Adolescent Medicine

Irish Michelle Tan-Becina, MD, DPPS

PEDIATRICS
Adolescent Physical and Social Development

• undergo dramatic changes in physical appearance also

changes in physiologic, psychological, and social
functioning

• 3 phases
• Early Adolescence
• Middle Adolescence
• Late Adolescence
 EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE
Approximate age
10-13 yr 14-17 yr 18-21 yr
range
Sexual maturity
1-2 3-5 5
rating*

•Females: peak
growth velocity,
•Females: menarche (if not
Secondary sex already attained)
characteristics
• Physical
(breast, pubic, •Males: growth spurt,
maturation
axillary hair), start secondary sex
Physical slows
• Increased
of growth spurt characteristics,
lean muscle mass
nocturnal emissions,
in males
•Males: testicular facial and body hair,
enlargement, start voice changes
of genital growth •Change in body
composition
•Acne
 EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE

Approximate
10-13 yr 14-17 yr 18-21 yr
age range
•Future-oriented
•Emergence of
with sense of
abstract thought
perspective
(formal operations)
• Concrete •Idealism
•May perceive future
operations •Able to think
implications, but
• Egocentricity things through
may not apply in
• Unable to perceive •independently
decision making
Cognitive and long-term •Improved
•Strong emotions
moral outcome of current impulse control
may drive decision
decisions •Improved
making
• Follow rules to assessment of
•Sense of
avoid risk vs.
invulnerability
punishment •reward
•Growing ability to
•Able to
see others’
distinguish law
•perspectives
from morality
 EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE
Approximate
10-13 yr 14-17 yr 18-21 yr
age range
• More stable body
• Preoccupied with
• Concern with image
•
Self- changing body
attractiveness • Attractiveness may
concept/identity • Self-consciousness
Increasing still be of concern •
formation about appearance
introspection Consolidation of
and attractiveness
identity
• Conflicts over •Emotional and
control and physical separation
• Increased need for
independence from family
privacy
• Struggle for •Increased
• Exploration of
Family greater autonomy
dependence/
autonomy •Reestablishment
independence
• Increased of “adult”
boundaries
separation from •relationship with
the parents parents
 EARLY MIDDLE LATE
VARIABLE
ADOLESCENCE ADOLESCENCE ADOLESCENCE
Approximate age
10-13 yr 14-17 yr 18-21 yr
range

• Intense peer
group involvement • Peer group and
• Same-sex peer
Peers • Preoccupation values recede in
affiliations
with peer culture • importance
Conformity

• Consolidation of
• Testing ability to sexual identity
•Increased interest
attract partner • Focus on
in sexual anatomy
• Initiation of intimacy and
•Anxieties and
relationships and formation of
Sexual questions about
sexual stable
pubertal changes
activity relationships
•Limited capacity
• Questions of • Planning for
for intimacy
sexual orientation future and
commitment
PHYSICAL DEVELOPMENT
• Puberty
• is the biologic transition from childhood to adulthood
• changes include the appearance of the secondary sexual
characteristics, increase in height, change in body composition,
and development of reproductive capacity
• Production of
• Androgen – dihydroepiandrosterone sulfate (DHEAS)
• GNRH
• LH
• FSH
Sexual Development

• progression of the development of the secondary sex

characteristics

• using the sexual maturity rating (SMR) scale (ranging from

1, preadolescence, to 5, sexual maturity) or Tanner stages
Tanner Staging
(Males)

• SMR 2 is testicular
enlargement, beginning
as early as 9.5 yr

• SMR 3 penile growth

• SMR 4 peak growth occurs

where testis volumes reach
approx 9-10cm
Sexual Development

• Males
• 40-65% breast tissue growth, typically bilateral during SMR 2-3
as a consequence of a relative excess of estrogenic
stimulation
• resolves with ongoing maturation
Tanner (females)
• SMR 2 is the appearance of
breast buds (thelarche), between
8 and 12 yr of age

• Menses begins 2.5 yr after the

onset of puberty ( SMR 3-4 )
average age: 12.5 yr; normal
range: 9-15 yr
Somatic Growth

• Linear growth acceleration begins in early adolescence

for both genders, (15-20% of adult height)

• Females attain a peak height velocity (PHV) of 8-9 cm/yr

at SMR 2-3, approximately 6 mo before menarche.

• Males typically begin their growth acceleration with a

PHV of 9-10 cm/yr at SMR 3-4 and continue their linear
growth for approximately 2-3 yr after females have
stopped growing
Somatic Growth

• growth spurt begins

distally, with enlargement
of the hands and feet,
followed by the arms and
legs, and finally, the trunk
and chest. This growth
pattern imparts a
characteristic “awkward”
appearance to some
early adolescents
Sexual Identity Development

• Sexual identity

• Sex assigned at birth

• Gender identity

• Social sex role

• Sexual orientation
• Gender variant

• Transgender

• Transsexuals

• Cross dresser/transvestites

• Bigender

• Drag queens/kings

• Queer
PSYCHOSOCIAL ASSESSMENT
• peer relationships • School
• “Do you have a best friend with • “How are your grades this year
whom you can share even the compared with last year?”
most personal secret?”
• personal decisions
• self-image • “Are you feeling pressured to
engage in any behav- ior for which
• “Is there anything you would like to
you do not feel you are ready?”
change about your- self?”
• eating disorder
• depression
• “Do you ever feel that food controls
• “What do you see yourself doing 5 you rather than vice versa?”
yr from now?”
HEADS/SF/FIRST
Home. Space, privacy, frequent geographic moves,
neighborhood.
Education/School. Frequent school changes, repetition of a
grade/ in each subject, teachers’ reports, vocational goals, after-
school educational clubs (language, speech, math, etc.), learning
disabilities
Abuse. Physical, sexual, emotional, verbal abuse; parental
discipline
Drugs. Tobacco, alcohol, marijuana, inhalants, “club drugs,”
“rave” parties, others. Drug of choice, age at initiation, frequency,
mode of intake, rituals, alone or with peers, quit methods, and
number of attempts
Safety. Seat belts, helmets, sports safety measures, hazardous
activities, driving while intoxicated
Sexuality/Sexual Identity. Reproductive health (use of
contraceptives, presence of sexually transmitted infections,
feelings, pregnancy)
HEADS/SF/FIRST
Family and Friends. Family: Family constellation, genogram, single/
married/separated/divorced/blended family, family occupations and shifts;
history of addiction in 1st- and 2nd-degree relatives, parental attitude toward
alcohol and drugs, parental rules; chronically ill physically or mentally challenged
parent. Friends: peer cliques and configuration (“preppies,” “jocks,” “nerds,”
“computer geeks,” cheerleaders), gang or cult affiliation

Image. Height and weight perceptions, body musculature and physique,

appearance (including dress, jewelry, tattoos, body piercing as fashion trends or
other statement)
Recreation. Sleep, exercise, organized or unstructured sports, recreational
activities (television, video games, computer games, Internet and chat rooms,
church or community youth group activities [e.g., Boy/Girl Scouts; Big
Brother/Sister groups, campus groups]). How many hours per day, days per
week involved?
Spirituality and Connectedness. adherence, rituals, occult practices,
community service or involvement
Threats and Violence. Self-harm or harm to others, running away, cruelty to
animals, guns, fights, arrests, stealing, fire setting, fights in school
Sexually Transmitted Infection
Sexually Transmitted
Infections
• Any adolescent who has had oral, vaginal, or anal sexual
intercourse is at-risk for acquiring an STI.

• Adolescents who initiate sex at a younger age, youth residing in

detention facilities, youth attending sexually transmitted diseases
clinics, young men having sex with men, and youth who are
injecting-drug users are at higher risk for STIs.

• Risky behaviors, such as sex with multiple concurrent partners or

multiple sequential partners of limited duration, failure to use barrier
protection
Circumstances Contributing to Adolescents’ Susceptibility to Sexually
Transmitted Infections
PHYSICAL
Younger age at puberty
Cervical ectopy
Smaller introitus leading to traumatic sex
Asymptomatic nature of sexually transmitted infection
Uncircumcised penis
BEHAVIOR LIMITED BY COGNITIVE STAGE OF DEVELOPMENT

Early adolescence: have not developed ability to think abstractly

Middle adolescence: develop belief of uniqueness and invulnerability

SOCIAL FACTORS
Poverty
Limited access to “adolescent friendly” healthcare services
Adolescent health-seeking behaviors (forgoing care because of
confidentiality concerns or denial of health problem)
Sexual abuse and violence
Homelessness
Young adolescent females with older male partners
Epidemiology
Pathogenesis

• During puberty, increasing levels of estrogen cause the

vaginal epithelium to thicken and cornify and the cellular
glycogen content to rise, the latter causing the vaginal
pH to fall.

• These changes increase the resistance of the vaginal

epithelium to penetration by certain organisms (including
Neisseria gonorrhoeae) and increase the susceptibility to
others (Candida albicans and Trichomonas
Sexually Transmitted Infection
Screening

• Some of the most common STIs in adolescents, including

HPV, HSV, chlamydia, and gonorrhea, are usually
asymptomatic

• STI screening, should be offered to all sexually

experienced adolescents
Routine Laboratory Screening Recommendations for Sexually Transmitted
Infections in Sexually Active Adolescents and Young Adults

Chlamydia trachomatis and Neisseria gonorrhoeae

• Routinely screening for C. trachomatis of all sexually active females aged ≤25 yr is
recommended annually
•Consider screening for C. trachomatis of sexually active adolescent and young adult
males annually who have a history of multiple partners
•in settings with high prevalence rates, such as jails or juvenile corrections facilities,
national job training programs, STD clinics, high school
•clinics, or adolescent clinics
•Routinely screening for N. gonorrhoeae of all sexually active females age <25 yr is
recommended annually
•Routinely screen sexually active adolescent and young adult MSM for rectal and urethral
chlamydia and gonorrhea annually if they engage in
•receptive anal or insertive intercourse, respectively, and for routine gonorrhea if they
engage in receptive oral sex. More frequent STD screening (i.e., at 3-6 mo intervals) is
indicated for MSM who have multiple or anonymous partners or who have sex in
conjunction with illicit drug use

HIV

• HIV screening should be discussed and offered to all adolescents ≥15 yr in healthcare
settings, unless identified at an earlier age with HIV risk factors
Routine Laboratory Screening Recommendations for Sexually Transmitted
Infections in Sexually Active Adolescents and Young Adults

SYPHILIS

• Syphilis screening should be offered to sexually active adolescents reporting risk factors
• The majority of U.S. syphilis cases occurring among young MSM and many early
syphilis cases are identified from correctional facilities
• Providers should consult with their local health department regarding local syphilis
prevalence and associated risk factors that are associated
with syphilis acquisition

HEPATITIS C VIRUS

• Screening adolescents for hepatitis C virus who report risk factors, i.e., injection drug
use, MSM, received blood products or organ donation before 1992, received clotting
factor concentrates before 1987, long-term hemodialysis, or high prevalence setting, i.e.,
correctional facilities or STD clinics
Definitions, Etiology, and
Clinical Manifestations
of STI
Urethritis

• inflammation of the urethra, usually caused by an

infectious etiology

• Urethritis may present with urethral discharge, dysuria,

urethral irritation, or meatal pruritus

• Less common presentation are urgency, frequency of

urination, erythema of the urethral meatus, and urethral
pain or burning
Urethritis
• On examination, the classic finding is
mucoid or purulent discharge from the
urethral meatus

• Chlamydia trachomatis and N.

gonorrhoeae are the most commonly
identified pathogens

• Mycoplasma genitalium, Trichomonas

vaginalis, HSV-1, HSV-2, and Epstein-Barr
virus are also potential urethritis
Epididymitis

• inflammation of the epididymis in adolescent males is

most often associated with an STI, most frequently C.
trachomatis or N. gonorrhoeae.

• presentation of unilateral scrotal swelling and tenderness,

often accompanied by a hydrocele and palpable
swelling of the epididymis, associated with the history of
urethral discharge
• evaluation for epididymitis
• evidence of urethral inflammation by physical exam
• Gram stain of urethral secretions
• urine leukocyte esterase test
• urine microscopy

• C. trachomatis and N. gonorrhoeae nucleic acid

amplification test (NAAT) should be performed
Vaginitis

• superficial infection of the vaginal mucosa frequently

presenting as a vaginal discharge, with or without vulvar
involvement

• Bacterial vaginosis, vulvovaginal candidiasis, and

trichomoniasis are the predominant infections associated
with vaginal discharge.
• Bacterial vaginosis is replacement of the normal H2O2–
producing Lactobacillus sp. vaginal flora by an
overgrowth of anaerobic microorganisms as well as
Gardnerella vaginalis, Ureaplasma, and Mycoplasma.

• Although bacterial vaginosis is not categorized as an STI,

sexual activity is associated with increased frequency of
vaginosis
• Vulvovaginal candidiasis
• caused by C. albicans, can trigger vulvar pruritus, pain,
swelling, and redness and dysuria Findings on vaginal exam
include vulvar edema, fissures, excoriations, or thick curdy
vaginal discharge.

• Trichomoniasis
• Caused by protozoan T. vaginalis. Infected females may
present with symptoms characte ized by a diffuse,
malodorous, yellow-green vaginal discharge with vulvar
irritation or may be diagnosed by screening an
asymptomatic patient.
Cervicitis

• inflammatory process in cervicitis involves the deeper

structures in the mucous membrane of the cervix uteri

• Vaginal discharge can be a manifestation of cervicitis,

however, cervicitis frequently is asymptomatic, Patients
also commonly present with complaints of irregular or
postcoital bleeding.

• pathogens identified most commonly with cervicitis are C.

trachomatis and N. gonorrhoeae less commonly HSV
infection
Cervicitis

• Two major diagnostic signs

• (1) a purulent or
mucopurulent endocervical
exudate visible in the
endocervical canal or on an
endocervical swab specimen
commonly referred to as
mucopurulent cervicitis or
cervicitis
• (2) sustained endocervical bleeding easily induced by
gentle passage of a cotton swab through the cervical os
signifying friability
Pelvic Inflammatory Disease
• encompasses a spectrum of inflammatory disorders of the
female upper genital tract, including endometritis, salpingitis,
tuboovarian abscess, and pelvic peritonitis, usually in
combination

• N. gonorrhoeae and C. trachomatis predominate as the

involved pathogenic organisms in younger adolescents,

• PID should be approached as multiorganism etiology, including

pathogens such as anaerobes, G. vaginalis, Haemophilus
influenzae, enteric Gram-negative rods, and Streptococcus
agalactiae. In addition, cytomegalovirus, Mycoplasma hominis,
U. urealyticum, and M. genitalium
• PID is difficult to diagnose because of the wide variation in
the symptoms and signs. Many females with PID have
subtle or mild symptoms resulting in many unrecognized
cases

• consider the possibility of PID in young sexually active

females presenting with vaginal discharge and/or
abdominal pain.
• clinical diagnosis of PID is based on the presence of at
least 1 of the minimal criteria, either cervical motion
tenderness, uterine tenderness, or adnexal tenderness,

• majority of females with PID have either mucopurulent

cervical discharge or evidence of white blood cell (WBC)
on a microscopic evaluation of a vaginal fluid saline
preparation.
• specific, but not always practical, criteria for PID include
evidence
• endometritis on biopsy
• transvaginal sonography
• MRI evidence of thickened fluid-filled tubes
• Doppler evidence of tubal hyperemia
• laparoscopic evidence of PID
Evaluation for Pelvic Inflammatory Disease

2014 CENTERS FOR DISEASE CONTROL AND PREVENTION DIAGNOSTIC

CRITERIA

Minimal Criteria
• Cervical motion tenderness • or
• Uterine

tenderness
• or
• Adnexal tenderness

Additional Criteria to Enhance Specificity of the Minimal Criteria

• Oral temperature >38.3°C (>101°F)
• Abnormal cervical or vaginal
mucopurulent discharge*
• Presence of abundant numbers of white
blood cells on saline
microscopy of vaginal secretions*
• Elevated ESR or C-reactive protein
•
Laboratory documentation of cervical Neisseria gonorrhoeae or
Chlamydia trachomatis infection
Evaluation for Pelvic Inflammatory Disease

2014 CENTERS FOR DISEASE CONTROL AND PREVENTION DIAGNOSTIC

CRITERIA

Most Specific Criteria to Enhance the Specificity of the Minimal Criteria

• Transvaginal sonography or MRI techniques showing thickened, fluid-
filled tubes, with or without free pelvic fluid or tuboovarian complex, or
Doppler studies suggesting pelvic infection (e.g., tubal hyperemia)
•Endometrial biopsy with histopathologic evidence of endometritis
•Laparoscopic abnormalities consistent with PID

Differential Diagnosis (Partial List)

• GI: appendicitis, constipation, diverticulitis, gastroenteritis,
inflammatory bowel disease, irritable bowel syndrome
•GYN: ovarian cyst (intact, ruptured, or torsed), endometriosis,
•dysmenorrhea, ectopic pregnancy, mittelschmerz, ruptured
•follicle, septic or threatened abortion, tuboovarian abscess
•Urinary tract: cystitis, pyelonephritis, urethritis, nephrolithiasis
Genital Ulcer Syndromes

• An ulcerative lesion in a mucosal area exposed to sexual

contact

• lesions are most frequently seen on the penis and vulva,

but also occur on oral and rectal mucosa depending on
the adolescent’s sexual practices

• HSV and Treponema pallidum (syphilis) are the most

common organisms associated with genital ulcer
syndromes.
Genital herpes

• most common ulcerative STI among adolescents, is a

chronic, lifelong viral infection

• HSV-1 and HSV-2 are sexually transmitted, majority of

recurrent genital herpes are caused by HSV-2.

• Most HSV-2–infected persons are unaware of their

diagnosis because they experience mild or unrecognized
infections but continue to shed virus intermittently in the
genital tract
• initial herpetic lesion is a
vesicle

• the vesicle ruptured

spontaneously, leaving a
shallow, painful ulcer

• recurrences are generally

less intense and painful
Signs, Symptoms, and Presumptive and Definitive Diagnoses of Genital Ulcers

SIGNS/SYMPT HERPES SIMPLEX SYPHILIS

CHANCROID
OMS VIRUS (PRIMARY)

Ulcer with well-

Unindurated and
Vesicles rupture to form demarcated indurated
Ulcers undermined borders
shallow ulcers borders and a clean
and a purulent base
base (chancre)

Painful Painful Painless* Painful

Number of
Usually multiple Usually single Multiple
lesions

Unilateral or bilateral
First-time infections
painful adenopathy in
Inguinal may cause
Usually mild and >50%
lymphadenopat constitutional
minimally tender Inguinal bubo
hy symptoms and
formation and rupture
lymphadenopathy
may occur
 HERPES
SIGNS/SYMPT
SIMPLEX SYPHILIS (PRIMARY) CHANCROID
OMS
VIRUS

Early syphilis: a typical

Exclusion of other
chancre plus a reactive
causes of ulcers in the
nontreponemal test (RPR,
presence of (a) typical
VDRL) and no history of
Typical ulcers and
syphilis or a 4-fold increase in
lesions; lymphadenopathy,
Clinical a quantitative nontreponemal
positive HSV-2 (b) a typical Gram stain
suspicion test in a person with a history
type-specific and
of syphilis; positive treponemal
serology test a history of contact with
EIA with reactive
a high-risk individual
nontreponemal test (RPR,
(prostitute) or living in
VDRL) and no prior history of
an endemic area
syphilis treatment

Detection of
HSV by culture Identification Treponema
Detection of
Definitive or PCR from pallidum, from a chancre or
Haemophilus ducreyi by
diagnosis ulcer scraping lymph node aspirate, on dark-
culture
or aspiration of field microscopy
vesicle fluid
Genital Lesions and Ectoparasites
• present as outgrowths on the surface of the epithelium and
other limited epidermal lesions

• HPV can cause genital warts and genital cervical abnor-

malities that can lead to cancer.

• HPV types 6 and 11

• low-risk types, can cause benign or low- grade changes in cells of
the cervix, genital warts,

• HPV types 16 and 18

• High risk types, cause cervical, anal, vulvar, vaginal, and head and
neck cancers.
Treatment
PATHOGEN RECOMMENDED REGIMENS
Azithromycin 1 g orally
Chlamydia trachomatis once
or
Doxycycline 100 mg
orally twice daily for 7 days
Ceftriaxone 250 mg IM in a single Azithromycin 1 g orally once
Neisseria gonorrhoeae dose or
(cervix, urethra, and Single-dose injectable
rectum) cephalosporin plus
Azithromycin 1 g orally once
ALTERNATIVE REGIMENS AND SPECIAL
CONSIDERATIONS
For pregnancy:
Azithromycin 1 g orally once
Alternative regimens:
Erythromycin base 500 mg orally 4 times a day for
7 days or
Erythromycin ethylsuccinate 800 mg orally 4 times
a day
for 7 days or
Levofloxacin 500 mg orally once daily for 7 days or
Ofloxacin 300 mg orally twice a day for 7 days
Alternative if unable to offer IM: Cefixime 400 mg
orally in a single dose
plus
If azithromycin is not available or if patient is
allergic to
azithromycin, doxycycline 100 mg orally twice
daily for 7 days may be substituted for
azithromycin as the second antimicrobial
Severe cephalosporin allergy: contact infectious
disease specialist
 RECOMMENDED ALTERNATIVE REGIMENS AND
PATHOGEN
REGIMENS SPECIAL CONSIDERATIONS

No alternative therapy available

Ceftriaxone 250 mg IM
Neisseria gonorrhoeae in a single dose
(pharynx) plus
Azithromycin 1 g
orally once
Patients treated with an alternative
regimen should
return 14 days after treatment for a
test of cure using either culture or
NAAT. If the NAAT is positive, every
effort should be made to perform a
confirmatory culture

Treponema pallidum
Penicillin allergy: doxycycline 100 mg
(primary and Benzathine penicillin G
orally twice daily for 14 days. Limited
secondary syphilis or 2.4 million units IM in 1
data suggest ceftriaxone 1-2 g daily
early latent syphilis, dose
either IM or IV for 10-14 days.
i.e., infection <12 mo)

Benzathine penicillin G
Treponema pallidum
7.2 million units total, Penicillin allergy: doxycycline 100 mg
(late latent syphilis or
administered as 3 doses orally twice daily for 28 days with
syphilis of unknown
of 2.4 million units IM close serologic and clinical follow-up
duration)
each at 1 wk intervals
 ALTERNATIVE REGIMENS
RECOMMENDED
PATHOGEN AND SPECIAL
REGIMENS
CONSIDERATIONS
Azithromycin 1 g orally in
a single dose or
Ceftriaxone 250 mg IM in
Haemophilus ducreyi a single dose or
(chancroid: genital Ciprofloxacin 500 mg
ulcers, orally twice a day for 3
lymphadenopathy) days or
Erythromycin base 500
mg orally 3 times a day
for 7 days
Alternative: erythromycin
Chlamydia trachomatis base 500 mg orally 4
serovars L1, L2, or L3 Doxycycline 100 mg orally times a day for 21 days
(lymphogranuloma twice daily for 21 days or
venereum) Azithromycin 1 g orally
once a week for 3 wk
Management Guidelines for Uncomplicated Miscellaneous Sexually Transmitted
Infections in Adolescents and Adults

ALTERNATIVE
PATHOGEN RECOMMENDED REGIMENS REGIMENS AND SPECIAL
CONSIDERATIONS

Metronidazole 2 g orally in a single

Metronidazole 500 mg orally
Trichomonas vaginalis dose or
Tinidazole 2 g orally in a single
twice daily for 7 days
dose
Permethrin 1% cream rinse applied to
affected areas and washed off after 10 Malathion 0.5% lotion
min applied for 8-12 hr and
Phthirus pubis (pubic or washed off
lice) Pyrethrins with piperonyl butoxide or
applied to affected Ivermectin 250 μg/kg PO,
areas and washed off after 10 min repeat in 2 wk
Launder clothing and bedding

Permethrin 5% cream applied to all

Lindane (1%) 1 oz of lotion
areas from the neck down, washed off
or 30 g of cream in thin
Sarcoptes scabiei after 8-14 hr
layer to all areas of body
(scabies) or
from neck down; wash off in
Ivermectin 200 μg/kg orally, repeated
8 hr
in 2 wk Launder clothing and bedding
Management Guidelines for Uncomplicated Genital Warts and Genital Herpes in
Adolescents and Adults
PATHOGEN RECOMMENDED REGIMENS

Patient-applied:
Podofilox 0.5% solution or gel self-applied to
warts twice daily for 3 consecutive days each wk followed by 4 days
of no therapy. May be repeated for up to 4 cycles.
or
Imiquimod 3.75% cream or 5% cream self-
applied to warts at bedtime 3 times wkly for
up to 16 wk; wash off after 6-10 hr or
Human Sinecatechins 15% ointment self-applied 3 times daily for up to 16
papillomaviruses wk. Do not wash off after use
external genital Provider-administered:
warts Cryotherapy with liquid nitrogen or cryoprobe.
Repeat applications every 1-2 wk or
Trichloroacetic acid (TCA) or bichloracetic acid (BCA) 80-90%. A
small amount should be applied only to the warts and allowed to
dry, at which time a white “frosting” develops. Can be repeated
weekly
or
Surgical removal either by tangential scissor
excision, tangential shave excision, curettage, or electrosurgery
Management Guidelines for Uncomplicated Genital Warts and Genital Herpes in
Adolescents and Adults
Treat for 7-10 days with 1 of the
following: Acyclovir 400 mg orally 3
times daily
or Consider extending
Herpes simplex virus
Acyclovir 200 mg orally 5 times daily treatment if healing is
(genital herpes): First
or incomplete after 10
clinical episode
Valacyclovir 1 g orally twice daily days of therapy
or
Famciclovir 250 mg orally 3 times
daily
Management Guidelines for Uncomplicated Genital Warts and
Genital Herpes in Adolescents and Adults

Acyclovir 400 mg orally 3 times daily for 5 days

or
Acyclovir 800 mg orally twice daily for 5 days or
Acyclovir 800 mg orally 3 times daily for 2 days
Herpes or Effective episodic
simplex Valacyclovir 500 mg orally twice daily for 3 treatment of recurrences
virus (genital days or requires initiation of
herpes): Valacyclovir 1,000 mg orally once daily for 5 therapy within 1 day of
Episodic days or lesion onset or during the
therapy for Famciclovir 125 mg orally twice daily for 5 days prodrome that precedes
recurrences or some outbreaks.
Famciclovir 1,000 mg orally twice daily for 1
day or
Famciclovir 500 mg orally once then 250 mg
twice daily for 2 days
Substance Abuse
• adolescents will engage in use of a wide range of sub-
stances such as alcohol, tobacco, or marijuana

• Their reactions to and the consequences of these

exposures are influenced by a complex interaction
between biologic and psychosocial development,
environmental messages, and societal attitudes.
Etiology

• Substance abuse is biopsychosocially determined

• Biologic factors, including genetic predisposition, are

established contributors. Behaviors such as rebelliousness,
poor school performance, delinquency, and criminal
activity and personality traits such as low self-esteem,
anxiety, and lack of self-control

• psychiatric disorders are often comorbidly associated with

adolescent substance use. Conduct disorders and
antisocial personality disorders coexist with substance
abuse
• Risk factors for adolescent drug use may differ from those
associated

• with adolescent drug abuse. Adolescent use is more

commonly related to social and peer factors, whereas
abuse is more often a function of psychological and
biologic factors.
 Assessing the Seriousness of Adolescent Drug Abuse
VARIABLE 0 +1 +2
Age (yr) >15 <15
Sex Male Female
Family history of drug abuse Yes
Setting of drug use In group Alone
Affect before drug use Happy Always poor Sad
Good,
School performance Recently poor
improving
Use before driving None Yes
History of accidents None Yes
Time of week Weekend Weekdays

Before or
Time of day After school
during school

Whiskey,
Marijuana, Hallucinogens, opiates,
Type of drug
beer, wine amphetamines cocaine,
barbiturates
Stages of Adolescent Substance Abuse
STAGE DESCRIPTION

Potential for abuse
• Decreased impulse control
• Need for immediate gratification •
1
Available drugs, alcohol, inhalants • Need for peer acceptance

Experimentation: learning the euphoria

• Use of inhalants, tobacco, marijuana, and alcohol
2 with friends
• Few, if any, consequences
• Use may increase to weekends regularly • Little change in behavior

Regular use: seeking the euphoria
• Use of other drugs, e.g., stimulants, LSD,
3 sedatives • Behavioral changes and some consequences
• Increased frequency of
use; use alone
• Buying or stealing drugs

Regular use: preoccupation with the “high” • Daily use of drugs

• Loss of control
4
• Multiple consequences and risk taking
• Estrangement from family and “straight” friends

Burnout: use of drugs to feel normal
• Polysubstance use/cross-addiction
• Guilt,

5 withdrawal, shame, remorse, depression • Physical and mental deterioration
•
Increased risk taking, self-destructive, suicidal
EPIDEMIOLOGY

• Alcohol, cigarettes, and marijuana are the most

commonly reported substances

• Prescription drug abuse, or nonmedical use of a

prescription drug or an over-the counter (OTC) medicine
• most commonly used substances were Adderall (7.6%),
Vicodin (7.5%), OTC cough medicine (5.6%), tranquilizers
(5.3%), sedatives (4.5%), and OxyContin (4.3%)
CLINICAL MANIFESTATIONS

• no obvious physical findings

• Drug use is more frequently detected in adolescents who

experience trauma such as motor vehicle crashes, bicycle
injuries, or violence.

• substance use are associated with the route of use;

intravenous drug use is associated with venous “tracks”
and needle marks, while nasal mucosal injuries are
associated with nasal insufflation of drugs.
SCREENING FOR SUBSTANCE ABUSE
DISORDERS
CRAFFT Mnemonic Tool

• Have you ever ridden in a Car driven by someone (including yourself) who
was high or had been using alcohol or drugs?

• Do you ever use alcohol or drugs to Relax, feel better about yourself or fit in?

• Do you ever use alcohol or drugs while you are by yourself (Alone)?

• Do you ever Forget things you did while using alcohol or drugs?

• Do your Family or Friends ever tell you that you should cut down on your
drinking or drug use?

• Have you ever gotten into Trouble while you were using alcohol or drugs?
The Most Common Toxic Syndromes

ANTICHOLINERGIC SYNDROMES

Delirium with mumbling speech, tachycardia, dry, flushed skin, dilated

pupils, myoclonus, slightly elevated temperature, urinary retention, and
Common signs
decreased bowel sounds. Seizures and dysrhythmias may occur in severe
cases.

Antihistamines, antiparkinsonian medication, atropine, scopolamine,

amantadine, antipsychotic agents, antidepressant agents, antispasmodic
Common causes
agents, mydriatic agents, skeletal muscle relaxants, and many plants
(notably jimson weed and Amanita muscaria).

SYMPATHOMIMETIC SYNDROMES

Delusions, paranoia, tachycardia (or bradycardia if the drug is a pure α-

adrenergic agonist), hypertension, hyperpyrexia, diaphoresis, piloerection,
Common signs
mydriasis, and hyperreflexia. Seizures, hypotension, and dysrhythmias
may occur in severe cases.

Cocaine, amphetamine, methamphetamine (and its derivatives 3,4-

methylenedioxyamphetamine, 3,4-met hylenedioxymethamphetamine,
3,4-methylenedioxyethamphetamine, and 2,5-dimethoxy-4-
Common causes bromoamphetamine), and OTC decongestants (phenylpropanolamine,
ephedrine, and pseudoephedrine). In caffeine and theophylline overdoses,
similar findings, except for the organic psychiatric signs, result from
catecholamine release.
The Most Common Toxic Syndromes

OPIATE, SEDATIVE, OR ETHANOL INTOXICATION

Coma, respiratory depression, miosis, hypotension, bradycardia,

hypothermia, pulmonary edema, decreased bowel sounds,
Common signs
hyporeflexia, and needle marks. Seizures may occur after overdoses
of some narcotics, notably propoxyphene.

Narcotics, barbiturates, benzodiazepines, ethchlorvynol, glutethimide,

Common causes methyprylon, methaqualone, meprobamate, ethanol, clonidine, and
guanabenz.

CHOLINERGIC SYNDROMES

Confusion, central nervous system depression, weakness, salivation,

lacrimation, urinary and fecal incontinence, gastrointestinal cramping,
Common signs
emesis, diaphoresis, muscle fasciculations, pulmonary edema,
miosis, bradycardia or tachycardia, and seizures.

Organophosphate and carbamate insecticides, physostigmine,

Common causes
edrophonium, and some mushrooms.
Alcohol

• Alcohol is the most popular drug among teens in the

United States

• Alcohol contributes to more deaths in young individuals

• Alcohol is often mixed with energy drinks (caffeine,

taurine, sugars), which can result in a spectrum of alcohol
related negative behaviors.

• Caffeine may counter the sedative effects of alcohol

resulting in more alcohol consumption and a perception
of not being intoxicated thus leading to risk taking
behavior like driving while intoxicated
PHARMACOLOGY AND PATHOPHYSIOLOGY
• transport
ed to • Engorgement of
the liver hepatocytes with
fat causes
necrosis,
triggering an
• primary inflammatory
metabolic process
Alcohol (ethyl pathway (alcoholic
alcohol or contributes hepatitis)
ethanol) is to the
rapidly excess
absorbed in synthesis of
the stomach triglyceride • later followed by
s( fatty fibrosis (hallmark
liver) of cirrhosis)
CLINICAL MANIFESTATIONS

• primarily as a central nervous system depressant

• It produces euphoria, grogginess, talkativeness, impaired

short-term memory, and an increased pain threshold

• Alcohol’s ability to produce vasodilation and hypothermia

is also centrally mediated.

• At very high serum levels, respiratory depression occurs.

Complications

• gastrointestinal complications of alcohol use can occur

from a single large ingestion

• The most common is acute erosive gastritis, which is

manifested by epigastric pain, anorexia, vomiting, and
heme-positive stools

• vomiting and mid abdominal pain may be caused by

acute alcoholic pancreatitis; diagnosis is confirmed by the
finding of elevated serum amylase and lipase levels.
Tobacco

• average smoker in the United States starts at age 12 yr,

and most are regular smokers by age 14 yr.

• Factors associated with youth tobacco use include

• exposure to smokers (friends, parents)
• availability of tobacco
• low socioeconomic status
• poor school performance
• low self-esteem
• lack of perceived risk of use
• lack of skills to resist influences to tobacco use.
PHARMACOLOGY

• Nicotine, the primary active ingredient in

cigarettes(addictive)

• Nicotine is absorbed by multiple sites in the body,

including the lungs, skin, gastrointestinal tract, and buccal
and nasal mucosa.

• The action of nicotine is mediated through nicotinic

acetylcholine receptors

• Nicotine also stimulates the adrenal glands to release

epinephrine, causing an immediate elevation in blood
pressure, respiration and heart rate.
• Average nicotine content of 1 cigarette is 10 mg

• average nicotine intake per cigarette ranges from 1-3 mg

• Nicotine, as delivered in cigarette smoke, has a half-life of

about 2 hr.

• Cotinine is the major metabolite of nicotine via C-

oxidation. It has a biologic half-life of 19-24 hr and can be
detected in urine, serum, and saliva.
CLINICAL MANIFESTATIONS

• Adverse health effects from regular smoking include an

increased prevalence of chronic cough, sputum
production, and wheezing.
ELECTRONIC CIGARETTES (E-CIGARETTES)

• Adverse effects include dry cough, throat irritation, and

lipoid pneumonia.

• Potentially toxic substances have been detected in the

vapor (diethylene glycol) as well as carcinogens
(nitrosamines)

• These products have been banned in some countries;

they are not regulated by the FDA.
SMOKELESS TOBACCO

• 2 forms of smokeless tobacco (SLT) are “chew,” a leafy

tobacco product sold in pouches, and “snuff,” a finely
ground tobacco product sold in tins or packets.

• Exposure to SLT increases the users risk for oral cancers of

the mouth, pharynx, larynx, and esophagus, as well as
gum disease and nicotine addiction.
TREATMENT

• approach to smoking cessation in adolescents includes

the 5 As (Ask, Advise, Assess, Assist, and Arrange) and use
of nicotine replacement therapy in addicted teens

• Nicotine patch studies to date in adolescents suggest a

positive effect on reducing withdrawal symptoms and
that pharmacotherapy should be combined with behav
ioral therapy

• Nicotine replacement therapy is also available as a gum,

inhaler, nasal spray, lozenge, or microtab
 Smoking Cessation Pharmacotherapy Available in the United States

FDA-
STUDIED IN
THERAPY APPROVED AVAILABILITY
NAME STRENGTHS ADOLESCENT QUIT DATE
BRAND ADULT *
S
DOSING

NICOTINE REPLACEMENT THERAPY

The 0.4-mg strength should be used by

patients who smoke 25 or more cigarettes a
day; otherwise the 2-mg strength should be
Gum‡ Nicorette 2 mg, 4mg used OTC* Yes
Wk 1-6: 1 piece every 1-2 hr Wk 7-9: 1
piece every 2-4 hr Wk 10-12: 1 piece every
4-8 hr

Nicotrol
Inhaler 4 mg 6-16 cartridges a day for up to 12 wks Rx No
Inhaler

The 4-mg strength should be used by

patients who smoke their first cigarette
Prior to
within 30 minutes of waking; otherwise, the
beginning
CommitTM, 2-mg strength should be used
Lozenge 2 mg, 4 mg OTC No nicotine
Nicorette mini Wk 1-6: 1 lozenge every 1-2 hr Wk 7-9: 1
replacement
lozenge every 2-4 hr Wk 10-12: 1 lozenge
therapy
every
4-8 hr
 Smoking Cessation Pharmacotherapy Available in the United States—
cont’d
STUDIED
AVAI
THERAPY STRENG FDA-APPROVED ADULT IN QUIT
NAME LABIL
BRAND THS DOSING ADOLESCE DATE
ITY*
NTS
1-2 sprays/hr up to a
Nasal 0.5
Nicotrol NS maximum of 80 sprays per Rx Yes
Spray mg/spray
day
For patients who smoke >10
cigarettes daily:
Step 1: one 21-mg patch daily
for wks 1-6
Step 2: one 14-mg patch daily
for wks 7-8
Transderm 7, 14, 21
NicoDerm CQ Step 3: one 7-mg patch daily OTC Yes
al Patch‡ mg/24 hr
for wks 9-10
For patients who smoke <10
cigarettes daily: begin with the
14-mg patch daily for
6 wks, followed by the 7-mg
patch for 2 wks
NONNICOTINE THERAPY
150-mg
150 mg by mouth in the
sustaine
Bupropion morning for 3 days, then 1 wk after starting
Zyban d Rx Yes
SR‡ increase to 150 mg by therapy
release
mouth twice daily
tablets
0.5 mg by mouth in the
morning for 3 days;
0.5-, 1-
increase to 0.5 mg by
Varenicline Chantix mg Rx No
mouth twice daily for 4
tablets
days, then increase to 1
mg by mouth twice daily
Marijuana
• “pot,” “weed,” “hash,” “grass”

• Derived from the Cannabis sativa hemp plant

• most commonly abused illicit drug

• tetrahydrocannabinol (THC): hallucinogenic properties

• absorbed rapidly by:

• nasal - peak effect of 10 minutes

• oral - peak subjective effect of 1 hour

• elation and euphoria

• impairment of short-term memory, poor performance of tasks requiring

divided attention (e.g., those involved in driving)

• Visual hallucinations and perceived body distortions occur rarely

• Smoking marijuana for a minimum of 4 days/wk for 6 mo = dose-related

suppression of plasma testosterone levels and spermatogenesis

• antiemetic effect of oral THC or smoked marijuana

• appetite stimulation, which is the basis of the drug’s use in patients

receiving cancer chemotherapy
Effects of Marijuana
Inhalants

• rapid action, easy availability, and low cost

• volatile solvents (paint thinners, glue), aerosols (spray

paint, hair spray), gases (propane tanks, lighter fluid), and
nitrites (“poppers” or “video head cleaner”

• glue, shoe polish, and spray paint - Most Common

Stages of effects
Hazards
Hallucinogens
LSD

• acid, big “d,” blotters

• lysergic acid found in ergot, a fungus that grows on rye

and other grain

• onset of action - between 30 and 60 min

• peaks between 2 and 4 hr

• 10-12 hr, returns to the predrug state

• 3 categories:

• somatic (physical effects) - dizziness, dilated pupils, nausea,

increase temp and tachycardia

• perceptual (altered changes in vision and hearing) - sensation

of synesthesia, or “seeing” smells and “hearing” colors, as well as
major distortions of time and self: high doses

• psychic effects (changes in sensorium) - Delusional ideation,

body distortion, and suspiciousness to the point of toxic psychosis
are the more serious symptoms

• LSD is not considered to be an addictive drug since it does not

typically produce drug-seeking behavior.
METHYLENEDIOXYMETHAMPHETAMINE

• MDMA- ‘x’; Ecstasy ; “E”

• interact with serotoninergic neurons in the central nervous

system (CNS)

• preferred drug at “raves,” all- night dance parties, and is

also known as one of the “club drugs”
• Euphoria, a heightened sensual awareness, and increased psychic
and emotional energy: acute effects - effect on neurons that use
serotonin as a neurotransmitter (mood, sexual activity, sleep and
sensitivity to pain)

• Somatic symptoms: Nausea, jaw clenching, teeth grinding, and

blurred vision

• Psychiatric outcomes: anxiety, panic attacks, and psychosis

• In high doses, MDMA can interfere with the body’s ability to

regulate temperature

• hyperthermia in association with vigorous dancing at a “rave” has

resulted in severe liver, kidney, and cardiovascular system failure
and death.
Phenycyclidine

• PCP: sternyl, angel dust, “hog,” “peace pill,” “sheets”

• causes cramps, diarrhea, and hematemesis

• a “dissociative drug” that produces feelings of detachment

from the surrounding environment and self
• 1-5 mg : Euphoria, nystagmus, ataxia, and emotional lability
occur within 2-3 min and last for 4-6 hr

• At these low doses the user is likely to experience shallow

breathing, flushing, generalized numbness of extremities, and
loss of motor coordination

• Hallucinations may involve bizarre distortions of body image

that often precipitate panic reactions

• 5-15 mg: toxic psychosis may occur, with disorientation, hyper-

salivation, and abusive language lasting for >1 hr

• 40-200 mg/dl Hypotension, generalized seizures, and cardiac

arrhythmias

• Death has been reported during psychotic delirium, from

hypertension, hypotension, hypothermia, seizures, and trauma
Cocaine
• an alkaloid extracted from the leaves of the South American
Erythroxylon coca, is supplied as the hydrochloride salt in
crystalline form

• “snorting” - rapidly absorbed into the bloodstream from the nasal

mucosa, detoxified by the liver, and excreted in the urine as
benzoylecgonine.

• Smoking the cocaine alkaloid (“freebasing”) involves inhaling

the cocaine vapors in pipes, or cigarettes mixed with tobacco or
marijuana
• strong central nervous system stimulant that increases dopamine
levels by preventing reuptake

• Produces euphoria, increased motor activity, decreased

fatigability, and mental alertness.

• pupillary dilatation, tachycardia, hypertension, and hyperthermia

• Snorting chronically= loss of sense of smell, nosebleeds, and

chronic rhinorrhea

• Injecting = increases risk for HIV infection

• Chronic abusers experience anxiety, irritability, and sometimes
paranoid psychosis

• Lethal effects are

• Lethal effects: in combination with other drugs, such as heroin,

injectable “speedball”

• when taken with alcohol, is metabolized by the liver to produce

cocaethylene, a substance that enhances the euphoria and is
associated with a greater risk of sudden death
Methamphetamine

• “ice,” accounted for >25% of stimulant use.

• nervous system stimulant

• white, odorless, bitter tasting powder that is particularly

popular among adolescents and young adults because
of its potency and ease of absorption

• orally, smoking, needle injection, or absorption across

mucous membranes
• rapidly increases the release and blocks the reuptake of
dopamine, a powerful “feel good” neurotransmitter

• Effects are dose related

• Small amounts: increased physical activity, rapid and/or

irregular heart rate, increased blood pressure and decreased
appetite

• High doses: slowing of cardiac conduction in the face of

ventricular irritability, Hypertensive and hyperpyrexic episodes
can occur as seizures

• Binge effects result in the development of psychotic ideation

with the potential for sudden violence.

• Cerebrovascular damage, psychosis, severe receding of the

gums with tooth decay, and infection with HIV and hepatitis B
and C can result from long-term use
Opiates

• Heroin - opium poppy

• injected (intra- venously or subcutaneously),

snorted/sniffed, or smoked

• Intravenous: immediate effect

• Subcutaneous: in minutes

• snorting: 30 minutes
• euphoria, diminution in pain, flushing of the skin, and pinpoint
pupils

• hypothalamus: lowering of body temperature

• most common dermatologic lesions are the “tracks,” the

hypertrophic linear scars that follow the course of large veins

• Smaller, discrete peripheral scars, resembling healed insect

bites

• injects heroin subcutaneously= fat necrosis, lipodystrophy, and

atrophy over portions of the extremities

• Loss of libido
T
h
a
n
k
Y
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u