l PATIENT AND CARER ADVICE Avoid contact with clothing.
l EXCEPTIONS TO LEGAL CATEGORY A 30 mL pack of
aluminium chloride hexahydrate 20% is on sale to the
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 15
▶ Anhydrol (Dermal Laboratories Ltd)
Aluminium chloride 200 mg per 1 ml Anhydrol Forte 20% solution
▶ Driclor (GlaxoSmithKline Consumer Healthcare)
Aluminium chloride 200 mg per 1 ml Driclor 20% solution | 75 ml p £3.01 DT = £3.01
Pruritus may be caused by systemic disease (such as
obstructive jaundice, endocrine disease, chronic renal
disease, iron deficiency, and certain malignant diseases),
skin disease (e.g. psoriasis, eczema, urticaria, and scabies),
drug hypersensitivity, or as a side-effect of opioid analgesics.
Where possible, the underlying causes should be treated. An
emollient may be of value where the pruritus is associated
with dry skin. Pruritus that occurs in otherwise healthy
elderly people can also be treated with an emollient.
Levomenthol cream p. 1266 can be used to relieve pruritus;
it exerts a cooling effect on the skin. Local antipruritics have
a role in the treatment of pruritus in palliative care.
Preparations containing crotamiton below are sometimes
used but are of uncertain value. Preparations containing
calamine are often ineffective.
A topical preparation containing doxepin 5% p. 1266 is
licensed for the relief of pruritus in eczema; it can cause
drowsiness and there may be a risk of sensitisation.
Pruritus is common in biliary obstruction, especially in
primary biliary cirrhosis and drug-induced cholestasis. Oral
administration of colestyramine p. 197 is the treatment of
Topical antihistamines and local anaesthetics are only
marginally effective and occasionally cause hypersensitivity.
For insect stings and insect bites, a short course of a topical
corticosteroid is appropriate. Short-term treatment with a
sedating antihistamine may help in insect stings and in
intractable pruritus where sedation is desirable. Calamine
preparations are of little value for the treatment of insect
Topical local anaesthetics are indicated for the relief of
local pain. Preparations may be absorbed, especially through
mucosal surfaces, therefore excessive application should be
avoided and they should preferably not be used for more
than 3 days; not generally suitable for young children and
are less suitable for prescribing.
Topical antihistamines should be avoided in eczema and
are not recommended for longer than 3 days. They are less
p. 283 . Coal tar with calamine, p. 1254 . Hydroxyzine
hydrochloride, p. 285 . Levocetirizine hydrochloride, p. 281
Calamine with zinc oxide 15-Jan-2019
▶ Child: (consult product literature)
▶ Adult: (consult product literature)
MHRA/CHM ADVICE (UPDATED DECEMBER 2018): EMOLLIENTS:
NEW INFORMATION ABOUT RISK OF SEVERE AND FATAL BURNS
WITH PARAFFIN-CONTAINING AND PARAFFIN-FREE EMOLLIENTS
See Emollient and barrier preparations p. 1221.
l CONTRA-INDICATIONS Avoid application of preparations
containing zinc oxide prior to x-ray (zinc oxide may affect
l LESS SUITABLE FOR PRESCRIBING Less suitable for
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 15
▶ Calamine with zinc oxide (Non-proprietary)
Phenoxyethanol 5 mg per 1 gram, Zinc oxide 30 mg per 1 gram,
Calamine 40 mg per 1 gram, Cetomacrogol emulsifying wax
50 mg per 1 gram, Self-emulsifying glyceryl monostearate 50 mg
per 1 gram, Liquid paraffin 200 mg per 1 gram Aqueous calamine
cream | 100 gram G £1.43 DT = £1.43
▶ Calamine with zinc oxide (Non-proprietary)
Phenol liquefied 5 mg per 1 ml, Sodium citrate 5 mg per 1 ml,
Bentonite 30 mg per 1 ml, Glycerol 50 mg per 1 ml, Zinc oxide
50 mg per 1 ml, Calamine 150 mg per 1 ml Calamine lotion | 200 ml G £0.94–£1.09 DT = £1.09
Pruritus (including pruritus after scabies)
▶ Child 1 month–2 years (on doctor’s advice only): Apply
▶ Child 3–17 years: Apply 2–3 times a day
▶ Adult: Apply 2–3 times a day
l CONTRA-INDICATIONS Acute exudative dermatoses
l CAUTIONS Avoid use in buccal mucosa . avoid use near
eyes . avoid use on broken skin . avoid use on very inflamed
skin . use on doctor’s advice for children under 3 years
l PREGNANCY Manufacturer advises avoid, especially during
the first trimester—no information available.
l BREAST FEEDING No information available; avoid
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Beeswax, cetostearyl alcohol (including cetyl
and stearyl alcohol), fragrances, hydroxybenzoates (parabens)
▶ Eurax (GlaxoSmithKline Consumer Healthcare)
▶ Child 12–17 years: Apply up to 3 g 3–4 times a day, apply
thinly; coverage should be less than 10% of body
surface area; maximum 12 g per day
▶ Adult: Apply up to 3 g 3–4 times a day, apply thinly;
coverage should be less than 10% of body surface area;
l CAUTIONS Avoid application to large areas . cardiac
arrhythmias . mania . severe heart disease . susceptibility
to angle-closure glaucoma . urinary retention
l INTERACTIONS → Appendix 1: tricyclic antidepressants
tendencies .taste altered . urinary retention . vision
l PREGNANCY Manufacturer advises use only if potential
l BREAST FEEDING Manufacturer advises use only if
potential benefit outweighs risk.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
l PATIENT AND CARER ADVICE A patient information leaflet
Driving and skilled tasks Drowsiness may affect
performance of skilled tasks (e.g. driving).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 2, 10
EXCIPIENTS: May contain Benzyl alcohol
▶ Xepin (Cambridge Healthcare Supplies Ltd)
Doxepin hydrochloride 50 mg per 1 gram Xepin 5% cream | 30 gram P £11.70 DT = £11.70
▶ Adult: Apply 1–2 times a day
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: cream
▶ AquaSoothe (Ennogen Healthcare Ltd)
Menthol 10 mg per 1 gram AquaSoothe 1% cream | 100 gram £3.70
DT = £3.97 | 500 gram £15.43 DT = £16.59
Menthol 20 mg per 1 gram AquaSoothe 2% cream | 50 gram £1.86
Menthol 5 mg per 1 gram Arjun 0.5% cream | 500 gram £15.30 DT =
Menthol 10 mg per 1 gram Arjun 1% cream | 100 gram £3.25 DT =
£3.97 | 500 gram £15.30 DT = £16.59
Menthol 20 mg per 1 gram Arjun 2% cream | 500 gram £15.30 DT =
▶ Dermacool (Pern Consumer Products Ltd)
Menthol 5 mg per 1 gram Dermacool 0.5% cream | 100 gram £3.85
Menthol 10 mg per 1 gram Dermacool 1% cream | 100 gram £3.97
DT = £3.97 | 250 gram £8.99 | 500 gram £16.59 DT = £16.59
Menthol 20 mg per 1 gram Dermacool 2% cream | 100 gram £4.07
Menthol 50 mg per 1 gram Dermacool 5% cream | 100 gram £4.69
Menthol 5 mg per 1 gram Menthoderm 0.5% cream | 100 gram
£3.12 | 500 gram £14.59 DT = £16.07
Menthol 10 mg per 1 gram Menthoderm 1% cream | 100 gram
£3.20 DT = £3.97 | 500 gram £14.79 DT = £16.59
Menthol 20 mg per 1 gram Menthoderm 2% cream | 100 gram
£3.85 | 500 gram £14.99 DT = £16.97
Treatment of acne should be commenced early to prevent
scarring. Patients should be counselled that an improvement
may not be seen for at least a couple of months. The choice
of treatment depends on whether the acne is predominantly
inflammatory or comedonal and its severity.
Mild to moderate acne is generally treated with topical
preparations. Systemic treatment with oral antibacterials is
generally used for moderate to severe acne or where topical
preparations are not tolerated or are ineffective or where
application to the site is difficult. Another oral preparation
used for acne is the hormone treatment co-cyprindiol
p. 1267 (cyproterone acetate with ethinylestradiol); it is for
Severe acne, acne unresponsive to prolonged courses of
oral antibacterials, scarring, or acne associated with
psychological problems calls for early referral to a consultant
dermatologist who may prescribe isotretinoin p. 1270 for
In mild to moderate acne, comedones and inflamed lesions
respond well to benzoyl peroxide p. 1269 or to a topical
retinoid. Alternatively, topical application of an antibacterial
such as erythromycin p. 539 or clindamycin p. 1268 may be
effective for inflammatory acne. If topical preparations prove
inadequate, oral preparations may be needed.
Benzoyl peroxide and azelaic acid
Benzoyl peroxide is effective in mild to moderate acne. Both
comedones and inflamed lesions respond well to benzoyl
peroxide. The lower concentrations seem to be as effective as
higher concentrations in reducing inflammation. It is usual
to start with a lower strength and to increase the
concentration of benzoyl peroxide gradually. Adverse effects
include local skin irritation, particularly when therapy is
initiated, but the scaling and redness often subside with
treatment continued at a reduced frequency of application. If
the acne does not respond after 2 months then use of a
topical antibacterial should be considered.
Azelaic acid p. 1269 has antimicrobial and anticomedonal
properties. It may be an alternative to benzoyl peroxide or to
a topical retinoid for treating mild to moderate comedonal
acne, particularly of the face. Some patients prefer azelaic
acid because it is less likely to cause local irritation than
Topical antibacterials for acne
For many patients with mild to moderate inflammatory acne,
topical antibacterials may be no more effective than topical
benzoyl peroxide or tretinoin p. 939. Topical antibacterials
are probably best reserved for patients who wish to avoid
oral antibacterials or who cannot tolerate them. Topical
preparations of erythromycin and clindamycin are effective
for inflammatory acne. Topical antibacterials can produce
mild irritation of the skin, and on rare occasions cause
sensitisation; gastro-intestinal disturbances have been
reported with topical clindamycin.
Antibacterial resistance of Propionibacterium acnes is
increasing; there is cross-resistance between erythromycin
and clindamycin. To avoid development of resistance:
. when possible use non-antibiotic antimicrobials (such as
benzoyl peroxide or azelaic acid);
. avoid concomitant treatment with different oral and
. if a particular antibacterial is effective, use it for repeat
courses if needed (short intervening courses of benzoyl
peroxide or azelaic acid may eliminate any resistant
. do not continue treatment for longer than necessary
(however, treatment with a topical preparation should be
continued for at least 6 months).
Some manufacturers of topical antibacterial preparations
for acne advise that preparations containing alcohol are not
suitable for use with benzoyl peroxide.
Topical retinoids and related preparations for acne
Topical tretinoin, its isomer isotretinoin, and adapalene
p. 1269 (a retinoid-like drug), are useful for treating
comedones and inflammatory lesions in mild to moderate
acne. Several months of treatment may be needed to achieve
an optimal response and the treatment should be continued
until no new lesions develop. Isotretinoin is given by mouth
Other topical preparations for acne
Preparations containing aluminium oxide are not considered
A topical preparation of nicotinamide p. 1272 is available
Systemic antibacterial treatment is useful for inflammatory
acne if topical treatment is not adequately effective or if it is
inappropriate. Anticomedonal treatment (e.g. with topical
benzoyl peroxide) may also be required.
Either oxytetracycline p. 567 or tetracycline p. 567 is
usually given for acne. If there is no improvement after the
first 3 months another oral antibacterial should be used.
Maximum improvement usually occurs after 4 to 6 months
but in more severe cases treatment may need to be
continued for 2 years or longer.
Doxycycline p. 564 and lymecycline p. 566 are alternatives
Although minocycline p. 566 is as effective as other
tetracyclines for acne, it is associated with a greater risk of
lupus erythematosus-like syndrome. Minocycline sometimes
causes irreversible pigmentation; it is given in a once or
Erythromycin in a twice daily dose is an alternative for the
management of acne but propionibacteria strains resistant to
erythromycin are becoming widespread and this may explain
Trimethoprim p. 574 may be used for acne resistant to
other antibacterials [unlicensed indication]. Prolonged
treatment with trimethoprim may depress haematopoiesis;
it should generally be initiated by specialists.
Concomitant use of different topical and systemic
antibacterials is undesirable owing to the increased
likelihood of the development of bacterial resistance.
Co-cyprindiol (cyproterone acetate with ethinylestradiol)
contains an anti-androgen. It is licensed for use in women
with moderate to severe acne that has not responded to
topical therapy or oral antibacterials, and for moderately
severe hirsutism. Although it is an effective hormonal
contraceptive, it should not be used solely for contraception.
Improvement of acne with co-cyprindiol probably occurs
because of decreased sebum secretion which is under
androgen control. Some women with moderately severe
hirsutism may also benefit because hair growth is also
The retinoid isotretinoin reduces sebum secretion. It is used
for the systemic treatment of nodulo-cystic and conglobate
acne, severe acne, scarring, acne which has not responded to
an adequate course of a systemic antibacterial, or acne which
is associated with psychological problems. It is also useful in
women who develop acne in the third or fourth decades of
life, since late onset acne is frequently unresponsive to
Isotretinoin is a toxic drug that should be prescribed only
by, or under the supervision of, a consultant dermatologist.
It is given for at least 16 weeks; repeat courses are not
Side-effects of isotretinoin include severe dryness of the
skin and mucous membranes, nose bleeds, and joint pains.
The drug is teratogenic and must not be given to women of
child-bearing age unless they practise effective
contraception (oral progestogen-only contraceptives not
considered effective) and then only after detailed assessment
and explanation by the physician. Women must also be
registered with a pregnancy prevention programme.
Although a causal link between isotretinoin p. 1270 use
and psychiatric changes (including suicidal ideation) has not
been established, the possibility should be considered before
initiating treatment; if psychiatric changes occur during
treatment, isotretinoin should be stopped, the prescriber
informed, and specialist psychiatric advice should be sought.
Rosacea is not comedonal (but may exist with acne which
may be comedonal). Brimonidine tartrate p. 1273 is licensed
for the treatment of facial erythema in rosacea. The pustules
and papules of rosacea respond to topical azelaic acid
p. 1269, topical ivermectin p. 1273 or to topical
metronidazole p. 1230. Alternatively oral administration of
oxytetracycline p. 567 or tetracycline p. 567, or erythromycin
p. 539, can be used; courses usually last 6–12 weeks and are
repeated intermittently. Doxycycline p. 564 can be used
[unlicensed indication] if oxytetracycline or tetracycline is
inappropriate (e.g. in renal impairment). A modified-release
preparation of doxycycline is licensed in low daily doses for
the treatment of facial rosacea. Isotretinoin is occasionally
given in refractory cases [unlicensed indication].
Camouflagers may be required for the redness.
Moderate to severe acne in females of child-bearing age
refractory to topical therapy or oral antibacterials |
▶ Females of childbearing potential: 1 tablet daily for
21 days, to be started on day 1 of menstrual cycle;
subsequent courses repeated after a 7-day interval
(during which withdrawal bleeding occurs), time to
symptom remission, at least 3 months; review need for
l CONTRA-INDICATIONS Acute porphyrias p. 1058 . gallstones . heart disease associated with pulmonary
hypertension or risk of embolus . history during pregnancy
of cholestatic jaundice . history during pregnancy of
chorea . history during pregnancy of pemphigoid
gestationis . history during pregnancy of pruritus . history
of breast cancer but can be used after 5 years if no evidence
for varicose veins . severe or multiple risk factors for
arterial disease or for venous thromboembolism . systemic
lupus erythematosus with (or unknown) antiphospholipid
antibodies .transient cerebral ischaemic attacks without
headaches . undiagnosed vaginal bleeding
l CAUTIONS Active trophoblastic disease (until return to
normal of urine- and plasma-gonadotrophin
1). history of severe depression especially if induced by
hormonal contraceptive . hyperprolactinaemia—seek
specialist advice . inflammatory bowel disease including
Crohn’s disease . migraine . personal or family history of
hypertriglyceridaemia (increased risk of pancreatitis).risk
factors for venous thromboembolism . sickle-cell disease . undiagnosed breast mass
▶ Venous thromboembolism There is an increased risk of
venous thromboembolism in women taking co-cyprindiol,
particularly during the first year of use. The incidence of
venous thromboembolism is 1.5–2 times higher in women
using co-cyprindiol than in women using combined oral
contraceptives containing levonorgestrel, but the risk may
be similar to that associated with use of combined oral
contraceptives containing third generation progestogens
(desogestrel and gestodene) or drospirenone. Women
requiring co-cyprindiol may have an inherently increased
risk of cardiovascular disease.
l INTERACTIONS → Appendix 1: combined hormonal
▶ Rare or very rare Cholelithiasis . photosensitivity reaction . systemic lupus erythematosus (SLE)
▶ Frequency not known Abdominal cramps . amenorrhoea
(on discontinuation). breast abnormalities . cervical
neoplasm . hypertension . irritability . leg cramps . libido
common when factor V Leiden present or in blood groups
A, B, and AB). visual impairment. vomiting . vulvovaginal
l PREGNANCY Avoid—risk of feminisation of male fetus with
l BREAST FEEDING Manufacturer advises avoid; possibility
of anti-androgen effects in neonate with cyproterone.
l HEPATIC IMPAIRMENT Manufacturer advises avoid in
severe impairment (until liver function returns to normal.)
l PRESCRIBING AND DISPENSING INFORMATION A mixture of
cyproterone acetate and ethinylestradiol in the mass
proportions 2000 parts to 35 parts, respectively.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Co-cyprindiol (Non-proprietary)
Ethinylestradiol 35 microgram, Cyproterone acetate
2 mg Clairette 2000/35 tablets | 63 tablet P £5.90 DT = £5.70
Ethinylestradiol 35 microgram, Cyproterone acetate
2 mg Dianette tablets | 63 tablet P £7.71 DT = £5.70
▶ Teragezza (Morningside Healthcare Ltd)
Ethinylestradiol 35 microgram, Cyproterone acetate
2 mg Teragezza 2000microgram/35microgram tablets | 63 tablet P £11.10 DT = £5.70
▶ Child: Apply twice daily, to be applied thinly
▶ Adult: Apply twice daily, to be applied thinly
▶ Child: Apply twice daily, to be applied thinly
▶ Adult: Apply twice daily, to be applied thinly
▶ Child 12–17 years: Apply once daily, to be applied thinly
▶ Adult: Apply once daily, to be applied thinly
l INTERACTIONS → Appendix 1: clindamycin
▶ Common or very common Skin reactions
▶ Frequency not known Abdominal pain . antibiotic
associated colitis . folliculitis gram-negative . gastrointestinal disorder
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Propylene glycol
▶ Zindaclin (Crawford Healthcare Ltd)
Clindamycin (as Clindamycin phosphate) 10 mg per
1 gram Zindaclin 1% gel | 30 gram P £8.66 DT = £8.66
EXCIPIENTS: May contain Cetostearyl alcohol (including cetyl and
stearyl alcohol), hydroxybenzoates (parabens), propylene glycol
Clindamycin (as Clindamycin phosphate) 10 mg per 1 ml Dalacin T
1% topical lotion | 30 ml P £5.08 DT = £5.08 | 60 ml P £10.16
Dalacin T 1% topical solution | 30 ml P £4.34 DT = £4.34 |
Combinations available: Benzoyl peroxide with clindamycin,
p. 1269 . Tretinoin with clindamycin, p. 1272
Erythromycin with zinc acetate
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, erythromycin p. 539.
l CAUTIONS Some manufacturers advise preparations
containing alcohol are not suitable for use with benzoyl
l INTERACTIONS → Appendix 1: macrolides
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Zinc acetate 12 mg per 1 ml, Erythromycin 40 mg per 1 ml Zineryt
lotion | 30 ml P £9.25 DT = £9.25 | 90 ml P £20.02 DT =
ANTISEPTICS AND DISINFECTANTS › PEROXIDES
▶ Child 12–17 years: Apply 1–2 times a day, preferably
apply after washing with soap and water, start
treatment with lower-strength preparations
▶ Adult: Apply 1–2 times a day, preferably apply after
washing with soap and water, start treatment with
l UNLICENSED USE Not licensed for use in treatment of
l CAUTIONS Avoid contact with broken skin . avoid contact
with eyes . avoid contact with mouth . avoid contact with
mucous membranes . avoid excessive exposure to sunlight
▶ Common or very common Skin reactions
▶ Frequency not known Facial swelling
SIDE-EFFECTS, FURTHER INFORMATION Reduce frequency
or suspend use until skin irritation subsides and reintroduce at reduced frequency.
l PATIENT AND CARER ADVICE May bleach fabrics and hair.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Cetostearyl alcohol (including cetyl and
stearyl alcohol), fragrances, isopropyl palmitate, propylene glycol
▶ Brevoxyl (GlaxoSmithKline Consumer Healthcare)
Benzoyl peroxide 40 mg per 1 gram Brevoxyl 4% cream | 50 gram p £4.13 DT = £4.13
EXCIPIENTS: May contain Fragrances, propylene glycol
▶ Acnecide (Galderma (UK) Ltd)
Benzoyl peroxide 50 mg per 1 gram Acnecide 5% gel | 30 gram p
£5.44 DT = £5.44 | 60 gram p £10.68 DT = £10.68
Acnecide Wash 5% gel | 50 gram p £5.44 DT = £5.44
Combinations available: Adapalene with benzoyl peroxide,
Benzoyl peroxide with clindamycin
The properties listed below are those particular to the
combination only. For the properties of the components
please consider, benzoyl peroxide above, clindamycin
▶ Child 12–17 years: Apply once daily, dose to be applied in
▶ Adult: Apply once daily, dose to be applied in the
l INTERACTIONS → Appendix 1: clindamycin
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Disodium edetate
▶ Duac (Stiefel Laboratories (UK) Ltd)
Clindamycin (as Clindamycin phosphate) 10 mg per 1 gram,
Benzoyl peroxide 30 mg per 1 gram Duac Once Daily gel (3% and
1%) | 30 gram P £13.14 DT = £13.14 | 60 gram P £26.28
Clindamycin (as Clindamycin phosphate) 10 mg per 1 gram,
Benzoyl peroxide 50 mg per 1 gram Duac Once Daily gel (5% and
1%) | 30 gram P £13.14 DT = £13.14 | 60 gram P £26.28 DT
DERMATOLOGICAL DRUGS › ANTICOMEDONALS
▶ Child 12–17 years: Apply twice daily, discontinue if no
▶ Adult: Apply twice daily, discontinue if no
▶ Adult: Apply twice daily, discontinue if no
▶ Child 12–17 years: Apply twice daily
Acne vulgaris in patients with sensitive skin
▶ Child 12–17 years: Apply once daily for 1 week, then
▶ Adult: Apply once daily for 1 week, then apply twice
l CAUTIONS Avoid contact with eyes . avoid contact with
mouth . avoid contact with mucous membranes
▶ Rare or very rare Asthma exacerbated . cheilitis
▶ Frequency not known Angioedema . eye swelling
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
EXCIPIENTS: May contain Propylene glycol
Azelaic acid 200 mg per 1 gram Skinoren 20% cream | 30 gram P £4.49 DT = £4.49
EXCIPIENTS: May contain Disodium edetate, polysorbates, propylene
Azelaic acid 150 mg per 1 gram Finacea 15% gel | 30 gram P £7.48 DT = £7.48
Mild to moderate acne vulgaris
▶ Child 12–17 years: Apply once daily, apply thinly in the
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