Posted in Patient Information

Keratosis Pilaris

Keratosis pilaris is a very common harmless skin condition appearing as small, whitish bumps on the upper arms and thighs, especially of children and young adults. Individual lesions of keratosis pilaris begin when a hair follicle becomes plugged with keratin, a protein found in skin, hair, and nails.

Who’s At Risk

Keratosis pilaris can affect people of any age, any race, and either sex. It is more common in females.

Keratosis pilaris usually starts in early childhood (by age 10) and can worsen during puberty. However, it frequently improves or even goes away by early adulthood.

Keratosis pilaris can affect 50-80% of teenagers and up to 40% of adults. Many people have a family history of keratosis pilaris. A large number of individuals with ichthyosis vulgaris (an inherited skin condition characterized by very dry, very scaly skin) also report having keratosis pilaris.

Signs & Symptoms

The most common locations for keratosis pilaris include the following:

  • Backs of the upper arms
    • Fronts and sides of the thighs
    • Buttocks
    • Cheeks

Tiny (1-2 mm) white to gray bumps occur, centered in the hair follicle. Sometimes, a thin, red ring may surround the white bump, indicating inflammation. The bumps all look very similar to one another, and they are evenly spaced on the skin surface.

Rarely, people with keratosis pilaris may complain of mild itching.

Keratosis pilaris tends to improve in warmer, more humid weather, and it may worsen in colder, drier weather.

Self-Care Guidelines

There is no cure for keratosis pilaris, though its appearance can be improved. It is often helpful to keep the skin moist (hydrated) and to use mild, fragrance-free cleansers, with daily applications of moisturizer.

Creams and ointments are better moisturizers than lotions, and they work best when applied just after bathing, while the skin is still moist. The following over-the-counter products may be helpful:

  • Preparations containing alpha-hydroxy acids such as glycolic acid or lactic acid
    • Creams containing urea
    • Over-the-counter cortisone cream (if the areas are itchy) such as 1% hydrocortisone cream
Gold Bond rough & bumpy skin is an inexpensive cream which contains urea, lactic acid, and salicylic acid, all of which are helpful for keratosis pilaris.
Gold Bond rough & bumpy skin is an inexpensive cream which contains urea, lactic acid, and salicylic acid, all of which are helpful for keratosis pilaris.

Do not try to scrub the bumps away with a pumice stone or similar harsh material; these approaches may irritate the skin and worsen the condition.

Similarly, try to discourage your child from scratching or picking at the bumps, as these actions can lead to bacterial infections or scarring.

When to Seek Medical Care

Keratosis pilaris is not a serious medical condition and has no health implications. However, if self-care measures are not improving the appearance of the skin and it continues to bother your child there are some prescription options for treatment that could be considered.

Prescription Treatment Options

Treatments are aimed at controlling the rough bumps, not curing them. Keratosis pilaris bumps will come back if therapy is stopped.

Prescription treatments for keratosis pilaris sometimes include:

  • Prescription-strength alpha- or beta-hydroxy acids (glycolic acid, lactic acid, salicylic acid)
  • Prescription-strength urea
  • A retinoid such as tretinoin or tazarotene
  • High concentrations of propylene glycol
  • If the skin is itchy or inflamed, the short-term prescription strength topical corticosteroid to reduce the inflammation may be considered

Usually, consistent home use of over-the counter creams is enough to manage the symptoms of keratosis pilaris.


Posted in Clinician Information

Misoprostol Only Protocol for Management of Early Pregnancy Loss

This protocol was useful when stationed in Sasebo, Japan, for managing missed abortions. The Japanese clinics did not have access to these medications and could only offer mechanical evacuation. Our clinic only had access to misoprostol (not mifepristone). Before you start this, it’s critical to know your backup plan in case of serious bleeding.


Adapted verbatim January 2019 from


Patients with a nonviable pregnancy up to 12 weeks gestational age are eligible for medical management.

Non-viable pregnancy is diagnosed by ultrasound and/or falling quantitative hCG levels. Gestational age is based on ultrasound findings rather than last menstrual period (LMP). Ectopic pregnancy must be excluded, as medical treatment for ectopic pregnancy differs from that of nonviable intrauterine pregnancy.

Exclusionary criteria include severe anemia, allergy to mifepristone or misoprostol, bleeding disorders, and liver disease.


1. Labs:Necessary labs include Rh screen, hematocrit, and quantitative serum hCG level. If prior knowledge of Rh status is available, Rh typing need not be repeated. Serum hCG level may be deferred in patients who can follow-up with ultrasound, if the initial diagnosis was made by ultrasound. Consider gonorrhea and chlamydia screening for those at risk.

2. Counseling:Clinically stable patients should be counseled on all options for managing early pregnancy loss including expectant, medical management, and uterine aspiration. Patients who choose medical management with misoprostol alone should understand that mifepristone/misoprostol is more effective for treatment of nonviable intrauterine pregnancy.

3. Misoprostol:Prescribe or dispense four tablets of 200 mcg misoprostol (800 mcg total) for the patient to use vaginally. The patient places 800 mcg of misoprostol in the vagina at home at a convenient time. The patient should be given a second dose of 800 mcg of misoprostol in case passage of tissue does not occur with the first dose.

4. Pain medications:A prescription for ibuprofen 600 mg should be offered to the patient. Instruct the patient to take ibuprofen prior to misoprostol insertion, and then every 6 hours as needed for pain. A small supply of low-dose narcotic may also be prescribed for severe breakthrough pain.

5. Patient Instructions(see RHAP take home instructions to give to patient):

The patient should be given contact information for how to reach their provider and be provided with guidelines regarding when to call. Patients should be instructed to call for:

  • Heavy bleeding, defined as soaking through two thick maxi pads per hour for 2 hours in a row;
  • Fever or purulent vaginal discharge; or
  • Uncontrolled pelvic cramps or pain not improved with medication.
  • The patient does not need to bring products of conception back to the provider and should not be instructed to do so.

6. Follow up:Patients should schedule follow-up to ensure a complete passage of tissue in one of two ways: 1) repeat quantitative serum hCG level following passage of tissue (a drop of 80% by 7 days) or 2) a transvaginal ultrasound with absence of sac. Note: if one of these criteria has been met, no further follow-up of serum hCGs is warranted.

If no passage of tissue occurs (the patient has not bled as much as a period) within 12-24 hours of taking the misoprostol, the patient may use a second vaginal dose of 800 mcg misoprostol. If no passage of tissue occurs by 48 hours, the patient may resume expectant management or be referred for uterine aspiration.

7. Documentation:A chart note must be completed, to document the above and ensure a follow-up plan.


Chung TKH et al. Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol. Fertility and Sterility, 1999, 71(6)1054-1059. Prine LW, MacNaughton H. Office Management of Early Pregnancy Loss. American Family Physician. 2011 July 1; 84(1):75-82.

Wood SL, Brain PH. Medical management of missed abortion: A randomized clinical trial. Obstetrics and Gynecology, 2002, 99(4)563-566.

Considering the loss of abortion protection for our sailors, marines, and their spouses

Background reading

Although the SECDEF has vowed to maintain access to reproductive rights, we have already entered a time of uncertainty. Although many states that rushed to overturn Roe v. Wade laws are not fleet concentrations, there are likely over 15,000 active duty Navy personnel in states whose trigger laws were enacted in July 2022.

Update 17-Aug-2022: DoD Q&A about post-Dobbs care

Number of active duty Navy and Marines in States that are moving to ban pregnancy termination:

  • Texas (6,164 active duty Navy personnel / 2,282 active duty Marines)
  • Mississippi (4,742 / 447)
  • Oklahoma (1,647 / 558)
  • Tennessee (1,634 / 150)
  • Missouri (233 / 1,440)
  • Louisiana (398 / 761)
  • Utah (50 / 92)
  • Kentucky (53 / 89)
  • Arkansas (10 / 109)
  • Idaho (33 / 41)
  • South Dakota (4 / 14)
  • North Dakota (2 / 14)
  • Wyoming (2 / 8)

How can Navy physicians help?

Talk to your sailors, marines, and their family about this issue! Young servicemembers may be wary of starting this discussion. So create a safe space in the exam room or clinic to discuss their concerns. Train corpsmen on women’s health. Educated HMs act as your agent, sharing insight with patients (in the clinic) and other junior servicemembers (in casual settings).

Consider how you will react to challenging logistic and potentially ethically tough situations. If you are operational, find out what kind of support the CO gives to requests for travel for abortion services so that you can better counsel your patients as to their options.

Navy Pregnancy Instructions

Know the governing instructions. Current instructions do not provide guidance on the nuances of the recent legal changes, but they are essential background. My Navy HR’s AD pregnancy page has links to the relevant documents:

Emergency Contraception Options

When possible, educate servicemembers and patients on their emergency contraceptive options BEFORE they need them!

  • Levongesterol, 1.5 mg (Plan B One Step) – Available over the counter at any military pharmacy in any state, 1 dose.  2.5% pregnancy rate if taken within 120 hours, about half that if taken within 72 hours.
  • Ulipristal, 30 mg (Ella) – Requires prescription, 1 dose.  1.3% pregnancy rate if taken within 120 hours.
  • Copper IUD – 0.1% pregnancy rate if placed within 120 hours.
  • Mirena IUD – One large NEJM study suggests similar effectiveness to copper IUD, insufficient data for CDC to recommend yet.

Connecting Patients to Resources

Several organizations can connect patients to information and funding.

Medical Termination of Pregnancy

To be clear, military physicians working in an MTF may only offer treatment to terminate a pregnancy in cases of a nonviable pregnancy, rape, or to save the mother’s life. But it is helpful to understand the most likely treatment options in early pregnancy that may be offered at outside facilities (or online).

Mifepristone and Misoprostol for Undesired Pregnancy of Unknown Location

Preventing Future Pregnancies

Posted in Clinician Information

Clomiphene (Clomid) to Induce Ovulation

Adapted (partially verbatim) from LexiComp.

How to take it:

50 mg once daily for 5 days. Begin on or about the fifth day of cycle if progestin-induced bleeding is scheduled or spontaneous uterine bleeding occurs prior to therapy. Therapy may be initiated at anytime in patients with no recent uterine bleeding.


Hypersensitivity to clomiphene citrate or any of its components; liver disease or history of liver disease; abnormal uterine bleeding; enlargement or development of ovarian cyst (not due to polycystic ovarian syndrome); uncontrolled thyroid or adrenal dysfunction; presence of an organic intracranial lesion such as pituitary tumor; pregnancy

Canadian labeling: Additional contraindications (not in the US labeling): Hormone-dependent tumors, thrombophlebitis, uterine fibroids, mental depression.


Concerns related to adverse effects:

  • Ovarian enlargement: May be accompanied by abdominal distention or abdominal pain and generally regresses without treatment within a few days or weeks after therapy discontinuation. If ovaries are abnormally enlarged, withhold therapy until ovaries return to pretreatment size; reduce clomiphene dose and duration of future cycles.
  • Ovarian hyperstimulation syndrome (OHSS): OHSS is a rare exaggerated response to ovulation induction therapy (Corbett 2014; Fiedler 2012). This syndrome may begin within 24 hours of treatment but may become most severe 7 to 10 days after therapy (Corbett 2014). Symptoms of mild/moderate OHSS may include abdominal distention/discomfort, diarrhea, nausea, and/or vomiting. Severe OHSS symptoms may include severe abdominal pain, anuria/oliguria, ascites, severe dyspnea, hypotension, or nausea/vomiting (intractable). Decreased creatinine clearance, hemoconcentration, hypoproteinemia, elevated liver enzymes, elevated WBC, and electrolyte imbalances may also be present (ASRM 2016; Corbett 2014; Fiedler 2012). Treatment is primarily symptomatic and includes fluid and electrolyte management, analgesics, and prevention of thromboembolic complications (ASRM 2016; SOGC-CFAS 2011).
  • Visual disturbances: Blurring or other visual symptoms can occur; symptoms may increase with higher doses or duration of therapy and in some cases may be irreversible. Patients with visual disturbances should discontinue therapy and receive prompt ophthalmic evaluation.

Disease-related concerns:

  • Ovarian cancer: Prolonged use may increase the risk of borderline or invasive ovarian cancer.
  • Polycystic ovarian syndrome (PCOS): Use with caution in patients unusually sensitive to pituitary gonadotropins (eg, PCOS); a lower dose may be necessary.
  • Uterine fibroids: Use caution in patients with uterine fibroids, may cause further enlargement.

Other warnings/precautions:

  • Appropriate use: To minimize risks, use only at the lowest effective dose for the shortest duration of therapy (especially for the first course of therapy). Women with PCOS, amenorrhea-galactorrhea syndrome, psychogenic amenorrhea, post oral contraceptive amenorrhea, and some cases of secondary amenorrhea of undetermined cause may most likely benefit from clomiphene therapy.
  • Experienced physician: Use should be supervised by physicians who are thoroughly familiar with infertility problems and their management.
  • Multiple births: May result from the use of this medication; advise patient of the potential risk of multiple births before starting the treatment.
Posted in Patient Information

Picky Eating

Adapted (partially verbatim) from Am Fam Physician. 2015 Aug 15;92(4):274-278.

Kids don’t need as much food as you think!

One way children start to show their independence is by choosing what they want to eat. You should make meal times as pleasant as possible. The amount of calories and nutrition a child needs is less than many parents realize. You can find out how much your child needs by going to choose my plate.

Parents often describe their toddlers and preschoolers as picky eaters. The reluctance to eat or try new foods (food neophobia) is a normal developmental stage that the child usually outgrows. However, there are picky or fussy eaters who restrict their intake to only a few food items, regardless of whether they are new or familiar.

Some ways to reduce picky eating include:

  • Avoid offering many sweetened foods or foods with high carbohydrate content (breads, sweetened cereal, rice).
  • Don’t let your child drink too much milk or juice. The calories in liquids can take away appetite. A child should have no more than 16 to 24 oz of milk and 4 to 6 oz of juice per day.
  • Follow the rule of 10s: children should try a food at least 10 times before deciding they don’t like it.
  • Offer foods that are similar to ones your child likes. (For example, if your child likes canned peas, offer cooked carrots instead of raw carrots. The softness of the food may make a difference.)
  • Use an older sibling as a role model to help children try things they think they don’t like.
  • Mix foods, even if the mixture doesn’t make sense to you. (For example, a child may eat “ants on a log” because it is a fun way to present celery, peanut butter, and raisins.)

Mealtime Roles for Parents and Children:

The main approaches to picky eating include social modeling of normal eating behaviors, repeated exposures to new foods, and positive mealtime experiences. There is a strong correlation between parent and child nutritional behaviors. Parental efforts to control the child’s intake of food using pressure to eat a certain food or quantity of food, restriction of certain foods, or promise of a reward have negative effects on food acceptance and are discouraged. In the Satters’ Division of Responsibility Model, the parents’ role is to provide mealtime structure, positive social modeling, and a variety of healthy foods, whereas the child decides how much and which foods to eat.

Satters’ Division of Responsibility Model


  • Provide mealtime structure: time and place.
  • Create a positive environment: pleasant interaction.
  • Allow the child to feed himself or herself.
  • Provide a variety of healthy foods.


  • Eat if he or she wants to.
  • Choose what to eat out of the offered foods.
  • Stop eating when full.
Posted in Informatics

How to update Outlook Address Information

The steps below allow you to update the contact information shown when people find you in the Global Address List (GAL) in Outlook.

Go to Select your PIV (Authentication) cert to get into ID Card Office Online. Select “My Profile.”

Choose “My Profile”

Log in (again) using your CAC.

Choose “CAC”, then “Login”

Update your “My Profile,” first to verify your personal email, and family member contact information.

Update your personal email and family member contact information first.

Now update your work information.

Select “MIL” and verify your work information.

The last tab, “MIL” should be reflected in your address in Outlook. The Navy email system is undergoing yet another update. This is a good thing, as the current iteration is badly outdated. However as a result some or all of this post may not apply to you any longer. Historically changing this information could take up to 72 hours before it populated in Outlook, and this may still be true.

Posted in Patient Information

Thumb Sucking Parent Information

Adapted (partially verbatim) from Am Fam Physician. 2009Jul15;80(2):139-142.

About Thumb Sucking and Pacifiers

Thumb sucking is an innate reflex and one of the most common security and self-soothing mechanisms. In infants, thumb sucking and pacifier use are often classified together as nonnutritive sucking methods. Pacifier use has been linked to decreased breastfeeding duration, but the same effect of thumb sucking on breastfeeding has not been reported. In some studies, combinations of the use of pacifiers and thumb sucking have been reported to lead to decreased breastfeeding. Pacifier use has been documented to be protective against sudden infant death syndrome (SIDS) in children younger than six months and was included in the 2005 American Academy of Pediatrics SIDS guideline update; however, there have been few studies advocating thumb sucking as an equally preventive measure against SIDS.

The incidence of thumb sucking among children decreases with age, and most children spontaneously stop thumb sucking between two and four years of age.

When Should Children Stop Thumb Sucking?

School-aged children with persistent thumb sucking should be referred to a pediatric dentist. At this age, when the permanent teeth erupt, thumb sucking can affect a child’s teeth alignment and mouth shape. The greatest risk of developing malocclusive problems, such as overbite and crossbite, occurs in children who have persistent thumb sucking problems beyond four years of age.

American Dental Association Recommendations to Stop Thumb Sucking:

  • Praise children when they don’t suck their thumb (e.g., verbal praise, stickers).
  • Reward your child for not sucking his or her thumb (example: for every day children do not suck their thumb, they get to mark an “X” on a calendar. After a certain number of “X’s,” they can receive a reward).
  • Find alternative ways of comforting and soothing for children (e.g., stuffed toy or special blanket).
  • Provide reminders or negative reinforcement for thumb sucking (e.g., placing topical bitter liquids on the thumb, putting a bandage around the thumb to remind the child not to suck on it).
  • Involve older children in ways in which they can stop sucking (e.g., have children help create their own reward system).

Featured Image: Topical bitter liquids marketed to help discourage thumb sucking: Mavala Stop, Thum

Posted in Patient Information

Penile Adhesions in Male Children

Adapted from: Penile Adhesions Parent Information CHOP Website

What are penile adhesions

Penile adhesions in circumcised boys occur when the penile shaft skin adheres to the glans of the penis. There are three types of penile adhesions: glanular adhesions, penile skin bridges and cicatrix.


Some adhesions may develop due to an excess of residual foreskin following a newborn circumcision. Adhesions can also form as an infant develops more fat in his pubic area (the area around the penis and scrotum).


The penis may appear that it is “buried” in the prominent pubic fat pad. Because the penis remains hidden there is a tendency for the shaft skin to adhere to the glans.

With all adhesions you may notice a white discharge coming from the area of the adhesions. This is called smegma. Sometimes smegma can be mistaken for a cyst or pus under the skin, but it is not an infection and does not require antibiotics. Smegma consists of dead skin cells that accumulate underneath the adhesions and help to break them apart.

Diagnosis and treatment

Penile adhesions are generally benign and cause no pain or discomfort to your son. You or your pediatrician may notice them during a physical exam.

Treatment is generally performed by a urologist. They will determine by physical exam the type of penile adhesion and what treatment approach is recommended.

Glanular adhesions

On exam you may not be able to see the complete coronal margin. This is the purple line that separates the glans from the shaft of the penis. This is because the shaft skin has adhered to the glans, covering the coronal margin. Glanular adhesions are benign and when left alone tend to resolve on their own. To help the adhesions separate more quickly, we may suggest applying Vaseline® directly to the adhesions. The Vaseline will soften the adhesions, and with spontaneous erections, the adhesions will begin to break apart on their own.

Penile skin bridge

In some instance, the penile shaft skin will become attached to the coronal margin and develop a thicker permanent attachment that cannot be separated and will not separate on its own. You may notice a band of skin from the shaft adhering to the glans with a small tunnel underneath. In many situations the skin bridge can be divided during an outpatient procedure. Treatment may also involve division of the skin bridge and circumcision revision.


Following a circumcision, the penis may drop back into the pubic fat pad and the surgical area may contract, trapping the penis. In this situation, you will not be able to expose the glans of the penis at all. We have found that cicatrix can be safely and effectively treated with a topical steroid cream. Your child’s doctor will give you instructions on the proper use of the cream. If the steroid cream fails and the penis remains trapped, a circumcision revision and correction of a concealed penis may be necessary.

Posted in Patient Information

Allergy Medication Dosing for Children

Quick reference of allergy med dosing for children.

Zyrtec (cetirizine) dosing:

  • 6-12 months: 2.5 mg once daily
  • 1-2 years: 2.5 mg once to twice daily
  • 2-5 years: 2.5 – 5 mg once daily
  • 6 years and up: 5 – 10mg once daily

Claritin (loratadine) dosing:

  • 2 – 5 years: 5 mg once daily
  • 6 years and up: 5 – 10 mg once daily

Allegra (fexofenadine) dosing:

  • 6 months and < 10.5kg: 15mg twice daily
  • < 2 years or < 10.5kg : 15 – 30 mg twice daily
  • 2 – 11 years: 30 mg twice daily
  • 12 years and up: 180 mg ER once daily

Flonase (fluticasone) dosing:

  • 4 years and up: 1 spray per nostril once daily. If not working, ok to increase to 2 sprays each nostril, but reduce to once daily as soon as possible
  • 12 years and up: 2 sprays each nostril once daily