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The comparison between the efficacy of high dose acyclovir and erythromycin on the period and signs of pitiriasis rosea

Indian Journal of Dermatology, 09/30/2010  Free full text Clinical Article

Ehsani A et al. – A total of 30 patients including 15 males and 15 females completed the study. After eight weeks, 13 patients in the acyclovir group experienced complete response, while in the erythromycin group only six patients had complete response. Also, patients in the acyclovir group experienced faster resolution of pruritus in comparison with the erythromycin group (not significant). No adverse drug reaction was detected in both groups. It seemed that a high–dose of oral acyclovir was a safe and effective therapy for pitiriasis rosea, although this remained to be confirmed in larger studies.

2010 Annual Evidence Update on Atopic Eczema - Summary points and implications for practice

Summary points, and will the new evidence change our clinical practice?

Professor Hywel Williams, Clinical Lead for NHS Evidence - skin disorders and Co-ordinating Editor of the Cochrane Skin Group, and Dr Kave Shams, Dermatology Registrar, Southern General Hospital, Glasgow

GUIDELINE

Food allergy: The US National Institute of Allergy and Infectious Diseases has produced extensive, high quality draft guidelines on the management of food allergy. The advice on food allergy is still limited by lack of clear definitions and a poor evidence base. The guidelines emphasise the importance of taking a good clinical history of food allergy before proceeding to skin-prick or RAST tests, and of the need to be aware of non-IgE mediated food allergy.
Action: We will continue to ask all our eczema patients (especially younger children) about symptoms suggestive of immediate and delayed food allergy to foods such as egg, milk, fish, citrus and nuts. We will not blindly order "allergy tests" on patients, as positive tests have a low predictive value.

CAUSES OF ECZEMA

Risk of cancer: Some evidence points to a possible reduced risk of glioma and acute leukaemia in people who have had eczema in childhood, the reasons for which are unclear.
Action: Given that most of our messages are doom and gloom, this observation of a possible health benefit of having eczema is perhaps worth mentioning to some parents who feel despondent about eczema.

Risk of multiple sclerosis: There is no clear evidence to support an increased or decreased risk of multiple sclerosis in eczema and other atopic diseases.
Action: None, especially as we were not aware of the possibility of an association in the first place.

Attention deficit hyperactivity disorder (ADHD): Although some cross sectional studies suggest a possible association between reported eczema and ADHD, we are not convinced it is a true association at this stage and large prospective studies are needed to disentangle cause and effect.
Action: We shall be cautious accepting that children who are restless because of undertreated eczema have ADHD. We shall treat the underlying eczema aggressively and see how the behaviour improves.

Living in the city: Most studies in developed countries looking at whether eczema is commoner in urban as opposed to rural locations suggest an increased risk of disease expression in urban areas.
Action: The evidence is not strong enough to recommend our patients to move to “a place in the country”.

PREVENTION

Hydrolyzed milk formulas: Although a recent systematic review sponsored by the manufacturers of hydrolyzed milk formulas has suggested that partially hydrolyzed formulas from birth may prevent eczema to some degree, compared with standard cow’s milk formula, we would like to see an independent Cochrane Review update on this topic.
Action: We will continue to advise parents that breast-feeding is the most effective and appropriate method to nourish infants, and that mothers who cannot breastfeed can use conventional formula milk. If their child does develop cow’s milk allergy, then a hydrolyzed milk formula is appropriate.

Organic foods: There is no robust evidence that consumption of organic foods reduces the risk of eczema. One cohort study from the Netherlands has suggested that consumption of strictly organic dairy products may reduce eczema risk in infants, a finding that needs to be tested in new studies.
Action: We will not be recommending organic foods during infancy if parents do not choose to buy them.

Fish oils for pregnant mothers: Observational and intervention studies evaluating increased fish intake or fish supplementation during pregnancy suggest a possible reduction in subsequent eczema prevalence and severity.
Action: Although the evidence is not strong enough yet to inform guidelines, the possibility of increasing fish intake or of fish oil supplementation during pregnancy may be something to discuss with families with allergic disease, given the safety and other health benefits of fish oils.

Fish oils for infants: The evidence to support increased fish intake or fish oil supplementation in infant diets to prevent or reduce the severity of subsequent eczema is not so strong.
Action: Hold off the extra fish fingers for now.

ECZEMA TREATMENT

Food allergy: A very large, well conducted systematic review on food allergy has highlighted the confusion around the topic. The review calls for clearer definitions of food allergy, and for standardisation in testing methods and quantification.
Action: We shall continue to consider the possibility of food allergy in those with eczema, especially in infants, but we remain unclear about the best method of diagnosing such food allergy.

Bath emollients: Although few would question the value of emollients in the dry skin associated with eczema, the evidence showing any additional value of bath emollients is questionable because they may never achieve an adequate emollient concentration, much ends up down the drain rather than on the skin, and their use may divert attention away from direct application of emollients in the belief that the bath emollient has done the job.
Action: Whilst we would not actively stop a child from using bath emollients if they like them, we recommend more attention is paid to direct application of emollients after bathing rather than what is put in the bath.

Topical tacrolimus and pimecrolimus: Some comparative efficacy evidence shows that both 0.03% and 0.1% tacrolimus ointment is more effective than 1% pimecrolimus, with a similar range of short-term adverse events.
Action: It is still unclear whether 0.03% tacrolimus is any better than pimecrolimus. We will continue to use either for children with eczema within their licensed indications, and swap from one to the other if the child fails to notice any benefit or reports troublesome burning which lasts more than a week.

Silk clothing: Two small studies have evaluated specialised silk clothing for children with eczema. No clear positive findings were shown and both studies had significant flaws.
Action: We do not recommend that parents are advised to purchase silk clothing for children with eczema and we really need some better studies addressing this issue. If children with eczema try silk clothing and like it, then it is up to families whether they buy it.

Bandages: The evidence base for occlusive therapy with dry or wet-wrap bandages with or without emollients or topical corticosteroids is increasing, but the studies still differ too much in terms of who is studied, and how the occlusive therapy is used, to make any strong recommendations, especially with regards to dry bandages. Wet-wraps as an adjunctive treatment for refractory eczema appear to be useful, but concerns about skin infection and the clinical significance of enhanced absorption of topical corticosteroids require bigger and better studies.
Action: We will continue to use wet-wrap bandages over topical corticosteroids for short periods of up to one week for acute flares of uninfected and heavily excoriated limb eczema that does not respond to conventional topical corticosteroids and emollients.

Antistaphylococcal interventions including bleach baths: There is still no clear evidence that anti-staphylococcal treatments are useful in eczema.
Action: We will continue to use short courses of oral antibiotics for children with overtly infected eczema. We will not use or recommend topical corticosteroid/antibiotic combinations, antibacterial or silver textiles, bleach baths or long term antibiotics in people with clinically infected or non-infected eczema until better evidence becomes available.

Ciprofloxacin utility as antifibrotic in the skin of patients with scleroderma

Rubén EC, Manuel VR, Agustín OR, Huerta M, Antonio FM, Iván DE; Journal of Dermatology 37 (4), 323-9 (Apr 2010)

Abstract: Scleroderma is an autoimmune connective tissue disorder that is characterized by microvascular injury, excessive fibrosis of the skin, and distinctive visceral changes that can involve the lungs, heart, kidneys and gastrointestinal tract. To date, although several drugs have been used to reduce fibrosis in scleroderma, there exists no effective pharmacological treatment. To determine if oral ciprofloxacin reduces the severity of scleroderma, a controlled, double-blind randomized clinical trial, with placebo, was conducted on 32 patients with diffuse and limited scleroderma, who received oral ciprofloxacin (250 mg) or placebo every 12 h. Skin induration and thickness of the patients were clinically evaluated using the modified Rodnan skin score at the beginning and once per month during 6 months of treatment with ciprofloxacin. To monitor progression of the disease, a monthly hematological exam and clinical evaluation was done to explore renal and hepatic function for each patient. Thirty patients completed the study; one from the treatment group was excluded when presenting a skin reaction and another from the placebo group abandoned the study due to an exacerbation of disease. At the sixth month of the study, the ciprofloxacin group of patients showed a diminution in the modified Rodnan skin score (58% vs 18%, P = 0.003), showing no significant alterations in the laboratory assays in either groups of patients. Our results suggest that oral administration of ciprofloxacin for 6 months reduces the severity of symptoms affecting the skin of patients with systemic scleroderma, and does so without important secondary effects.

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Long-term oral azithromycin in chronic plaque psoriasis: a controlled trial.

Eur J Dermatol. 2010 May-Jun;20(3):329-33. Epub 2010 Mar 19.

Saxena V, Dogra J.

Department of Dermatology, SMS Medical College, 103, Burmese Colony, Jaipur-302004 (Rajasthan), India, CGHS, Jaipur (India)103, Burmese Colony,Jaipur-302004 (Rajasthan),India.

Abstract

Continued sub-clinical streptococcal infection might be responsible for chronic plaque psoriasis. Considering the beneficial effect of benzathine penicillin in chronic plaque psoriasis, but due to the risk of penicillin sensitivity and to its painful parenteral route of administration, we tried oral azithromycin in this single blind randomized case-control trial. 50 patients with moderate to severe chronic plaque psoriasis were enrolled. Of these, 30 randomly selected patients received azithromycin for 48 weeks as a single oral 500 mg daily dose for 4 days with a gap of 10 days (total 24 such courses). The remaining 20 patients received a vitamin C tablet (non-chewable) in the same dosage schedule. Informed consent was obtained from all patients enrolled. Though the trial concluded at 48 weeks, patients in the azithromycin-arm were followed for another year to observe any relapse. A significant improvement in PASI score was noted from 12 weeks in the majority of patients in the azithromycin group. At the end of 48 weeks, 18 patients (60%) showed excellent improvement, while 6 patients (20%) showed good improvement and 4 patients (13.33%) showed mild improvement. PASI 75 was 80%. No significant change was seen in lesions in the control group. 2 patients in the study group and 5 patients in the control group did not complete the prescribed duration of study. An exacerbation in lesions was reported in 5 cases (16.66%) in the group receiving azithromycin. These exacerbations also responded by continuing the same treatment. At the end of another one year follow up in the azithromycin-arm, 6 patients (20%) developed a recurrence of lesions. Relevant investigations and clinical assessments were done at regular intervals to observe any side-effects and to check progress of the disease. Data were analysed statistically by using the student t-test. Patients tolerated the therapy well.

PMID: 20299307 [PubMed - in process]

Scar Revision with co2 laser

Part 3 by Dr Young of Bellevue, near Seattle, Washington

Dermabrasion

http://www.webmd.com/skin-beauty/dermabrasion-21085

Dermabrasion

Dermabrasion is a technique that uses a wire brush or a diamond wheel with rough edges (called a burr or fraise) to remove the upper layers of the skin. The brush or burr rotates rapidly, taking off and leveling (abrading or planing) the top layers of the skin. This process injures or wounds the skin and causes it to bleed. As the wound heals, new skin grows to replace the damaged skin that was removed during dermabrasion.

Factors that affect the depth of the resurfacing include how coarse the burr or brush is, how quickly it rotates, how much pressure is applied and for how long, and the condition and features of your skin.

The face is the most common site for treatment, but other areas of the skin can be treated as well. Dermabrasion is used most often to improve the appearance of acne scars and fine lines around the mouth. It also may be used to treat an enlarged nose (rhinophyma) caused by rosacea, an inflammatory skin condition.

How it is done

The areas to be treated are cleaned and marked. A local anesthetic (such as lidocaine) is usually used to numb the skin before treatment, and ice packs are applied to the skin for up to 30 minutes. A freezing (cryogenic) spray may sometimes be used to harden the skin for deeper abrasions if the anesthetic and ice packs do not make the skin firm enough. For deep abrasions, or if the entire face is going to be treated, you may need stronger anesthesia, pain killers, sedation, or general anesthesia.

One small area at a time is treated. The freezing spray (if needed) is applied for a few seconds and then the rotating burr or brush is used to take off the top layers of skin. Gauze is used to stop any bleeding, and the area is covered with a clean dressing or ointment.

Dermabrasion is almost always done in your doctor's office or on an outpatient basis.

What To Expect After Surgery

Your recovery and healing time after dermabrasion depends on the size and depth of the area that was treated. Someone who has a full-face dermabrasion, for example, will require a longer recovery time than someone who has just a small area of skin treated. Deeper abrasions take longer to heal.

In general, regrowth of skin occurs within 5 to 8 days. This new skin is a pink or red color, which usually fades within 6 to 12 weeks. Until then, your normal skin tones can be achieved using makeup.

Many people have little or no pain and can get back to their regular activities soon after the procedure. Some people require pain relievers. If swelling occurs, a corticosteroid such as prednisone may be used to reduce the swelling.

Proper care of the treated area while the skin is healing is extremely important. This involves:

• Cleansing the skin several times a day to avoid infection and to get rid of the crusting that sometimes develops.
• Changing the ointment or dressing on the wound to keep the area moist and to promote healing.
• Avoiding sun exposure and, after peeling has stopped, using sunscreen every day. New skin is more susceptible to sun damage.

You may be given an antiviral drug called acyclovir to prevent infection if you have a history of infection with the herpes simplex virus.

Several follow-up visits to your doctor may be needed to monitor the skin's healing and regrowth and to identify and treat early signs of infection or other complications.

Why It Is Done

Dermabrasion is used to treat damage and defects in the upper layers of the skin, such as:¹

• Acne scars. Removing and improving the appearance of acne scars are the most common uses for dermabrasion.
• Scars caused by surgery or trauma, if they are not deep.
• Superficial skin growths, such as rhinophyma. On rare occasions, dermabrasion may be used to treat small cysts, epidermal nevi, some basal cell skin cancers, or Bowen's disease.
• Tattoos (rarely). There are better ways to remove tattoos (such as with laser resurfacing).
• Color changes in the skin (solar lentigines or melasma). Chemical peels or laser resurfacing are used more commonly than dermabrasion for these problems.
• Fine lines and wrinkles around the mouth.

You may not be a good candidate for dermabrasion if you:

• Have used isotretinoin (such as Accutane, a drug used to treat acne) within the last 6 to 12 months.
• Have recently had a face-lift or brow-lift, although skin areas that were not affected by the lift can be treated.
• Have a history of abnormal scarring (keloid or hypertrophic scars).
• Have an active herpes infection or other skin infection.
• Are overly sensitive to cold (if freezing spray needs to be used).
• Have a skin, blood flow, or immune disorder that could make healing more difficult.

How Well It Works

Your skin type, the condition of the skin, your doctor's level of experience, the type of brush or burr used, and your lifestyle following the procedure can all affect the short-term and long-term results. Some types of skin problems or defects respond better to dermabrasion than others. People with lighter skin who limit their sun exposure after the procedure tend to have better results than those with darker skin and those who continue to spend lots of time in the sun.

In general, dermabrasion results in a smooth, even skin texture and gives scarred skin a more uniform appearance.

• Dermabrasion is effective in improving superficial or nearly flat acne scars. Deeper, pitted acne scars may require another form of treatment (such as punch grafting, elevation, or excision) in addition to or instead of dermabrasion.
• Scars from surgery or injury may be improved when dermabrasion is done 8 to 12 weeks after the surgery or injury (although most new scars will heal and fade somewhat on their own for the first 6 months or so).
• Some superficial growths on the skin can be completely removed, but they are rarely treated using dermabrasion.
• Color changes in the skin can be improved, especially when dermabrasion is used with a bleaching agent and tretinoin (Retin-A), which can enhance the bleaching agent's effects.
• Dermabrasion does not have a dramatic effect on deeper wrinkles, but it may improve fine wrinkles around the mouth and eyes.

The removal of scars, growths on the skin, and tattoos using dermabrasion is permanent. However, changes in the color and texture of the skin caused by aging and sun exposure may continue to develop. Dermabrasion is not a lasting fix for these problems.

Risks

Common temporary side effects of dermabrasion include:

• Scarring.
• Redness. This usually fades within 6 to 12 weeks.
• Swelling.
• Flare-ups of acne or tiny cysts (milia). These can often be treated successfully with tretinoin. Antibiotics are sometimes needed.
• Increased color in the skin. The skin in the area that was treated may turn darker (hyperpigmentation) than the surrounding skin several weeks after dermabrasion.
• Increased sensitivity to sunlight.

Less common complications may include:

• Scarring. The risk of scarring is higher with deeper abrasions and is more likely to occur in bony areas. People who have taken isotretinoin to treat acne are also more likely to have scarring after dermabrasion.
• Lasting redness.
• Prolonged loss of color in the skin. This is more of a problem in darker-skinned people.
• Tissue damage caused by excessive freezing (when a freezing spray is used).
• Infection. This is rare. An antiviral drug may be given before the procedure if the area around the mouth or the entire face is going to be treated.

What To Think About

Expectations

Dermabrasion wounds and destroys the skin. You need to prepare yourself for how your skin will look immediately after treatment and throughout the healing process. It is also extremely important for you to follow your doctor's instructions on caring for your skin after the treatment so you can avoid infection and help your skin heal properly.

Be sure that your doctor understands what you hope to achieve and that you understand what results you can realistically expect. Do not expect a 100% improvement. In general, a 50% improvement in the skin condition is considered a good result. Even with realistic expectations, you may not see results for several weeks or months after dermabrasion.

Sun protection

After dermabrasion, you will need to wear sunscreen every day and avoid sun exposure as much as possible. New skin is more susceptible to damage and discoloration from sunlight.

Options for resurfacing

Dermabrasion, chemical peel, and laser resurfacing are the most commonly used techniques for improving the texture and appearance of the skin. Although these techniques use different methods, they have basically the same effect on the skin-they destroy and remove the upper layers of skin to allow for skin regrowth.

No one technique is necessarily better than the others. When performed by an experienced surgeon, laser resurfacing may be slightly more precise than dermabrasion or chemical peels. Laser treatment also tends to be more expensive than dermabrasion or chemical peeling. In general, the choice of technique is based on the site you want to treat, your skin type and condition, the doctor's experience, your preferences, and other factors. Some people may get the best results by using a combination of techniques.

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April 19, 2010

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More from Eyjafjallajokull

As ash from Iceland's Eyjafjallajokull volcano continued to keep European airspace shut down over the weekend, affecting millions of travelers around the world, some government agencies and airlines clashed over the flight bans. Some restricted airspace is now beginning to open up and some limited flights are being allowed now as airlines are pushing for the ability to judge safety conditions for themselves. The volcano continues to rumble and hurl ash skyward, if at a slightly diminished rate now, as the dispersing ash plume has dropped closer to the ground, and the World Health Organization has issued a health warning to Europeans with respiratory conditions. Collected here are some images from Iceland over the past few days. (35 photos total)

Lightning streaks across the sky as lava flows from a volcano in Eyjafjallajokul April 17, 2010. (REUTERS/Lucas Jackson)

2

The volcano in southern Iceland's Eyjafjallajokull glacier sends ash into the air just prior to sunset ON Friday, April 16, 2010. Thick drifts of volcanic ash blanketed parts of rural Iceland on Friday as a vast, invisible plume of grit drifted over Europe, emptying the skies of planes and sending hundreds of thousands in search of hotel rooms, train tickets or rental cars. (AP Photo/Brynjar Gauti) #

3

Long lens view of farm near the Eyjafjallajokull volcano as it continues to billow smoke and ash during an eruption late on April 17, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

4

A car is seen driving near Kirkjubaejarklaustur, Iceland, through the ash from the volcano eruption under the Eyjafjallajokull glacier on Thursday April 15, 2010. (AP Photo/Omar Oskarsson) #

5

Chunks of ice from a glacial flood triggered by a volcanic eruption lie in front of the still-erupting volcano near Eyjafjallajokul on April 17, 2010. (REUTERS/Lucas Jackson) #

6

Ash covers vegetation in Eyjafjallasveit, southern Iceland April 17, 2010. (REUTERS/Ingolfur Juliusson) #

7

This aerial photo shows the Eyjafjallajokull volcano billowing smoke and ash on April 17, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

8

A woman stands near a waterfall that has been dirtied by ash that has accumulated from the plume of an erupting volcano near Eyjafjallajokull, Iceland on April 18, 2010. (REUTERS/Lucas Jackson) #

9

Horses fight near the town of Sulfoss, Iceland as a volcano in Eyjafjallajokull erupts on April 17, 2010. (REUTERS/Lucas Jackson) #

10

Farmer Thorarinn Olafsson tries to lure his horse back to the stable as a cloud of black ash looms overhead in Drangshlid at Eyjafjoll on April 17, 2010. (REUTERS/Ingolfur Juliusson) #

11

A small plane (upper left) flies past smoke and ash billowing from a volcano in Eyjafjallajokul, Iceland on April 17, 2010. (REUTERS/Lucas Jackson) #

12

Smoke billows from a volcano in Eyjafjallajokull on April 16, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

13

The sun sets in a sky dusted with ash, over Lake Geneva, as seen from the Lavaux Vineyard Terraces, a UNESCO site in Switzerland, on April 17, 2010. (FABRICE COFFRINI/AFP/Getty Images) #

14

The volcano in southern Iceland's Eyjafjallajokull glacier sends ash into the air Saturday, April 17, 2010. (AP Photo/Brynjar Gauti) #

15

Farmers team up to rescue cattle from exposure to the toxic volcanic ash at a farm in Nupur, Iceland, as the volcano in southern Iceland's Eyjafjallajokull glacier sends ash into the air Saturday, April 17, 2010. (AP Photo/Brynjar Gauti) #

16

A rescue team helps landowners to clear volcanic ash from a roof in Seljavellir, Iceland on April 18, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

17

Sheep farmer Thorkell Eiriksson (R) and his brother-in-law Petur Runottsson work to seal a sheep barn, in case winds shift and ash from a volcano erupting across the valley lands on their farm, in Eyjafjallajokull April 17, 2010. The current season is when the spring lambs are born and such young animals are especially susceptible to volcanic ash in their lungs so they must be stored inside. (REUTERS/Lucas Jackson) #

18

A dark ash cloud looms over the Icelandic south coast April 17, 2010. (REUTERS/Ingolfur Juliusson) #

19

Lightning, smoke and lava above Iceland's Eyjafjallajokul volcano on April 17, 2010. (REUTERS/Lucas Jackson) #

20

View seen from a road leading to the Eyjafjallajokull volcano as it continues to billow smoke and ash during an eruption on April 17, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

21

A man runs along the roadside, taking pictures of the Eyjafjallajokull volcano as it continues to billow smoke and ash during an eruption on April 17, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

22

A huge ash cloud creeps over the Icelandic south coast April 16, 2010. (REUTERS/Ingolfur Juliusson) #

23

Wearing a mask and goggles to protect against the smoke, dairy farmer Berglind Hilmarsdottir from Nupur, Iceland, looks for cattle lost in ash clouds, Saturday, April 17, 2010. (AP Photo/Brynjar Gauti) #

24

A farmer checks muddy volcanic ash on his land in Iceland on April 18, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

25

This aerial image shows the crater spewing ash and plumes of grit at the summit of the volcano in southern Iceland's Eyjafjallajokull glacier Saturday April 17, 2010. (AP Photo/Arnar Thorisson/Helicopter.is) #

26

A pilot takes pictures of the Eyjafjallajokull volcano billowing smoke and ash during an eruption on April 17, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

27

Construction crews repair a road damaged by floods from glacial melting caused by a volcano in Eyjafjallajokull, Iceland April 17, 2010. (REUTERS/Lucas Jackson) #

28

Horses graze in a field near the Eyjafjallajokull volcano as it continues to billow dark smoke and ash during an eruption late on April 17, 2010. (HALLDOR KOLBEINS/AFP/Getty Images) #

29

Ingi Sveinbjoernsso leads his horses on a road covered volcanic ash back to his barn in Yzta-baeli, Iceland on April 18, 2010. They come galloping out of the volcanic storm, hooves muffled in the ash, manes flying. 24 hours earlier he had lost the shaggy Icelandic horses in an ash cloud that turned day into night, blanketing the landscape in sticky gray mud. (HALLDOR KOLBEINS/AFP/Getty Images) #

30

The ash plume of southwestern Iceland's Eyjafjallajokull volcano streams southwards over the Northern Atlantic Ocean in a satellite photograph made April 17, 2010. The erupting volcano in Iceland sent new tremors on April 19, but the ash plume which has caused air traffic chaos across Europe has dropped to a height of about 2 km (1.2 mi), the Meteorological Office said. (REUTERS/NERC Satellite Receiving Station, Dundee University, Scotland) #

31

A woman makes a phone call in the empty arrival hall of Prague's Ruzyne Airport after all flights were grounded due to volcanic ash in the skies coming from Iceland April 18, 2010. Air travel across much of Europe was paralyzed for a fourth day on Sunday by a huge cloud of volcanic ash, but Dutch and German test flights carried out without apparent damage seemed to offer hope of respite. (REUTERS/David W Cerny) #

32

Lava and lightning light the crater of Eyjafjallajokul volcano on April 17, 2010. (REUTERS/Lucas Jackson) #

33

The first of 3 photos by Olivier Vandeginste, taken 10 km east of Hvolsvollur at a distance 25 km from the Eyjafjallajokull craters on April 18th, 2010. Lightning and motion-blurred ash appear in this 15-second exposure. (© Olivier Vandeginste) #

34

The second of 3 photos by Olivier Vandeginste, taken 25 km from the Eyjafjallajokull craters on April 18th, 2010. The ash plume is lit from within by multiple flashes of lightning in this 168 second exposure. (© Olivier Vandeginste) #

35

The third of 3 photos by Olivier Vandeginste, taken 10 km east of Hvolsvollur Iceland on April 18th, 2010. Lightning flashes and glowing lava illuminate parts of Eyjafjallajokull's massive ash plume in this 30-second exposure. (© Olivier Vandeginste) #

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