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The average sur- vival after detection of cutaneous metastases is only 3 months generic provigil 100mg without a prescription, with the exception of breast cancer. The lesions Paget’s disease is an intraepidermal carcinoma of glan- may be treated with excision or systemic therapy. Management Further discussion of these conditions can be found in consists of surgery, radiotherapy, or chemotherapy. Extramammary Paget’s disease, clinically and histolo- gically similar to Paget’s disease of the breast, involves the anogenital and axillary skin. It is often associated with an underlying adenocarcinoma of the secretory Stasis dermatitis is caused by elevated venous pressures glands, lower gastrointestinal, urinary, or female genital secondary to either valvular incompetence or obstruc- tracts. It is an eczematous eruption of the lower extrem- tion for a possible underlying malignancy. Paget’s disease ities with brown hemosiderin-derived pigmentation clinically resembles eczema, so any treatment-resistant and, sometimes, petechiae, often preceded by edema and dermatitis should be biopsied. Predisposing factors include a history of thrombophlebitis, a positive family history, obesity, Kaposi’s sarcoma (KS) is a malignant, vascular tumor or multiple pregnancies. Low-dose topical corticosteroids characterized by purple macules, papules, or nodule, and reduction of edema, by such measures as leg eleva- usually on the lower legs. The ulcer is usually surrounded by brown-red ciation with the acquired immunodeficiency syndrome pigmentation, located at the medial malleolus, and has (AIDS), particularly in homosexual patients. There may be surrounding edema and extensive and has a poorer prognosis in these individuals pigmentation. Approximately 95% of KS lesions Ulcerations often recur unless the underlying risk factors have been found to be infected with Kaposi’s sarcoma- are corrected. Leg elevation and use of elastic support 50,51 associated herpesvirus (also known as human herpesvirus stockings can alleviate the venous hypertension.

The main difference is that CFS that a confident diagnosis of FMS is important to has an acute onset after an infectious type of disease generic 100 mg provigil free shipping, reduce both the patients’ anxiety and the use of med- followed by the persistence of symptoms suggestive ical resources. Key points Severity Deep pain is frequently associated with referred • Functional disability and quality of life can vary with: pain and/or hyperalgesia. FMS symptoms do not usually change over the years Muscle pain: basic mechanisms and clinical correlates. Myofascial trigger points, doses of tricyclic antidepressants, sedative-hypnotic a possible explanation. Lippincott may temporarily reduce some symptoms but none is Williams & Wilkins, Philadelphia, PA; p. William & Wilkins, Multidisciplinary treatment programs involving differ- Baltimore. The physiologists, nurses, other health care workers), adopt- American College of Rheumatology 1990 criteria for the ing a combination of strategies to reduce the intensity of classification of Fibromyalgia, a report of a Multicenter the main symptoms (Table 19. Jaggar Neuropathic pain was defined by the International Painful diabetic neuropathy (PDN): After 25 years • Association for the Study of Pain (IASP) in 1997 as of diabetes mellitus half the population have PDN. Presentation is of a heterogeneous group of pain conditions initiated by, Such pains show a considerable association with phys- or secondary to, dysfunction in normal sensory pro- ical and social disabilities, as well as an increase in cessing in the central or peripheral nervous system. However, it is recognised that patients with neuro- pathic pain may lack symptoms or signs of central Incidence nervous system (CNS) damage (i. Conversely, patients with clear evidence of lesions The overall incidence of neuropathic pain is 1–2% of in the nervous system may have no associated pain. However, some groups bear an increased burden of risk: Nerve dysfunction occurs consequent upon a wide range of pathological conditions (Table 20. Except for traumatic models (such as nerve ligation) • 10–15% of human immunodeficiency virus (HIV) the mechanisms of neuropathic pain have not been patients have neuropathic pain. Generalised nerve damage Abnormal sensation in response to a stimulus can be • Toxins classified as: • Metabolic effects (e. Experimentally induced pain has been used to study Mechanisms pain mechanisms and to test analgesic drugs.