MODERN MEDICINE CPD ARTICLE NUMBER THREE: 1 point

Pruritus ani: some answers for that maddening itch! JENNY MENZ, MB BS, FACD

Many cases of itch in the perianal region result from poor hygiene practices, but others may have underlying pathology which should be determined if possible. Patient education is mandatory.

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Pruritus ani is a distressing problem for those affected, and general practitioners need to be understanding and sympathetic to these patients as their problem is difficult to live with and difficult to discuss. Pruritus ani is a symptom rather than a diagnosis. Although many cases are due to a hygiene problem, a systematic history and examination are necessary to exclude other causes. H o w does it present?

Pruritus ani is itching without an easily identified cause that is localised to the anus or nearby perianal skin. It is seen most frequently in middle-aged, middleclass Caucasian men. In females, the condition can be associated with pruritus vulvae. People with pruritus ani complain of intermittent itching in the anal area, and there may be day and night variation. It is usually associated with scratching, and signs of excoriation may be present. What f a c t o r s c a u s e it? The perianal skin is richly supplied with sensory nerve endings that mediate a variety of sensations, interpreted as itch, that are caused by local irritation from Dr Menz practice 26

is a dermatologist in Unley, Australia

excoriation, alkaline secretions and chemical irritants. Table 1 lists some of the most common causes of this local irritation. Many dermatoses and carcinomas that are usually not itchy at other sites may be symptomatic in the perianal region because of the presence of faecal contamination and a broken skin barrier. Faecal contamination The common linking factor for most forms of pruritus ani is faecal contamination. Faeces contain endopeptidases of bacterial origin that are capable of inducing both itching and inflammation. One cause of faecal contamination of the perianal region is difficulty in cleansing the area. This may be due to factors such as: • simple obesity, with poor ventilation of the area and the resulting skin maceration also playing a role • increased frequency of defaecation — the more frequent the bowel actions, the more likely the development of perianal itching (patients with a colostomy do not suffer from perianal itching as there is no faecal soiling of the anal area) • anal hirsutism - can cause mechanical problems in the maintenance of hygiene. Anal leakage is another cause of in private faecal contamination, and can be

MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER/DECEMBER 2002

due to local problems such as haemorrhoids and fissures, or to sphincter dysfunction. Dermatoses Dermatoses such as atopic eczema, psoriasis, seborrhoeic dermatitis, lichen sclerosus et atrophicus and contact dermatitis may present as perianal pruritus. It is important to check for these problems. Infections Four important infections and infestations can cause itch in the perianal region. In adults particularly, fungal infection, usually tinea caused by Trichophyton rubrum, needs to be considered. Chronic Candida infection, particularly in people with diabetes, can also have a major aetiological role. In children particularly, threadworm infection (Enterobius) is suggested by the symptom of nighttime itching. Viral warts in all age groups are a major cause of perianal itch, especially if they are papillomatous. TABLE 1

C a u s e s of p e r i a n a l itch

• Faecal contamination • Local surgical problems • Improper hygiene {overor under-cleansing) • Dermatoses. Including contact dermatosis • Infections • Cancer • Psychological factors leading to hyperaernia and oversweating

A lack of physical findings can be as important as positive physical findings when examining a patient with pruritus ani.

PATIENT HANDOUT Advice for patients with perianal itch Diet

A high fibre diet witl change a loose stool Into a formed one and reduce perianal irritation. Reducing the consumption ot foods that decrease the time taken for food to pass through the body, such as hot and spicy foods, may be of help tor some patients.

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Hygiene Cleansing Cleansing after every bowel movement may have to be adopted as a lifelong strategy to prevent relapse. Both neglectful and obsessive hygiene are damaging. • Cleanse the perianal area after every bowel action, and not only when the area becomes itchy. • Cleanse with moist tissues or cotton wool. Use a bidet or handheld shower if possible. • Avoid harsh toilet paper. Coloured toilet paper may also need to be avoided. Baby wipes (for example, Wet Ones) are a good standby when away from home. • Dry the area by dabbing (not rubbing). Emphasis should be placed on avoiding friction Drying the area with a hair drier can be a good method. • Avoid liquid and bar soaps. Liquid soaps are just as irritating as bar soaps. If a cleanser is required, a non-irritant lotion is th6 best soap substitute. • Only apply to the area those preparations advised by your doctor. Ventilation Increasing the ventilation in the perianal area reduces the moistness that can lead to the skin becoming soft and more easily damaged. • Wear cotton underwear only. • Avoid light clothing and pantlhose. • Avoid sitting for long periods of time on vinyl seats. • Lose weight tt obese. Protective preparations If night itch is a problem, mild protective applications (such as liquid paraffin 20% in zinc paste) can be useful for night-time protection.

Carcinoma and malignancy Extramammary Paget's disease (intra-epithelial adenocarcinoma), Bowen's disease (in situ squamous cell carcinoma) and the precancerous bowenoid papulosis need to be considered. Psychological factors Stress and anxiety are two psychological factors that will contribute to pruritus ani by aggravating hyperaemia and sweating in this area. Both these factors will also promote irritability and lower the threshold of itching, and therefore scratching - which is deleterious to this condition.

Questions to ask History-taking is important in the investigation of perianal pruritus as often there are few physical findings. Patients are usually reticent to discuss this sensitive topic and may need encouragement. Important factors can be determined by asking the questions listed below. • How long has the itch been present? It is surprising how often a patient will have put up with this problem for five to ten years before seeking help. • Is there a day-night variation in itching? The itch of threadworm infection is always worse at night.

• What preparations have been applied to the area, both prescribed and self-administered? This is looking for potential causes of contact dermatitis. • What are their bowel habits like? Enquire particularly about frequency and looseness of stool and thefibre content of their diet. • How do they cleanse the area after opening their bowels? This will give information about perianal hygiene, and the use of sensitising or abrading materials. • Is there any past history of skin diseases? • Are there any other relevant medical problems, such as diabetes or Crohn's disease? Signs t o l o o k for A lack of physical findings can be as important as positive physical findings when examining a patient with pruritus ani - a bit like a detective investigating a crime. A thorough examination of the perianal area with good lighting should be done after all skin ointments have been removed. (Using a gentle cleanser on a tissue is a simple but effective technique for removing these ointments.) • Look for poor perianal hygiene and factors that would complicate hygiene, such as excess hirsutism. Soiled underwear could indicate a problem of anal incontinence or seepage. • Check the perianal area for haemorrhoids, fissures, mucosal prolapse or scars. • Look for dermatoses and infections. Inspection of the skin elsewhere is necessary to look for other signs of psoriasis (elbows, knees and scalp), eczema (flexures), seborrhoeic dermatitis (face and scalp) and tinea (feet and groin). • Look for tumours, checking for enlarged groin lymph nodes and abdominal masses. Dermatoses While skin diseases in the perianal area may present

NOVEMBER/DECEMBER 2002 / MODERN MEDICINE OF SOUTH AFRICA

27

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Pruritus ani

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Contact dermatitis in the perianal area is U y dramatic in its presentation, causing I oedema, erythema and weeping.

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nonspecifically with just erythema and scaling, specific signs can be found in some conditions. These are listed in Table 2.

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Atopic eczema There may be lichenification in the perianal area in cases of atopic eczema, and vulval or scrotal skin is often affected simultaneously. Check the flexural areas for evidence of the usual excoriation associated with atopic eczema. Psoriasis Psoriasis is usually moist and without scale in the perianal area (Figure 1). A clue to its diagnosis and perineal is its sharp demarcation from surwell demarcat-

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Figure 1. Perianal psoriasis, showing ed erythema and absence scale.

Figure 2. Look asis elsewhere. edge.

for flexural Note the

of

psoriabrupt

rounding skin and its extension up the natal cleft. It shows a definite trend to flare up with local humidity and friction. The perianal region is a common presenting area for psoriasis. Perianal psoriasis has a similar clinical presentation to flexural psoriasis, with a well demarcated, nonscaling erythema (Figure 2). Look at the elbows, knees and scalp for areas Figure 3. Inspect the knees offoradherent silvery scale for other classic silvery-scaled plaques of indications of psoriasis {Figure 3). psoriasis. Inspection of the nails for pitting is also useful for diagnosis. 30

MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER/DECEMBER 2002

TABLE 2

Dermatoses associated with perianal itch * Atopic eczema - check flexures • Psoriasis - check elbows, knees, scalp * Seborrhoeic dermatitis - check lace and scalp • Lichen sclerosus ef atrophicus check vutva * Contact dermatitis - ask about medicaments

Seborrhoeic dermatitis Seborrhoeic dermatitis rarely involves only the perianal area: the flexures (in particular under the breasts and in the axillae) and the scalp and face are usually also involved (Figure 4). It presents as a yellow scale adherent to a red base. The perianal itch associated with seborrhoeic dermatitis is not as pronounced as the itches associated with psoriasis and eczema. Lichen sclerosus et atrophicus Lichen sclerosus et atrophicus is a rare condition which shows up as atrophic white areas surrounding the anus (Figures 5 and 6) and, generally, the vulva. It is usually extremely itchy. Consider this condition if patchy depigmentation is present in the perianal area. Contact dermatitis Contact dermatitis in the perianal area is usually dramatic in its presentation, causing oedema, erythema and weeping (Figure7). It is often very itchy and a history of application of medicaments can usually be found. The type of preparation that is involved most commonly is one of the haemorrhoid creams or ointments that contains local anaesthetic; the anaesthetic component in these is a potent sensitiser. Other causes include tea-tree oil, antibiotics such as neomycin, and lanolin.

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Skin cancer in the perianal area is a rare but important cause of itch that needs to be excluded.

Figure 4. The scalp in seborrhoeic dermatitis has yellow, adherent scale.

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Figure 7. Acute contact dermatitis of the groin area resulting application of a haemorrhoid cream that contained local anaesthe Note the severity of the reaction. The local anaesthetic compone these creams is a potent sensitiser.

Figure 5. Lichen sclerosus et alrophicus of the perianal and vulval area showing depigmentation and atrophy.

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Infections

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Candida Candida infections can be a primary or a secondary cause of perianal itch. The damp and slightly Figure 6. Close-up view of the irritated skin in the perianal area patchy depigmentation of lichen provides good conditions for sclerosus et atrophicus. growth of Candida. Once the infection invades the stratum corneum

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it activates complement and is a potent cause of itch that induces scratching and produces more damage. Candida often secondarily infects other dermatoses, particularly psoriasis, thereby aggravating the primary condition. It is necessary to exclude concurrent diabetes in patients presenting with perianal candidiasis. Perianal candidiasis presents as a glazed erythema with peripheral red dots and pustules. It usually extends to the anal margin, and can be painful as well as itchy. Tinea Tinea often spreads to the perianal area from the groin or toes (Figures 8 and 9). The distinctive feature is a perianal rash with a well demarcated edge that is clearing from around the anus. Patients may treat themselves for tinea with some previously prescribed corticosteroid cream before consulting their general practitioner. This situation leads to a rapid spreading of the tinea with associated follicular pustules, often raising the differential diagnosis of bacterial infection. Tinea

NOVEMBER/DECEMBER 2002 / MODERN MEDICINE OF SOUTH AFRICA

31

Pruritus a n i

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continued

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Stress can heighten the perception of will confirm a n c [ m a n y patients that their pruritus ani is aggravated by stressful situations.

Figure 9, The source of perianal Figure 8. Tinea that has spread the feet Scaling eryfrom the perianal area after tinea appli-is often thema is evident on the margins of cation of a corticosteroid cream. Figure 10. Extensive Note the follicular pustules. the sole. perianal warts.

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in the perianal area is usually due to Trichophyton rubrum. Viral warts Viral warts cause itching, particularly when they are multiple and frond-like (Figure 10). The more exuberant the growth, the itchier they are likely to be. Threadworm, Threadworm (Enterobius) infestation presents with night-time itch in both children and adults. There is little to see apart from multiple excoriations, but the worms are

visible under a magnifying glass. The optimum time for seeing them is after nightfall so an appointment at late evening surgery is best. Carcinomas Skin cancer in the perianal area is a rare but important cause of itch that needs to be excluded. With the advent of HIV infection, squamous cell carcinoma and Bowen's disease in the perianal area have become more common. Clues to the diagnosis are a nonhealing painless ulcer in the perianal area

for squamous cell carcinoma, and a fixed plaque of scaling erythema that does not vary in outline from week to week for Bowen's disease (Figures 11 and 12). Extramammary Paget's disease presents as pruritus ani in 73% of cases (Figure 13). This tumour, which represents adenocarcinoma confined to the epidermis, usually spreads from an underlying adenocarcinoma within the anal or rectal area. It presents as a slowly-expanding well-demarcated plaque. Diagnostic features are seen on

Figure 12. Bowen's disease Figure (In 13. Extramammary extending from situ squamous cell carcinoma) disease neal to perianal area. presents as a fixed plaque of Figure f 1. Squamous cell carcinoscaling erythema. ma in the perianal area. This first presented as a nonhealing painless ulcer,

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MODERN MEDICINE OF SOUTH AFRICA / NOVEMBER/DECEMBER 2002

exuberant

the

Paget's peri-

I

The first rule of treatment of perianal itch is to treat all pathology first.

TABLE 3.

Treatment guidelines for perianal itch Diet and hygiene • Give advice on diet and perianal hygiene. Surgical problems • Rectify haemorrhoids, fissures, tags and scars. • Topical anorectal preparations may be tried but they can cause contact dermatitis if they contain local anaesthetics.

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Carcinomas • Remove tumours.

• Perianal warts can be treated by topical podophyllum, imiquimod cream or cryotherapy. • Threadworm infestations can be treated with a suitable antihelminthic — for example, mebendazole. The whole family should be treated. Suppression of Itch Suppression of itch is important in patients who show little on examination of the area but who complain ot severe itch. • A counterirritant cream, such as menthol 1% in aqueous cream, applied when the itch is present, is useful. • Night-time doxepin at a dose of 10 to 25mg is useful in the control of nocturnal pruritus ani • Crude coal lar 1 % In zinc cream also acts as a nonspecific antipruritic agent • The nonsedating antihistamines loratadine and fexofenadine can control daytime itch.

Concurrent dermatoses and Infections • Eczema seborrhoeic dermatitis and psoriasis are best Ireated with a weak corticosteroid ointment. Hydrocortisone 1 % ointment applied three limes a day is a good start. The occlusive nature of the ointment base makes it adhere better in this area and hence it is more effective than Ihe cream. Fluorinated corticosteroids should be avoided due to the potential for atro- Things to Ihink about • Advise patients on how to help control their pruritus ani. phy in this thin-skinned area. • Candida infection can be treated with a topical imid- • Explain the itch-scratch cycle to patients and tell them that the itch threshold can be lowered by stress. azole such as clotrimazole or miconazole; This often • Discuss suitable stress management techniques with needs to be combined in equal paits with a hydrocortipatients if stress is a significant part of the aetiology. sone cream to reduce the inflammatory component of Ihe cutaneous thrush. • Perianal tinea often requires oral griseofulvin for treatment. Trichophyton rubnjm is quite resistant to topical therapy.

punch biopsy and allow an early diagnosis. Things to think about Psychological factors are often involved and a clue to this can be the itch that appears to be out of proportion to the clinical findings. Stress can heighten the perception of itch and many patients will confirm that their pruritus ani is aggravated by stressful situations. Consideration of the itch-scratch cycle is also important: scratching will aggravate itch and vice versa, reinforcing the cycle. This cycle will need to be broken before healing will occur. I n v e s t i g a t i o n s required To confirm a diagnosis, various investigations will be needed in addition to the complete and accurate history.

• If there is any suspicion of anal incontinence, a digital examination noting sphincter tone is indicated. • Suspected sphincter dysfunction is best referred to a surgeon for investigation. • Patients with contact dermatitis should be patch-tested to investigate the cause of their sensitivity. • If thrush is suspected, swabs for Candida should be taken. • If tinea is suspected, fungal scrapings should be taken from the advancing edge of the rash. • If threadworm infestation is suspected, 'adhesive tape' swabs taken nocturn ally are indicated. This is best done by attaching adhesive tape, sticky side out, to the end of a wooden tongue depressor, and placing this on the perianal skin several hours after retiring orfirst thing in the morning. The tape can then be

applied direct to a microscope slide for examination for thread worm. • If there is any suspicion of cancer (ulceration, induration or tumour formation), a punch biopsy should be performed under local anaesthetic. If there is a clinical suspicion of a tumour, a rectal examination and sigmoidoscopy are indicated. Treatment The first rule of treatment of perianal itch is to treat all pathology first. With the removal of underlying pathology, the itch often subsides spontaneously. Any surgically correctable problems such as haemorrhoids, fissures and tags should be rectified, and tumours should be removed. Infections should be treated (see Table 3). All patients with dermatoses

NOVEMBER/DECEMBER 2002 / MODERN MEDICINE OF SOUTH AFRICA

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should be advised about good perianal hygiene procedures because hygiene and faecal contamination can play a large role in the aetiology of perianal itch. Patients should be encouraged to follow the guidelines outlined in the patient handout on page 27. If thorough evaluation fails to reveal underlying pathology or surgically correctable problems, then a conservative trial of improved perianal hygiene, increased ventilation (cotton underwear, loose clothing, avoiding lengthy periods sitting on vinyl seats and losing weight if obese), and bland protective applications (such as liquid paraffin 20% in zinc paste which protects the skin from moistness in the area) is indicated. The general practitioner plays an important role in providing ongoing support to this patient group as well as investigating psychological factors. Conclusion

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IN S U M M A R Y

• Pruritus ani is a common condition and is more frequent in men than women. • Pruritus ani Is a symptom rather than a diagnosis. Simultaneously looking at today and the future, • Faecal contamination is a predisposing factor. IHS SOUTH AFRICA, the publisher of this journal, Local hygiene problems frequently contribute to has established these websites to complement its faecal contamination, and surgical problems such existing range of print media and electronic products. as haemorrhoids, fissures, mucosal prolapse or To discover more about IHS SOUTH AFRICA, visit our scars may be causes of ana) leakage, website at fflffllTCflfflfffc — or tor Into on the IHS OROUP • Dermatoses, infections or cancers are other possiIntomattonaRy, cheek out dffWWTCfflfffffitSfflfc ble underlying causes. In addition. Group subsidiary, National Publishing'* stable • With removal of underlying pathology, the Itch often of journals may be visited at 4UJJ1UI.I.U.1II J J . i m resolves • Patients are often reticent in discussing the condition and the general practitioner has an important IHS SOUTH AFRICA role to play In supporting the patient. AN COMPANY

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MODERN MEDICINE'S CPD Journal Programme for general practitioners has been designed to offer readers a choice. Discrete CPD units provide you with the opportunity of selecting the subjects that interest you or that most relate to your typo of practice. You can complete as many or as few of the units as you wish and earn CPD points every month. The programme has been compiled with the assistance of authors, referees, general practitioner reviewers, the Australian Board of Continuing Education and the University of Sydney Department of General Practice, and lias been endorsed by the South African Medical Association's Health Care/Policy and CPD Unit.

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Q U E S T I O N S FOR CPD ARTICLE NUMBER T H R E E CPD: 1 point Part 3. Regarding the investigation of pruritus ani: a. A digital examination is useful in assessing anal itch if anal incontinence is suspected. b. Patch testing may be useful in assessing anal itch. c. Candida infections in the perianal area can be diagInstructions nosed by taking a swab. 1. Before you fill out the computer answer form, mark d. Perianal tinea is diagnosed by fungal scrapings. your answers in the box on this page. This e.provides Suspected perianal tumours are investigated by a you with your own record. punch biopsy under local anaesthetic. 2 The answer form is perforated and bound Part into 4. this The following are true of the treatment of journal. Tear it out carefully. pruritus ani:

Pruritis ani: some answers

All patients with dermatoses in the perianal region forma. and folshould be advised about good perianal hygiene. b. Liquid paraffin 20% in zinc paste is useful in treating 4. Your answers for the November/December Issue perianal itch. must reach MODERN MEDICINE, PO Box 2271, c. A high fibre diet increases perianal irritation. Clareinch 7740, by Mi n h • I d. Reducing consumption of hot and spicy foods may be of help for some patients. 5. You must score at least 60% In order to be awarde. Patients may be advised to cleanse the perianal area ed Ihe assigned CPD points. with moist tissue.

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3 Read the instructions low them carefully.

Answer true questions.

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to parts

(a)

to (e)

Part 1. The following statements are true of the aetiology of pruritus: a. Pruritus ani is more common in women than men. b. Faecal contamination is an aetiological factor in most forms of pruritus ani. c. Obesity may be a factor in pruritus ani. d. Increased frequency of defaecation may cause itching in the perianal region. e. Viral warts do not cause pruritus ani. Part 2. Concerning the clinical features of pruritus ani, the following statements are true: a. The itch of threadworm infection is always worse at night. b. Psoriasis causes a scaling rash in the perianal area. c. Seborrhoeic dermatitis is often limited to the perianal area. d. Seborrhoeic dermatitis in the perianal area produces more itch than psoriasis. e. Perianal candidiasis often presents as a glassy erythema.

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NOVEMBER/DECEMBER 2002 / MODERN MEDICINE OF SOUTH AFRICA

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Qim

Chronic Obstructive Pulmonary Disease (COPD)

^lllr Ingelheim

Chronic Obstructive Pulmonary Disease (COPD) is a chronic respiratory disorder characterised by chronic airflow limitation, shortness of breath (dyspnoea), cough, wheezing and increased sputum production. 1 Approximately 6 0 0 million people worldwide currently suffer from COPD. 2 It is the fastest growing cause of death in the world's advanced economies and is predicted soon to become the fourth leading cause of death in developed regions. 3 COPD also carries a significant burden in terms of productivity losses due to incapacity. 4

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Patient morbidity is most commonly characterised by shortness of breath on physical exertion which can restrict a patient's ability to perform normal daily activities and cause a decrease in health-related quality of life (HRQoL).1 The airway limitation associated with COPD has often been misunderstood as being irreversible. However, established guidelines now clearly state that this airway limitation is in fact partially reversible.1 Patients with COPD periodically experience exacerbations which are defined as

341690

an increase in, or new onset of, more than one lower respiratory symptom such as cough, wheezing or dyspnoea.1 Exacerbations usually require either a call or visit to the clinician or an emergency room visit, as well as a change in medication, making exacerbations an expensive part of COPD care.1 COPD is a progressive disease that encompasses both chronic bronchitis and emphysema.15 It is often misdiagnosed as asthma or goes undiagnosed in its mild and

moderate stages.1 As a disease that generally strikes after the age of 40, symptoms are often first attributed to aging, and patients therefore often do not present until symptoms are severe.6 It has been estimated that up to 75% of Europeans with COPD are undiagnosed.7 Diagnosis of COPD is based on an assessment of risk factors (eg smoking, exposure to pollutants) and symptoms and is then confirmed with spirometry (lung function testing).' To aid diagnosis, it is often subdivided into stages depending on the severity of

the disease characterised by lung function (FEV,) as well as clinical signs and symptoms.1

Causes of COPD Cigarette smoking is the predominant risk factor for COPD, accounting for 80-90% of the risk for developing the disease,8 yet only about 15% of all smokers develop COPD severely enough to cause symptoms.9 On a population basis, rising rates of smoking have dramatically increased the levels of illness and death associated with COPD.8 Smoking is, however, not the only risk. Populations exposed to indoor pollution resulting from the use of wood and coal-buming stoves and heaters have a greatly increased risk as well. Occupational exposure to a variety of airborne dusts and air pollution also increases theriskof COPD.1

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Furthermore, heredity is a risk factor for COPD. At present the only clearly identified genetic disorder that may cause COPD is alpha 1-antitrypsin (AAT) deficiency. AAT is an enzyme

that normally prevents loss of the lungs' elasticfibres. People with AAT deficiency generally develop airflow obstruction in their early 40s.1

• to prevent and treat complications; • to prevent and treat exacerbations; and • to reduce mortality.

Although most studies have reported a higher prevalence of COPD in men, it is now believed that with an equivalent amount of smoking, women have at least the same risk of developing COPD.1 There are insufficient data to quantify any racial differences in susceptibility to COPD, although differences in frequency have been observed among different regions and ethnic groups.1013

A key step in COPD treatment is to eliminate or reduce further pulmonary irritation. The two most common irritants that contribute to the progression of COPD are smoking and environmental pollutants. Exposure to these risk factors should be reduced or eliminated.1 Only smoking cessation (and in some advanced cases of COPD, oxygen therapy) has been shown to reduce mortality. Smokers who quit can slow the rate of the decline of lung function, but lost lung function can never be regained.1415

Management of COPD Clinical practice guidelines for the management of COPD are available in many countries and a new international consensus guideline has been developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). It states that treatment goals for COPD1 are: • to prevent disease progression; • to relieve symptoms; • to improve exercise tolerance and health status;

A NEW WORLD OF

Following the avoidance of known risk factors, established pharmaceutical treatments are available to help treat COPD and manage some of the common symptoms.1 References available from Tanya Elston at (011) 320 6151 or email [email protected]

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