and tapeworm.This topic will review the signs and symptoms, potential causes, diagnostic tests, and treatment of iron deficiency anemia in adults.WHAT IS ANEMIA? — Anemia is defined as a decreased number of red blood cells (RBCs), as measured by one of the following blood tests:●Hemoglobin (Hb) is the iron-containing molecule in RBCs that carries oxygen. Iron is a critical component of hemoglobin; without iron, hemoglobin cannot be formed and fewer RBCs are produced. This is the most accurate of the tests as it is measured on specialized machinery in a laboratory or in the doctor's office.●Hematocrit (Hct) is the percent of a sample of blood made up of RBCs. The rest of the blood is mostly made up of a fluid called plasma. This test used to be more popular, but the hemoglobin is considered more reliable because hemoglobin is measured and hematocrit is calculated.●RBC count is the number of RBCs in a certain amount of whole blood, usually one microliter (one millionth of a liter).Iron deficiency (too little iron) anemia occurs when there is insufficient iron in the body to make hemoglobin. When the quantity of hemoglobin is reduced, fewer RBCs are formed, and the RBCs that are formed are smaller. Symptoms of iron deficiency vary from person to person. Iron deficiency can even cause symptoms in the absence of anemia. Over time, without iron, anemia will develop.ANEMIA SIGNS AND SYMPTOMS — Many people with iron deficiency anemia have no symptoms at all. Of those who do, the most common symptoms include:●Weakness●Headache●Irritability●Fatigue●Difficulty exercising (due to shortness of breath or exhaustion)●Brittle nails●Sore tongue●Restless legs syndrome●Pica (an abnormal craving to eat nonfood items, such as clay or dirt, paper products, or cornstarch)●Pagophagia (a form of pica in which there is an abnormal craving to eat ice)CAUSES OF ANEMIA — Common causes of iron deficiency anemia are blood loss (most common) and decreased absorption of iron from food.Blood loss — The source of blood loss may be obvious, such as in people who have heavy menstrual bleeding or a person with a known bleeding ulcer. Pregnancy can use up as much as five- to six-fold more iron for the developing fetus and placenta (figure 1). Blood loss during childbirth can also contribute to iron deficiency.In other cases, the source of the blood loss is not visible, as in someone who has chronic bleeding in their gastrointestinal (GI) tract (stomach, small intestine, colon). This may appear as diarrhea with black, tarry stools, or, if the blood loss is very slow, the stool may appear normal. Donating blood can also cause iron deficiency, especially if it is done on a regular basis. Anyone with unexplained iron deficiency should get a thorough evaluation to make sure a serious cause is not missed, like cancer of the GI tract.Decreased iron absorption — Normally, the body absorbs iron from food through the GI tract. In people with certain conditions such as celiac disease, autoimmune gastritis, Helicobacter pylori (H. pylori) infection, other forms of stomach inflammation, gastric bypass surgery (for weight loss), or other forms of weight loss surgery, an inadequate amount of iron may be absorbed, leading to iron deficiency anemia.Other causes — In some parts of the world, there is not enough iron available from food, and iron deficiency may develop due to low iron intake. In some countries such as the United States, some foods have added iron (breakfast cereal, bread, pasta). Iron is also available in some plant-based foods. (See 'Iron and diet' below.)ANEMIA DIAGNOSIS — Since iron deficiency occurs before anemia develops, a person may be diagnosed with iron deficiency with or without anemia. In some cases, testing is done to evaluate symptoms, and in others it is done for an unrelated reason. The initial evaluation generally involves a medical history to look for possible causes of iron deficiency; physical examination to look for causes and typical findings of iron deficiency; and blood tests to measure iron stores in the body and check for other possible conditions that could contribute to iron deficiency. This is especially important in early pregnancy, where the likelihood of having iron deficiency is as high as 40 percent in high-resource countries and up to 90 percent in resource-limited countries.Complete blood count — A complete blood count (CBC) is a group of tests that includes a red blood cell (RBC) count, hemoglobin (Hb), and hematocrit (Hct). It reports the size of the RBCs (referred to as the mean corpuscular volume), amount of hemoglobin per RBC (referred to as mean corpuscular hemoglobin [MCH]), and others. It also measures white blood cells and platelets, which are the two other main types of blood cells.In people with iron deficiency anemia, the RBC count, Hb, and Hct can be low. The MCV and MCH are usually normal early on but can become lower over time, indicating that the RBCs are smaller (called microcytic) and contain less Hb than normal RBCs. The shape, color, and size of the RBCs can help to determine the type of anemia.White blood cells are not affected by iron deficiency. Platelets may be increased in some cases, or they may be normal.Other blood tests — In many cases, iron deficiency anemia is suspected based upon the results of the medical history and the CBC. Further testing is used to confirm the diagnosis. Blood tests to check iron levels include:●Ferritin — Measures a protein that stores iron. This protein decreases when a person has iron deficiency. The ferritin measurement is most useful when it is low, as nothing other than iron deficiency causes a low ferritin. In some cases, the ferritin level can be checked by itself. In others, an "iron studies panel" is used that contains the other tests listed below. Ferritin can increase in some conditions unrelated to iron, which can confuse the interpretation of the results. These are generally conditions associated with inflammation, such as chronic rheumatologic disorders (inflammation of the joints) or infections. In people with chronic inflammation, the transferrin saturation (TSAT; see below) and sometimes other specialized testing can be used to see if there is a need for iron replacement. ●Serum iron — Measures how much iron is circulating in the blood. The result can be affected by iron supplements and even recent meals. It is not a good measure of the iron stores in the body.●Total iron binding capacity (TIBC or transferrin) — Measures the amount of a protein (transferrin) in the blood that transports iron to RBCs or storage cells. When iron stores are low, the TIBC or transferrin increases.●Transferrin saturation (TSAT) — Measures how much iron is bound to transferrin. This number is a percentage, calculated by dividing the serum iron by the TIBC. A lower TSAT indicates iron deficiency. If this test is being used to make the diagnosis, it may be done on an overnight fast (after not eating for a night) because iron in foods can sometimes make the TSAT appear higher than it should be.In a person with iron deficiency anemia the ferritin and the TSAT are the most useful tests. In iron deficiency, the ferritin and TSAT are low.Search for source of blood and iron loss — Once the diagnosis of iron deficiency anemia is made, it is very important to identify the cause. Your health care team may ask questions about the following causes:●History of heavy menstrual periods, pregnancies, and deliveries●Gastrointestinal (GI) problems such as ulcers, Helicobacter pylori (H. pylori) infection, autoimmune gastritis, or celiac disease●Signs of bleeding from the GI tract such as dark, tarry stools (even if only occasionally), visible bleeding, or vomiting dark-colored material●Travel history (if the person has visited a place where GI parasites are common) ●Surgery on the GI tract (such as gastric bypass for weight loss) ●Family or personal history of bleeding disorders●Family or personal history of colon cancer●Multiple blood donations●Use of medications that can irritate the GI tract, such as nonsteroidal antiinflammatory drugs (NSAIDs), which include aspirin, ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand names: Aleve, Naprosyn) If a cause of blood loss is not obvious (or if a GI source of blood loss is suspected), additional tests should be done. These include colonoscopy or upper endoscopy to look for areas of bleeding in the GI tract, and blood tests for certain conditions that interfere with iron absorption, such as autoimmune gastritis, celiac disease, and H. pylori infection. Looking for bleeding in the colon is especially important in people over the age of 40 to 50. (See"Patient education: Colonoscopy (Beyond the Basics)" and"Patient education: Upper endoscopy (Beyond the Basics)" and"Patient education: Helicobacter pylori infection and treatment (Beyond the Basics)".)TREATMENTIron administration — Iron deficiency is treated with iron supplements, which can be given orally (as a pill) or intravenously (this is sometimes called "parenteral iron" or "IV iron"). Iron allows the body to increase production of hemoglobin (Hb) and rebuild the body's iron reserves. In rare cases of severe anemia, a blood transfusion is needed.The choice between oral and IV iron depends on several factors, including the severity of anemia, the cause of iron deficiency, and whether oral iron is well-tolerated. In general:●Oral iron tablets are used in most people with iron deficiency anemia and iron deficiency without anemia. ●Intravenous iron can be used for people whose GI tract cannot adequately absorb iron (such as gastric bypass surgery), during the second and third trimester of pregnancy, or, more commonly, in those who are unable to tolerate oral iron. Some people experience side effects like constipation, nausea, or cramping, which can make the supplements hard to take. Intravenous iron is often given to people with chronic kidney disease and people with inflammatory bowel disease. During pregnancy, the developing fetus needs iron for normal brain development, and iron deficiency is associated with a number of problems for both mother and child.●A blood transfusion may be given if a person is actively bleeding and/or the Hb or hematocrit (Hct) levels are very low, but transfusions are not commonly needed.All of these treatment approaches are discussed more below.Find and treat the cause — It is also critically important to determine the cause of iron deficiency and correct it, so that iron does not continue to be lost, and any serious condition (for example, colon cancer) is treated as early as possible. Oral iron — Oral iron tablets are a safe, inexpensive, and effective treatment for people with iron deficiency. Gastrointestinal (GI) side effects are common and should be discussed with your doctor; these are discussed below. (See 'Side effects' below.) The following tips are recommended when taking oral iron:●Iron is best absorbed if it is taken every other day (or, for example, on Monday, Wednesday, and Friday), for people who are able to keep track of this type of schedule.●Certain foods and medicines can reduce the absorption of iron tablets. Iron tablets usually should not be taken with tea, coffee, calcium supplements, or milk. Iron can be taken one hour before or two hours after these items. If you take antacids, your iron tablets should be taken at least two hours before or four hours after the antacids. Tell your doctor if you take any supplements, vitamins, or other medications. ●"Enteric coated" (EC) iron tablets should be avoided. These tablets have a special coating that does not dissolve quickly in the GI tract. These are not recommended because iron is best absorbed from the duodenum and jejunum (the first and middle parts of the small intestine), and EC iron releases iron further down in the intestinal tract, where it is not as easily absorbed. In some cases, an EC iron tablet can pass through the entire intestinal tract with the coating intact, meaning that none of the iron was absorbed.Types of oral iron — There are several forms of oral iron, and with the exception of the enteric coated (EC) iron tablets mentioned above, they are all equally effective. Different formulations contain different amounts of iron. For many products, the number of milligrams for the pill is different from the number of milligrams of actual iron molecules (called "elemental iron"):●Ferrous fumarate — 106 mg elemental iron/tablet●Ferrous sulfate — 65 mg elemental iron/tablet●Ferrous sulfate liquid — 44 mg elemental iron/teaspoon (5 mL)●Ferrous gluconate — 28 to 36 mg iron/tablet●Polysaccharide-iron complex – various doses availableIn the past, iron pills were typically prescribed once or multiple times per day. Recent evidence suggests that taking oral iron every other day (or on Monday, Wednesday, and Friday) allows the body to absorb more iron, while reducing GI side effects. (See 'Side effects' below.) Side effects — Some people experience a metallic taste, nausea, constipation, stomach upset, nausea, vomiting, and/or dark-colored stools after taking oral iron. Options for dealing with these side effects include:●Take a smaller dose●Take iron with food (even though this will reduce the amount of iron your body absorbs, it's better than not taking it at all)●Use a formulation with a lower elemental iron content (eg, ferrous gluconate instead of ferrous sulfate)●Take the liquid form of ferrous sulfate and adjust the dose until symptoms are tolerable●Switch to IV ironTaking iron tablets can turn the stool a dark, almost black color (actually dark green). This is normal, and does not mean that the iron tablets are causing GI bleeding.Children are at particular risk of iron poisoning (overdose), making it very important to store iron tablets out of the reach of children. If you think a child ingested iron pills, call a poison control center (in the United States, 1-800-222-1222) or their pediatrician.Duration of treatment — Treatment with oral iron is recommended for as long as it takes the hemoglobin (Hb) and hematocrit (Hct), and usually the tests of iron stores, to return to normal. Typically this takes approximately six months with oral iron. Treatment with IV iron is completed with one or more doses. (See 'Intravenous iron' below.)If oral iron does not increase hemoglobin — On occasion, a person's Hb will not improve despite treatment with oral iron. There are several possible reasons for this. The next step depends upon why the person's Hb did not increase, which needs to be evaluated by a clinician. However, several points are worth keeping in mind:●It is important that iron be taken. Not taking iron as prescribed is probably the most common reason it does not work. If side effects are preventing you from taking oral iron, IV iron can be used instead. ●The type of iron preparation being taken is important. One should avoid any preparation that is labeled "slow release," or is enteric coated (EC), as these may prevent iron from being efficiently absorbed.●Another condition may prevent iron from being absorbed, such as autoimmune gastritis, celiac disease, or Helicobacter pylori infection. These conditions can be diagnosed by blood tests in some cases.●In some people, there may be another cause of anemia in addition to iron deficiency, such as vitamin B12 deficiency. In others, the diagnosis of iron deficiency may be incorrect.●If there is ongoing bleeding that depletes iron stores faster than they are being replaced, it may appear that the oral iron is not working.●During the second and third trimester of pregnancy, oral iron may take too long to correct iron deficiency in time to provide iron to the developing fetus.●For any of the above, changing to IV iron may be a good option.Intravenous ironUses — Iron may be given by IV injection in certain situations, such as in people who cannot tolerate the side effects of oral iron or whose GI tract cannot absorb an adequate amount of iron from pills. People who may be candidates for IV iron due to health conditions include those who:●Have inflammatory bowel disease●Have chronic kidney disease●Have had bariatric (weight loss) surgery ●Are pregnant, especially in the late second and third trimesters IV iron is infused into a vein. This is done in a doctor's office or hospital, where the person can be monitored. The length of time required for the infusion and the number of infusions needed depend on which iron product is used and the severity of iron deficiency.Side effects — The IV iron used in the past (high molecular weight iron dextran [brand name: Dexferrum]) had a risk of severe allergic reactions. However, IV iron products used today have an exceedingly low risk of allergic or anaphylactic reactions (less than one tenth of one percent). Infusion reactions are more common, and may include temporary flushing, back pain, and other symptoms that usually go away when the infusion is slowed or stopped. Some patients with a history of rheumatoid arthritis may have an arthritis flare, which can be reduced or prevented by a short course of steroids.The best ways to minimize these reactions include avoiding the use of antihistamines as "premedication" or to treat minor symptoms, giving the infusion more slowly, or in some people (those with a history of multiple drug allergies) giving a steroid before the infusion. If you have back pain or joint pain at home after the infusion, a nonsteroidal antiinflammatory drug (NSAID) may be helpful. NSAIDs include ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve).Blood transfusionUses — Blood transfusion may be used in people with anemia that is severe or causes significant symptoms such as chest pain or difficulty breathing.Blood transfusion involves giving one or more units of packed red blood cells (pRBCs) into a vein. Each unit of pRBCs contains the RBCs from one unit of blood donated by a voluntary donor. It contains approximately 200 mg of iron and will raise the hemoglobin (Hb) by approximately 1 gram/deciliter (g/dL; 1 gram per 100 milliliters).Blood transfusions are generally reserved for people who have a very low Hb level (less than 7 g/dL), low or unstable blood pressure, and/or breathing difficulties caused by severe anemia. Symptoms may include chest pain and/or shortness of breath, or in more extreme circ*mstances, passing out. Blood transfusion is described in detail in a separate topic. (See"Patient education: Blood donation and transfusion (Beyond the Basics)".)Side effects — There can be side effects of blood transfusion, with the most common being fever or itching. However, this only occurs in 0.1 to 1 percent of transfusions. More serious or even life-threatening allergic reactions or other complications can occur, although this is even less common.The risk of infection with the hepatitis C virus or the HIV virus is extremely low because of better screening of blood donors as well as improved laboratory testing. These infections occur approximately once in every two million transfusions (table 1).Iron and diet — Although dietary iron is important in preventing iron deficiency, people with iron deficiency anemia need more iron than they can consume through their diet alone. A 2000 calorie diet contains approximately 10 mg of elemental iron (compared with 65 mg in one 325 mg ferrous sulfate tablet). Therefore, increasing dietary iron alone is not usually sufficient as a treatment for iron deficiency anemia.Dietary sources of iron include meat, especially organ meats, grains, fruits, and vegetables (table 2). For people who do not eat meat, good plant sources of iron include whole or enriched breads or grains, iron-fortified cereals, legumes (beans, chickpeas, peanuts), green leafy vegetables, dried fruits, soy products, blackstrap molasses, bulgur, and wheat germ. Maintaining a healthy, balanced diet is good for your overall health.PREVENTION — Some people will require iron supplementation for life. For example, people who have had weight loss surgery may continue to need iron supplements to maintain the body's iron stores. Extra iron is commonly included in prenatal multivitamins to prevent iron deficiency from developing during pregnancy, but it may not be sufficient to treat iron deficiency. Iron deficiency is very common in pregnancy.Iron supplements and multivitamins that contain iron should not be taken without consulting your health care team, because too much iron in the body can also cause problems. Most people do not need supplemental iron unless they have an underlying illness that reduces iron absorption or causes bleeding.COMMUNICATING WITH YOUR HEALTH CARE TEAM — It is essential to communicate openly with your health care team and be thorough and honest about your health history. Your health history includes any recent surgeries, medications, blood donations, and dietary and exercise habits. All of this information can help your team to diagnose and treat your iron deficiency anemia.Your opinion matters when creating your care plan. If you do not understand your diagnosis or treatment plan, or if you any have questions, concerns, or side effects of treatment, let your team know. They can help.WHERE TO GET MORE INFORMATION — Your health care team is the best source of information for questions and concerns related to your medical problem.This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.Patient level information — UpToDate offers two types of patient education materials.The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient education: Complete blood count (CBC) (The Basics) Patient education: Anemia caused by low iron (The Basics) Patient education: Nutrition before and during pregnancy (The Basics) Patient education: Restless legs syndrome (The Basics) Patient education: Angiodysplasia of the GI tract (The Basics) Patient education: Medicines for chronic kidney disease (The Basics)Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient education: Screening for colorectal cancer (Beyond the Basics) Patient education: Blood donation and transfusion (Beyond the Basics)Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Diagnostic approach to anemia in adults Iron requirements and iron deficiency in adolescents Causes and diagnosis of iron deficiency and iron deficiency anemia in adults Treatment of iron deficiency anemia in adults Indications and hemoglobin thresholds for red blood cell transfusion in the adultThe following websites also provide reliable health information.●National Library of Medicine      (https://medlineplus.gov/ency/article/000584.htm)●National Institutes of Health (NIH)      (https://ods.od.nih.gov/factsheets/Iron-Consumer/)●National Heart, Lung, and Blood Institute      (www.nhlbi.nih.gov/health/dci/Diseases/ida/ida_diagnosis.html)●Centers for Disease Control and Prevention(https://www.cdc.gov/nutrition/infantandtoddlernutrition/vitamins-minerals/iron.html)ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges the extensive contributions of William C Mentzer, MD, to earlier versions of this and many other topic reviews.This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circ*mstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2023 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.Topic 695 Version 34.0

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