Decrease in appetite causes

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causes of decreased appetite anorexia medical

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Causes of Decreased Appetite (Anorexia)

The medical term for a prolonged loss of appetite is anorexia (distinct from the eating disorder anorexia nervosa). It is one of the most common symptoms in medicine and can reflect pathology across virtually every organ system.

1. Malignant Neoplasms

Cancer is one of the leading causes of unexplained appetite loss, accounting for about 25% of unintentional weight loss cases. Tumor-derived cytokines (TNF-alpha, IL-1, IL-6) suppress appetite centrally. Common culprits include:

GI cancers (stomach, pancreas, colorectal, liver)
Lung cancer
Lymphoma and leukemia
Renal cell carcinoma

2. Chronic Inflammatory and Infectious Diseases

Infections: Tuberculosis, HIV/AIDS, subacute bacterial endocarditis, fungal diseases, parasitic infections, hepatitis
Inflammatory disorders: Rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease (Crohn's, ulcerative colitis)
Organ failure: Chronic kidney disease (uremia directly suppresses appetite; leptin, TNF-alpha, and IL-6 are elevated in dialysis patients), chronic liver disease (cirrhosis), chronic heart failure, COPD

(Harrison's Principles of Internal Medicine 22E, p. 358)

3. Metabolic and Endocrine Disorders

Hyperthyroidism - paradoxically increases appetite in some but can cause anorexia in elderly ("apathetic thyrotoxicosis")
Hypothyroidism
Adrenal insufficiency (Addison's disease)
Diabetes mellitus (especially poorly controlled or late-stage)
Hypercalcemia (any cause)
Hyponatremia
Metabolic acidosis (e.g., in CKD - directly suppresses appetite)

4. Psychiatric and Psychological Causes

Depression - one of the most common causes; appetite loss is a core DSM criterion ("SIG: E CAPS" - A = Appetite/weight disturbance)
Anxiety disorders and panic attacks
Anorexia nervosa / bulimia nervosa
Grief and bereavement
Stress
Schizophrenia and other psychotic disorders

(Goldman-Cecil Medicine; Kaplan & Sadock's Comprehensive Textbook of Psychiatry)

5. Gastrointestinal Causes

Gastroparesis (delayed gastric emptying - causes early satiety and nausea)
Peptic ulcer disease / gastritis
Intestinal obstruction
Chronic pancreatitis (pain with eating leads to food aversion)
Celiac disease / malabsorption
Constipation
Acid reflux (GERD)

(Yamada's Textbook of Gastroenterology; Schwartz's Principles of Surgery)

6. Medications and Substances

Common drug causes:

Chemotherapy and radiation therapy (especially to the abdomen)
Opioids (appetite suppression via mu-receptor)
Stimulants - amphetamines, cocaine, ADHD medications (methylphenidate, amphetamine salts)
Antibiotics (especially metronidazole, macrolides)
Digoxin toxicity
SSRIs / antidepressants (early treatment phase)
Immunotherapy
Alcohol (poor appetite, malabsorption)
Cannabis withdrawal (paradoxically - intoxication usually stimulates appetite)

(Harrison's, p. 358; Yamada's Gastroenterology)

7. Neurological Causes

Dementia (Alzheimer's, vascular dementia)
Parkinson's disease (dysphagia, delayed gastric emptying, depression)
Stroke
Brain tumors (hypothalamic involvement)
Delirium

8. Physiological / Age-Related ("Anorexia of Aging")

In older adults (15-30% affected), multiple overlapping factors reduce appetite:

Reduced chemosensory function (smell and taste decline)
Slowed gastric emptying
Altered neuroendocrine regulation: increased cholecystokinin (enhanced satiety), decreased ghrelin (less hunger drive), altered leptin and neuropeptide Y
Reduced lean body mass and physical activity lowering caloric demand
Social isolation, poverty, immobility, institutional food monotony

(Harrison's Principles of Internal Medicine 22E, p. 358)

9. Acute and Short-Term Causes

Viral/bacterial infections (flu, common cold, gastroenteritis)
Food poisoning
Postoperative state (anesthesia effect)
Pregnancy (especially first trimester - morning sickness and hormonal changes)
Acute pain

Summary Table

Category	Key Examples
Malignancy	GI cancers, lung, lymphoma
Infection/Inflammation	TB, HIV, endocarditis, IBD, CKD
Metabolic/Endocrine	Hyperthyroidism, adrenal insufficiency, hypercalcemia
Psychiatric	Depression, anxiety, anorexia nervosa
GI disorders	Gastroparesis, peptic ulcer, pancreatitis
Medications	Chemo, opioids, stimulants, antibiotics
Neurological	Dementia, Parkinson's, stroke
Aging	Sensory decline, hormonal changes, social isolation
Acute	Infections, pregnancy, postoperative

Clinical note: When appetite loss persists more than a few weeks, especially with unintentional weight loss (>5% body weight over 6-12 months), thorough investigation is warranted. Up to 25% of cases remain idiopathic despite workup, and those typically carry a better prognosis than identified organic causes.

Sources: Harrison's Principles of Internal Medicine 22E (2025); Goldman-Cecil Medicine; Yamada's Textbook of Gastroenterology; Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Brenner and Rector's The Kidney

Redness in private area causes

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Causes of Redness in the Private (Genital) Area

Genital redness (erythema) can affect the vulva, vagina, penis, scrotum, and surrounding perineal skin. It applies to both males and females, though specific causes differ. The causes fall into several broad categories:

1. Infections (Most Common)

Fungal

Vulvovaginal candidiasis (Yeast infection) - Candida albicans is the most common cause in females. Signs include vulvar erythema, edema, fissures, tenderness, and white "cottage cheese" discharge. Predisposed by antibiotics, diabetes, immunosuppression, pregnancy.
Candidal balanitis (in males) - redness, itching, and white patches on the glans penis.
Tinea cruris ("jock itch") - Dermatophyte fungal infection of the groin; red, ring-shaped, itchy rash.

Bacterial

Bacterial vaginosis (BV) - caused by Gardnerella vaginalis and anaerobes; malodorous discharge, mild vulvar irritation.
Gonorrhea (Neisseria gonorrhoeae) - urethritis, cervicitis, causing redness and discharge.
Chlamydia (Chlamydia trachomatis) - cervicitis/urethritis with redness and discharge; often asymptomatic.
Syphilis - primary stage: a painless chancre (ulcer with red base) on genitals; secondary stage: rash including on genitals.
Streptococcal/staphylococcal infections - cellulitis, folliculitis, abscess.
Erythrasma - Corynebacterium minutissimum causing reddish-brown patches in groin folds.

Viral

Genital herpes (HSV-1/HSV-2) - painful blisters/ulcers with surrounding erythema; can mimic candidal fissures. One of the most common causes of genital ulceration and redness.
Human papillomavirus (HPV) - genital warts (condyloma acuminata); cauliflower-like growths, sometimes with surrounding redness.
Molluscum contagiosum - pearly papules with surrounding redness.

Parasitic

Trichomoniasis (Trichomonas vaginalis) - profuse frothy discharge, vulvar itching and redness, "strawberry cervix."
Pubic lice (Pediculosis pubis / "crabs") - intense itching and redness from bites.
Scabies - Sarcoptes scabiei; intensely itchy, red burrows and papules in the genital and groin area.

(Harrison's Principles of Internal Medicine 22E; Symptom to Diagnosis, 4th Ed.)

2. Skin Conditions (Dermatological)

Contact/irritant dermatitis - very common; triggered by soaps, detergents, latex condoms, lubricants, scented products, sanitary pads, douches. Causes redness, burning, itching.
Lichen sclerosus - chronic inflammatory condition; white, thin, atrophic patches with surrounding erythema; affects the vulva or glans penis; associated with risk of squamous cell carcinoma.
Lichen planus - erosive form causes painful vulvovaginal or penile redness, ulceration, white lace-like lesions.
Lichen simplex chronicus (LSC) - thickened, red, itchy skin from chronic scratching.
Psoriasis - well-demarcated red plaques; in the genital area, it often lacks the typical silvery scale.
Eczema (Atopic dermatitis) - red, dry, itchy inflamed skin; may involve the genital region.
Seborrheic dermatitis - red, greasy, scaly patches in skin folds.

(Dermatology 2-Volume Set 5e; Harvard Health)

3. Sexually Transmitted Infections (STIs) - Summary

STI	Key Sign of Redness
Herpes (HSV)	Painful ulcers/blisters with red base
Syphilis	Painless red-based chancre (primary); rash (secondary)
Gonorrhea/Chlamydia	Urethral/cervical redness, discharge
Trichomoniasis	Vulvar/vaginal redness, frothy discharge
HPV	Warts with surrounding redness

4. Hormonal / Atrophic Causes

Atrophic vaginitis (Genitourinary syndrome of menopause) - estrogen deficiency post-menopause causes vaginal and vulvar erythema, dryness, thinning, dyspareunia, and recurrent infections.
Post-partum estrogen deficiency - similar thinning and redness in breastfeeding mothers.

5. Inflammatory / Autoimmune Conditions

Behcet's disease - painful genital ulcers with erythematous margins; recurrent oral and genital ulceration.
Crohn's disease - can cause perianal/vulvar abscesses, fistulas, and erythema as an extraintestinal manifestation.
Erythema multiforme / Stevens-Johnson syndrome - drug or infection-triggered blistering reaction; can affect genital mucosa.
Plasma cell balanitis (Zoon's balanitis) - chronic benign red patches on the glans penis in older uncircumcised men.

6. Mechanical / Physical Causes

Friction and chafing - tight clothing, exercise, obesity-related skin folds.
Shaving/hair removal - razor burn, folliculitis, ingrown hairs.
Sexual activity - friction-related redness, especially with inadequate lubrication.
Foreign body - especially in children.

7. Other / Serious Causes

Fournier's gangrene - rare, life-threatening necrotizing fasciitis of the perineum; starts with redness, pain, and swelling that rapidly progresses. Medical emergency.
Extramammary Paget's disease - rare; red, eczema-like plaques on the vulva or penis; may represent underlying malignancy.
Vulvar/penile intraepithelial neoplasia (VIN/PIN) or early carcinoma - persistent red or white patches that do not resolve.
Fixed drug eruption - localized red/brown patch that recurs at the same site with a specific drug (e.g., NSAIDs, tetracyclines, trimethoprim).

When to See a Doctor

Seek prompt medical evaluation if redness is:

Accompanied by fever, severe pain, or rapidly spreading (rule out necrotizing infection)
Associated with painful sores or ulcers (rule out herpes, syphilis)
Persistent beyond 1-2 weeks without an obvious cause
Accompanied by unusual discharge (rule out STI/vaginitis)
In a child (requires careful evaluation)

Note: Self-diagnosis is frequently incorrect, particularly for yeast infections vs. other causes. A clinical examination with appropriate swab testing is the only reliable way to identify the specific cause.

Sources: Harrison's Principles of Internal Medicine 22E (2025); Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed.; Berek & Novak's Gynecology; Dermatology 2-Volume Set, 5th Ed.

Create a comprehensive diagnostic flowchart for genital redness causes

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<div class="header">
  <h1>🔴 Diagnostic Flowchart: Genital Area Redness (Erythema)</h1>
  <p>A systematic clinical decision-tree for evaluating genital erythema in adults</p>
  <span class="disclaimer">⚠️ For educational use only. Clinical examination and laboratory testing required for diagnosis.</span>
</div>

<button class="print-btn no-print" onclick="window.print()">🖨️ Print / Save as PDF</button>

<!-- Legend -->
<div class="legend no-print">
  <div class="legend-item"><div class="legend-box" style="background:#e74c3c"></div> Emergency</div>
  <div class="legend-item"><div class="legend-box" style="background:#2980b9"></div> Decision Point</div>
  <div class="legend-item"><div class="legend-box" style="background:#e67e22"></div> Infection (non-STI)</div>
  <div class="legend-item"><div class="legend-box" style="background:#8e44ad"></div> STI</div>
  <div class="legend-item"><div class="legend-box" style="background:#16a085"></div> Skin/Dermatological</div>
  <div class="legend-item"><div class="legend-box" style="background:#27ae60"></div> Contact/Irritant</div>
  <div class="legend-item"><div class="legend-box" style="background:#d35400"></div> Hormonal/Atrophic</div>
  <div class="legend-item"><div class="legend-box" style="background:#7f8c8d"></div> Other</div>
  <div class="legend-item"><div class="legend-box" style="background:#f1c40f"></div> Workup</div>
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<!-- ── TIER 0: Entry ── -->
<div style="display:flex;justify-content:center;margin-bottom:0;">
  <div class="node n-start" id="n0">
    🔴 Genital Area Redness
    <div class="node-sub">(Erythema / Rash / Irritation)</div>
  </div>
</div>

<!-- arrow down -->
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<!-- ── TIER 1: EMERGENCY CHECK ── -->
<div class="section-heading">Step 1 — Rule Out Emergency</div>
<div class="row">
  <div class="node n-decision" id="n1" style="min-width:300px;max-width:360px;">
    <div class="node-title">⚠️ RED FLAG Signs Present?</div>
    <div class="node-sub">Rapidly spreading redness · Severe pain · Crepitus · Fever &gt;38.5°C · Skin necrosis · Sepsis signs</div>
    <div class="tooltip">Fournier's gangrene can be rapidly fatal. Any crepitus (crackling sensation), rapidly expanding redness, or hemodynamic instability = IMMEDIATE surgical referral.</div>
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  <div style="font-size:0.78rem;font-weight:700;color:#e74c3c;">YES ↙</div>
  <div style="font-size:0.78rem;font-weight:700;color:#27ae60;">NO ↘</div>
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  <div class="node n-emergency">
    <div class="node-title">🚨 EMERGENCY</div>
    <div class="node-sub">Fournier's Gangrene<br>Necrotizing Fasciitis</div>
    <div class="tooltip">Necrotizing fasciitis of the perineum. Polymicrobial. Mortality 20-40%. Requires IV antibiotics + urgent surgical debridement. CT imaging confirms gas in tissues.</div>
  </div>
  <div class="node n-decision" id="n2" style="min-width:200px;">
    <div class="node-title">Continue assessment ↓</div>
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<div class="section-heading">Step 2 — Key History</div>
<div class="row" style="gap:20px;align-items:flex-start;">
  <div class="node n-workup" style="min-width:160px;">
    <div class="node-title">🕐 Duration</div>
    <div class="node-sub">Acute (&lt;1 wk)<br>vs Chronic (&gt;4 wk)</div>
  </div>
  <div class="node n-workup" style="min-width:160px;">
    <div class="node-title">⚥ Sex / Gender</div>
    <div class="node-sub">Female (vulva/vagina)<br>Male (glans/prepuce)</div>
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    <div class="node-title">💊 Recent Triggers</div>
    <div class="node-sub">New soap/product<br>Antibiotics<br>Sexual activity</div>
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  <div class="node n-workup" style="min-width:160px;">
    <div class="node-title">🔬 Associated Sx</div>
    <div class="node-sub">Discharge · Ulcers<br>Itch · Pain<br>Dysuria</div>
  </div>
  <div class="node n-workup" style="min-width:160px;">
    <div class="node-title">📋 PMH</div>
    <div class="node-sub">Diabetes · HIV<br>Menopause<br>Skin disease hx</div>
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<!-- ── TIER 3: MAIN BRANCH ── -->
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    <div style="font-size:0.75rem;color:#27ae60;">YES ↓</div>
    <div class="node n-decision" style="min-width:155px;">
      <div class="node-title">Discharge type?</div>
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    <div style="font-size:0.75rem;color:#555;">↓ see Branch A detail</div>
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  <!-- Branch B -->
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    <div style="font-size:0.75rem;color:#27ae60;">YES ↓</div>
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    <div style="font-size:0.75rem;color:#555;">↓ see Branch B detail</div>
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  <!-- Branch C -->
  <div style="display:flex;flex-direction:column;align-items:center;gap:10px;">
    <div class="node n-decision" style="min-width:155px;">
      <div class="node-title">C. New Product/Drug?</div>
      <div class="node-sub">Soap · Latex · Medication</div>
    </div>
    <div style="font-size:0.75rem;color:#27ae60;">YES ↓</div>
    <div class="node n-contact" style="min-width:155px;">
      <div class="node-title">Contact Dermatitis</div>
      <div class="node-sub">Irritant or Allergic</div>
      <div class="tooltip">Stop the offending agent. Mild topical steroid (e.g. hydrocortisone 1%) for allergic type. Emollient for barrier repair. Patch testing if recurrent.</div>
    </div>
  </div>

  <!-- Branch D -->
  <div style="display:flex;flex-direction:column;align-items:center;gap:10px;">
    <div class="node n-decision" style="min-width:155px;">
      <div class="node-title">D. Chronic &amp; Scaly?</div>
      <div class="node-sub">Plaques · White patches · Thickening</div>
    </div>
    <div style="font-size:0.75rem;color:#27ae60;">YES ↓</div>
    <div class="node n-skin" style="min-width:155px;">
      <div class="node-title">Skin Disorder</div>
      <div class="node-sub">Psoriasis · Lichen · Eczema</div>
      <div class="tooltip">Consider: Lichen sclerosus (white, atrophic), Lichen planus (erosive, purple), Psoriasis (red plaques without scale in genital area), LSC (thickened from scratching). Biopsy often required.</div>
    </div>
  </div>

  <!-- Branch E -->
  <div style="display:flex;flex-direction:column;align-items:center;gap:10px;">
    <div class="node n-decision" style="min-width:155px;">
      <div class="node-title">E. Post-menopausal / Low Estrogen?</div>
    </div>
    <div style="font-size:0.75rem;color:#27ae60;">YES ↓</div>
    <div class="node n-hormonal" style="min-width:155px;">
      <div class="node-title">Atrophic Vaginitis</div>
      <div class="node-sub">Genitourinary Syndrome of Menopause</div>
      <div class="tooltip">Estrogen deficiency causes vaginal/vulvar thinning, dryness, redness, dyspareunia. Treat with topical vaginal estrogen or ospemifene. Also consider in breastfeeding women.</div>
    </div>
  </div>

  <!-- Branch F -->
  <div style="display:flex;flex-direction:column;align-items:center;gap:10px;">
    <div class="node n-decision" style="min-width:155px;">
      <div class="node-title">F. Ring-shaped / Groin Folds?</div>
      <div class="node-sub">Active border · Scaling</div>
    </div>
    <div style="font-size:0.75rem;color:#27ae60;">YES ↓</div>
    <div class="node n-infection" style="min-width:155px;">
      <div class="node-title">Tinea Cruris</div>
      <div class="node-sub">"Jock itch" — Dermatophyte</div>
      <div class="tooltip">Dermatophyte fungal infection. KOH scraping positive for hyphae. Treat with topical antifungal (clotrimazole, terbinafine) x 2-4 wks. Keep area dry.</div>
    </div>
  </div>

</div>

<!-- ══════════════════════════════════════
     BRANCH A DETAIL — Discharge
════════════════════════════════════════ -->
<div style="margin-top:40px;">
  <div class="section-heading">Branch A — Discharge Detail</div>
  <div class="row" style="gap:18px;align-items:flex-start;">

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">White, thick, curdy</div>
        <div class="node-sub">Cottage-cheese texture<br>Itching · Redness · Fissures</div>
      </div>
      <div>↓</div>
      <div class="node n-infection">
        <div class="node-title">Vulvovaginal Candidiasis</div>
        <div class="node-sub">Candida albicans (75%)</div>
        <div class="tooltip">Vulvar erythema, edema, fissures, white discharge. pH &lt;4.5. KOH smear: pseudohyphae. Rx: Fluconazole 150mg PO single dose or topical azole (clotrimazole). Check for diabetes/immunosuppression if recurrent.</div>
      </div>
    </div>

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">Gray/white, fishy odor</div>
        <div class="node-sub">Thin discharge<br>Clue cells on wet prep<br>pH &gt;4.5</div>
      </div>
      <div>↓</div>
      <div class="node n-infection">
        <div class="node-title">Bacterial Vaginosis</div>
        <div class="node-sub">Gardnerella + anaerobes</div>
        <div class="tooltip">Amsel criteria: ≥3 of — thin gray discharge, pH &gt;4.5, positive whiff test (KOH), clue cells on microscopy. Rx: Metronidazole 500mg PO BID x 7 days or vaginal metronidazole/clindamycin gel.</div>
      </div>
    </div>

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">Yellow-green, frothy</div>
        <div class="node-sub">Malodorous · Profuse<br>Strawberry cervix</div>
      </div>
      <div>↓</div>
      <div class="node n-sti">
        <div class="node-title">Trichomoniasis</div>
        <div class="node-sub">Trichomonas vaginalis</div>
        <div class="tooltip">STI. Wet prep: motile trichomonads. NAAT (nucleic acid test) most sensitive. Rx: Metronidazole 2g PO single dose (both partners). pH &gt;4.5. Associated with increased HIV risk.</div>
      </div>
    </div>

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">Yellow/purulent discharge</div>
        <div class="node-sub">From cervix/urethra<br>Dysuria · Pelvic pain</div>
      </div>
      <div>↓</div>
      <div class="node n-sti">
        <div class="node-title">Gonorrhea / Chlamydia</div>
        <div class="node-sub">N. gonorrhoeae / C. trachomatis</div>
        <div class="tooltip">NAAT on cervical/urethral swab or urine. Gonorrhea: Ceftriaxone 500mg IM + Azithromycin 1g. Chlamydia: Doxycycline 100mg BID x 7 days or Azithromycin 1g single dose. Treat partners.</div>
      </div>
    </div>

  </div>
</div>

<!-- ══════════════════════════════════════
     BRANCH B DETAIL — Sores / Ulcers
════════════════════════════════════════ -->
<div style="margin-top:40px;">
  <div class="section-heading">Branch B — Sores / Ulcers Detail</div>
  <div class="row" style="gap:18px;align-items:flex-start;">

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">Painful clusters of vesicles/ulcers</div>
        <div class="node-sub">Burning · Recurrent</div>
      </div>
      <div>↓</div>
      <div class="node n-sti">
        <div class="node-title">Genital Herpes (HSV-2/1)</div>
        <div class="node-sub">Herpes Simplex Virus</div>
        <div class="tooltip">Most common cause of genital ulcer. NAAT/culture from lesion. Serology (HSV IgG). Rx: Acyclovir 400mg TID x 7-10 days (primary); suppressive therapy for recurrent (Valacyclovir 500mg OD). Can mimic candidal fissures.</div>
      </div>
    </div>

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">PAINLESS single ulcer, clean base</div>
        <div class="node-sub">Indurated, firm edges</div>
      </div>
      <div>↓</div>
      <div class="node n-sti">
        <div class="node-title">Syphilitic Chancre</div>
        <div class="node-sub">Primary Syphilis (T. pallidum)</div>
        <div class="tooltip">Primary chancre: painless, clean-based ulcer with firm edges. Check RPR/VDRL + TPHA/FTA-ABS. Rx: Benzathine penicillin G 2.4 MU IM single dose. Secondary syphilis: maculopapular rash on palms/soles.</div>
      </div>
    </div>

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">Painful ulcers, ragged edges</div>
        <div class="node-sub">Multiple · Tender lymphadenopathy</div>
      </div>
      <div>↓</div>
      <div class="node n-sti">
        <div class="node-title">Chancroid</div>
        <div class="node-sub">Haemophilus ducreyi</div>
        <div class="tooltip">Soft, painful ulcer with undermined edges. "School of fish" on Gram stain. Rx: Azithromycin 1g single dose or Ceftriaxone 250mg IM. Rare in developed countries but endemic in tropics.</div>
      </div>
    </div>

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">Cauliflower-like growths</div>
        <div class="node-sub">Flesh-colored · Non-painful</div>
      </div>
      <div>↓</div>
      <div class="node n-sti">
        <div class="node-title">Genital Warts (HPV)</div>
        <div class="node-sub">Human Papillomavirus 6/11</div>
        <div class="tooltip">Condyloma acuminata. Acetowhitening with 5% acetic acid. Rx: Podophyllin, imiquimod, cryotherapy, or surgical excision. HPV 16/18 associated with genital cancers — screen with Pap smear.</div>
      </div>
    </div>

    <div style="display:flex;flex-direction:column;align-items:center;gap:8px;">
      <div class="node n-workup" style="min-width:170px;">
        <div class="node-title">Chronic, non-healing ulcer/plaque</div>
        <div class="node-sub">Persistent &gt;6 wks</div>
      </div>
      <div>↓</div>
      <div class="node n-other">
        <div class="node-title">⚠️ Biopsy Required</div>
        <div class="node-sub">Rule out VIN / Malignancy<br>Paget's disease · Behcet's</div>
        <div class="tooltip">Persistent, non-healing genital lesions require biopsy to exclude VIN (Vulvar Intraepithelial Neoplasia), squamous cell carcinoma, Extramammary Paget's disease, or Behcet's disease. Refer to dermatology/gynecology.</div>
      </div>
    </div>

  </div>
</div>

<!-- ══════════════════════════════════════
     SKIN CONDITIONS DETAIL
════════════════════════════════════════ -->
<div style="margin-top:40px;">
  <div class="section-heading">Dermatological / Skin Conditions</div>
  <div class="row" style="gap:14px;flex-wrap:wrap;">

    <div class="node n-skin" style="min-width:160px;max-width:190px;">
      <div class="node-title">Lichen Sclerosus</div>
      <div class="node-sub">White, atrophic patches<br>Intense itch · Fissures<br>Risk of SCC</div>
      <div class="tooltip">Chronic inflammatory dermatosis. White, cigarette-paper skin. Affects vulva (clitoral hood, labia minora) and glans penis. Biopsy confirms. Rx: Ultrapotent topical corticosteroid (clobetasol 0.05%) long-term. Annual skin exam for SCC.</div>
    </div>

    <div class="node n-skin" style="min-width:160px;max-width:190px;">
      <div class="node-title">Lichen Planus</div>
      <div class="node-sub">Erosive, painful<br>Wickham's striae<br>Vaginal scarring</div>
      <div class="tooltip">Autoimmune T-cell mediated. Erosive vulvovaginal LP can cause severe pain, dyspareunia, and vaginal stenosis. Check mouth for oral lesions. Rx: Topical potent steroids, tacrolimus. May require systemic therapy.</div>
    </div>

    <div class="node n-skin" style="min-width:160px;max-width:190px;">
      <div class="node-title">Psoriasis</div>
      <div class="node-sub">Well-demarcated red plaques<br>No scale in genital area<br>Check elbows/scalp</div>
      <div class="tooltip">Inverse psoriasis: lacks typical silver scale in flexural/genital areas. Look for plaques elsewhere. Rx: Low-potency topical steroids, calcipotriol, tacrolimus. Avoid high-potency steroids on genital skin.</div>
    </div>

    <div class="node n-skin" style="min-width:160px;max-width:190px;">
      <div class="node-title">Atopic Eczema</div>
      <div class="node-sub">Dry, itchy, lichenified<br>Personal/family allergy hx<br>Triggered by irritants</div>
      <div class="tooltip">Chronic relapsing inflammatory skin disease. Genital involvement uncommon but can occur. Rx: Emollients, mild topical steroid, avoid triggers. Tacrolimus/pimecrolimus for maintenance.</div>
    </div>

    <div class="node n-skin" style="min-width:160px;max-width:190px;">
      <div class="node-title">Seborrheic Dermatitis</div>
      <div class="node-sub">Greasy red-yellow scales<br>Groin/skin folds<br>Scalp involvement</div>
      <div class="tooltip">Malassezia yeast overgrowth. Common in groin folds. Rx: Topical antifungal (ketoconazole) + mild corticosteroid combination. Recurrent; requires maintenance therapy.</div>
    </div>

    <div class="node n-contact" style="min-width:160px;max-width:190px;">
      <div class="node-title">Contact Dermatitis</div>
      <div class="node-sub">Irritant: soaps, wipes<br>Allergic: latex, fragrance<br>Burning + redness</div>
      <div class="tooltip">Most common cause of genital redness with no infection. Common offenders: scented pads, fabric softener, lubricants, latex condoms, spermicides. Rx: Stop offending agent, emollient, topical hydrocortisone 1%.</div>
    </div>

    <div class="node n-skin" style="min-width:160px;max-width:190px;">
      <div class="node-title">Lichen Simplex Chronicus</div>
      <div class="node-sub">Thickened, leathery skin<br>Intense itch-scratch cycle</div>
      <div class="tooltip">Secondary to chronic rubbing/scratching. Break the itch-scratch cycle with sedating antihistamines at night + potent topical steroids. Address underlying cause (anxiety, original trigger).</div>
    </div>

    <div class="node n-other" style="min-width:160px;max-width:190px;">
      <div class="node-title">Fixed Drug Eruption</div>
      <div class="node-sub">Same spot each time<br>NSAIDs · Tetracyclines<br>Trimethoprim</div>
      <div class="tooltip">Recurs at the same anatomic site with re-exposure to the drug. Genital involvement common. Dark hyperpigmented patch after resolution. Rx: Stop the drug. Topical steroid for acute phase.</div>
    </div>

  </div>
</div>

<!-- ══════════════════════════════════════
     PARASITIC / INFESTATION
════════════════════════════════════════ -->
<div style="margin-top:40px;">
  <div class="section-heading">Parasitic Infestations</div>
  <div class="row" style="gap:18px;">

    <div class="node n-infection" style="min-width:200px;max-width:230px;">
      <div class="node-title">🦟 Pubic Lice (Crabs)</div>
      <div class="node-sub">Pthirus pubis<br>Intense itch, especially at night<br>Visible nits on pubic hair</div>
      <div class="tooltip">Visualize lice/nits with magnification. Blue-gray macular spots (maculae ceruleae) on skin. Rx: Permethrin 1% cream x 10 min, repeat in 7 days. Wash bedding/clothing. Treat partners.</div>
    </div>

    <div class="node n-infection" style="min-width:200px;max-width:230px;">
      <div class="node-title">🔴 Scabies</div>
      <div class="node-sub">Sarcoptes scabiei<br>Burrows · Worse at night<br>Check web spaces/wrists</div>
      <div class="tooltip">Intensely pruritic burrows in genital area, web spaces, wrists. Skin scraping for mites/eggs/feces. Rx: Permethrin 5% cream all over body overnight, repeat in 7 days. OR Ivermectin 200mcg/kg PO x 2 doses. Treat all contacts.</div>
    </div>

  </div>
</div>

<!-- ══════════════════════════════════════
     WORKUP SUMMARY BOX
════════════════════════════════════════ -->
<div style="margin-top:48px;background:#fff;border-radius:12px;padding:22px 26px;border:2px solid #dce3ea;max-width:900px;margin-left:auto;margin-right:auto;">
  <h3 style="color:#c0392b;margin-bottom:14px;font-size:1rem;">🔬 Recommended Workup at First Assessment</h3>
  <div style="display:grid;grid-template-columns:repeat(auto-fill,minmax(220px,1fr));gap:14px;font-size:0.82rem;">

    <div style="background:#f8f9fa;border-radius:8px;padding:12px;border-left:4px solid #2980b9;">
      <strong>All patients</strong>
      <ul style="padding-left:16px;margin-top:6px;line-height:1.8;">
        <li>Full skin examination</li>
        <li>pH of vaginal discharge</li>
        <li>Wet mount microscopy</li>
        <li>Vital signs (rule out sepsis)</li>
      </ul>
    </div>

    <div style="background:#f8f9fa;border-radius:8px;padding:12px;border-left:4px solid #8e44ad;">
      <strong>Suspected STI</strong>
      <ul style="padding-left:16px;margin-top:6px;line-height:1.8;">
        <li>NAAT: GC/Chlamydia/Trichomonas</li>
        <li>Syphilis serology (RPR + TPHA)</li>
        <li>HIV test</li>
        <li>HSV PCR from lesion swab</li>
        <li>Hepatitis B surface antigen</li>
      </ul>
    </div>

    <div style="background:#f8f9fa;border-radius:8px;padding:12px;border-left:4px solid #e67e22;">
      <strong>Suspected Fungal</strong>
      <ul style="padding-left:16px;margin-top:6px;line-height:1.8;">
        <li>KOH preparation (hyphae)</li>
        <li>Fungal culture</li>
        <li>Blood glucose (check DM)</li>
      </ul>
    </div>

    <div style="background:#f8f9fa;border-radius:8px;padding:12px;border-left:4px solid #16a085;">
      <strong>Chronic / Skin Disorder</strong>
      <ul style="padding-left:16px;margin-top:6px;line-height:1.8;">
        <li>Punch biopsy</li>
        <li>Patch testing (allergy)</li>
        <li>Skin scraping + KOH (tinea)</li>
        <li>Wood's lamp (erythrasma)</li>
      </ul>
    </div>

    <div style="background:#f8f9fa;border-radius:8px;padding:12px;border-left:4px solid #d35400;">
      <strong>Suspected Hormonal</strong>
      <ul style="padding-left:16px;margin-top:6px;line-height:1.8;">
        <li>FSH / LH / Estradiol levels</li>
        <li>Vaginal maturation index</li>
        <li>TSH (thyroid)</li>
      </ul>
    </div>

    <div style="background:#f8f9fa;border-radius:8px;padding:12px;border-left:4px solid #e74c3c;">
      <strong>Non-healing / Persistent</strong>
      <ul style="padding-left:16px;margin-top:6px;line-height:1.8;">
        <li>Excisional biopsy</li>
        <li>Colposcopy (females)</li>
        <li>Pap smear / HPV co-test</li>
        <li>Refer dermatology/gynecology</li>
      </ul>
    </div>

  </div>
</div>

<!-- ══════════════════════════════════════
     QUICK REFERENCE TABLE
════════════════════════════════════════ -->
<div style="margin-top:40px;background:#fff;border-radius:12px;padding:22px 26px;border:2px solid #dce3ea;overflow-x:auto;">
  <h3 style="color:#c0392b;margin-bottom:14px;font-size:1rem;">📋 Quick Reference: Key Distinguishing Features</h3>
  <table style="width:100%;border-collapse:collapse;font-size:0.8rem;">
    <thead>
      <tr style="background:#c0392b;color:#fff;">
        <th style="padding:9px 12px;text-align:left;border-radius:6px 0 0 0;">Diagnosis</th>
        <th style="padding:9px 12px;text-align:left;">Discharge</th>
        <th style="padding:9px 12px;text-align:left;">Pain/Itch</th>
        <th style="padding:9px 12px;text-align:left;">Key Sign</th>
        <th style="padding:9px 12px;text-align:left;">Confirmatory Test</th>
        <th style="padding:9px 12px;text-align:left;border-radius:0 6px 0 0;">1st-Line Rx</th>
      </tr>
    </thead>
    <tbody>
      <tr style="background:#f9f9f9;">
        <td style="padding:8px 12px;font-weight:600;">Candidiasis</td>
        <td>White, thick, curdy</td>
        <td>Intense itch</td>
        <td>Vulvar erythema + fissures</td>
        <td>KOH smear (pseudohyphae)</td>
        <td>Fluconazole 150mg PO</td>
      </tr>
      <tr>
        <td style="padding:8px 12px;font-weight:600;">Bacterial Vaginosis</td>
        <td>Gray-white, fishy odor</td>
        <td>Minimal</td>
        <td>Clue cells, pH &gt;4.5</td>
        <td>Amsel criteria / Nugent score</td>
        <td>Metronidazole 500mg BID x7d</td>
      </tr>
      <tr style="background:#f9f9f9;">
        <td style="padding:8px 12px;font-weight:600;">Trichomoniasis</td>
        <td>Yellow-green, frothy</td>
        <td>Itch + burning</td>
        <td>Strawberry cervix</td>
        <td>NAAT (most sensitive)</td>
        <td>Metronidazole 2g single dose</td>
      </tr>
      <tr>
        <td style="padding:8px 12px;font-weight:600;">Gonorrhea</td>
        <td>Purulent (urethral/cervical)</td>
        <td>Dysuria</td>
        <td>Cervicitis</td>
        <td>NAAT swab or urine</td>
        <td>Ceftriaxone 500mg IM</td>
      </tr>
      <tr style="background:#f9f9f9;">
        <td style="padding:8px 12px;font-weight:600;">Genital Herpes</td>
        <td>None (may have ulcer exudate)</td>
        <td>Painful ulcers</td>
        <td>Vesicles → ulcers, recurrent</td>
        <td>HSV PCR from lesion</td>
        <td>Acyclovir 400mg TID x10d</td>
      </tr>
      <tr>
        <td style="padding:8px 12px;font-weight:600;">Syphilis (Primary)</td>
        <td>None</td>
        <td>Painless</td>
        <td>Clean-based chancre</td>
        <td>RPR + TPHA</td>
        <td>Benzathine Pen G 2.4MU IM</td>
      </tr>
      <tr style="background:#f9f9f9;">
        <td style="padding:8px 12px;font-weight:600;">Lichen Sclerosus</td>
        <td>None</td>
        <td>Itch, soreness</td>
        <td>White atrophic skin</td>
        <td>Skin biopsy</td>
        <td>Clobetasol 0.05% ointment</td>
      </tr>
      <tr>
        <td style="padding:8px 12px;font-weight:600;">Contact Dermatitis</td>
        <td>None</td>
        <td>Burning, itch</td>
        <td>Recent product exposure</td>
        <td>Patch testing</td>
        <td>Stop trigger + hydrocortisone 1%</td>
      </tr>
      <tr style="background:#f9f9f9;">
        <td style="padding:8px 12px;font-weight:600;">Atrophic Vaginitis</td>
        <td>Scant / blood-tinged</td>
        <td>Dryness, dyspareunia</td>
        <td>Post-menopausal, thin pale mucosa</td>
        <td>Hormone levels, vaginal cytology</td>
        <td>Topical vaginal estrogen</td>
      </tr>
      <tr>
        <td style="padding:8px 12px;font-weight:600;">Tinea Cruris</td>
        <td>None</td>
        <td>Itch</td>
        <td>Ring-shaped with active border</td>
        <td>KOH scraping (hyphae)</td>
        <td>Topical clotrimazole x4 wks</td>
      </tr>
      <tr style="background:#f9f9f9;">
        <td style="padding:8px 12px;font-weight:600;">Scabies</td>
        <td>None</td>
        <td>Intense nocturnal itch</td>
        <td>Burrows, web-space involvement</td>
        <td>Skin scraping for mites</td>
        <td>Permethrin 5% cream</td>
      </tr>
    </tbody>
  </table>
</div>

<!-- Footer -->
<div style="text-align:center;margin-top:32px;font-size:0.78rem;color:#7f8c8d;padding-bottom:20px;">
  Sources: Harrison's Principles of Internal Medicine 22E (2025) · Symptom to Diagnosis 4th Ed. · Berek &amp; Novak's Gynecology · Dermatology 5th Ed. (Elsevier) · Campbell-Walsh-Wein Urology
  <br><br>
  <em>This flowchart is for educational purposes only. Always perform clinical examination and appropriate laboratory testing before diagnosis and treatment.</em>
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Running Command

ls -lh /home/daytona/workspace/genital-redness-flowchart/

Your comprehensive diagnostic flowchart is ready:

index
HTML File · HTML

What's included in the flowchart:

Step 1 - Emergency Triage

Red flag signs that indicate Fournier's gangrene / necrotizing fasciitis (requiring immediate surgical referral)

Step 2 - Key History Nodes

Duration, sex/gender, recent triggers, associated symptoms, past medical history

Step 3 - Six Primary Decision Branches

Branch A: Discharge type - leads to Candidiasis, BV, Trichomoniasis, or Gonorrhea/Chlamydia
Branch B: Sores/Ulcers - differentiates Herpes (painful) vs Syphilitic chancre (painless) vs Chancroid vs HPV warts vs biopsy-required lesions
Branch C: New product/drug exposure → Contact Dermatitis
Branch D: Chronic scaly plaques → Lichen Sclerosus, Lichen Planus, Psoriasis, Eczema
Branch E: Post-menopausal / low estrogen → Atrophic Vaginitis
Branch F: Ring-shaped groin redness → Tinea Cruris

Additional sections:

Parasitic infestations (Scabies, Pubic Lice)
Recommended workup panel (by suspected category)
Quick-reference table with 11 diagnoses showing discharge, pain/itch character, key sign, confirmatory test, and first-line treatment

Features: Color-coded by category, hover tooltips with clinical details, print-to-PDF button, fully responsive layout.

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