Incontinentia Pigmenti

Causes
Symptoms Explained
Diagnostic Tests and What They Show
Non-pharmacological management
Pharmacological care
Dietary molecular supplements
Advanced bone & regenerative agents
Surgical & procedural options
Everyday prevention tips
When should you see a doctor urgently?
What to do & what to avoid
Frequently asked questions

Incontinentia pigmenti (IP) is a rare, X-linked dominant genetic condition that mainly affects girls because boys who inherit the faulty gene (IKBKG/NEMO) often die before birth. The gene normally helps cells switch on NF-κB, a master “survival switch” that keeps skin, blood vessels, nerves, eyes, teeth, and hair healthy. When the switch fails, tissues made from the same embryonic layer (the ectoderm) become fragile, inflamed, or under-developed. Doctors recognise four skin stages that usually unfold in order—blistering in newborns, warty stripes in infancy, swirling dark pigment in childhood, and fading pale patches in teens and adults. Because the same gene is active in the brain, retina, and teeth, children may also have seizures, learning delays, crooked or missing teeth, brittle hair, retinal bleeding, or even retinal detachment without early care. Although the skin changes often fade, eye, tooth, brain, bone, and vascular problems can persist lifelong, so IP is best viewed as a whole-body syndrome that needs coordinated, lifelong follow-up. ncbi.nlm.nih.govrarediseases.org

Incontinentia pigmenti (often shortened to IP) is a very rare genetic disorder that mostly affects girls and women. It begins with striking skin changes in early infancy and can also touch the eyes, teeth, hair, nails, brain, and sometimes other organs. Although the first rashes often alarm parents, many children go on to live full lives when problems are found early and treated promptly. This article brings together the latest research and clinical experience so you can understand what IP is, why it happens, how it shows up, and how health professionals confirm the diagnosis. All explanations use everyday language so anyone—from students to new parents—can follow along. medlineplus.govdermnetnz.org

Causes

Note: The root cause in every proven case is an abnormal IKBKG gene. The extra items below describe variants, molecular details, or factors that can modify severity.

Classic IKBKG exon 4–10 deletion – found in ≈80 % of patients.
Nonsense mutations that create an early stop signal in IKBKG.
Missense mutations that change one amino acid and cripple NF-κB activation.
Small intragenic deletions/insertions inside IKBKG.
Chromosomal rearrangements at Xq28 disrupting the gene.
De novo (new) mutations arising in the father’s sperm or mother’s egg.
Maternal germline mosaicism—only some of the mother’s egg cells carry the mutation.
Somatic mosaicism in surviving males—the faulty gene exists in only part of the body.
Skewed X-chromosome inactivation—in females the “good” X is shut down more often, worsening disease.
Hypomorphic mutations that leave partial NF-κB activity, giving milder skin signs.
Modifier genes (e.g., TANK, IKBKB) that raise or lower NF-κB signaling.
Epigenetic methylation changes that silence IKBKG.
Prenatal hypoxia which stresses NF-κB-defective cells.
Maternal diabetes—high glucose may amplify oxidative stress in the fetus.
Maternal autoimmune antibodies crossing the placenta and injuring ectoderm.
In-utero viral infections (e.g., CMV) further damage fetal skin and vessels.
Oxidative environmental toxins like cigarette smoke exposure during pregnancy.
Advanced maternal age—higher chance of new mutations.
Radiation or chemotherapy in early pregnancy damaging DNA.
Rare duplications in NF-κB pathway regulators that mimic IP features. pmc.ncbi.nlm.nih.govojrd.biomedcentral.com

Symptoms Explained

Blistering rash at birth – first sign, follows Blaschko lines.
Warty streaks in infancy – dried blisters become rough plaques.
Dark marbled patches – brown-gray swirls develop in later infancy.
Pale hairless spots – thin, hypopigmented areas in childhood/adulthood.
Missing or peg-shaped teeth – up to 80 % have dental anomalies.
Delayed tooth eruption – baby teeth often appear late.
Wide gaps between teeth – called diastema.
Brittle or ridged nails – nails may split or spoon.
Sparse scalp hair or alopecia patches.
Strabismus (crossed eyes) – weak eye muscles.
Cataracts or cloudy lenses – can develop in early childhood.
Retinal vascular problems – may lead to vision loss or retinal detachment.
Seizures – about one in five children experience epileptic events.
Sudden stroke-like episodes – due to clogged brain vessels.
Developmental delay or learning difficulties.
Muscle weakness or spasticity – especially after brain injury.
Growth restriction – some infants are small for age.
Recurrent skin infections – fragile skin barrier.
Hearing loss – from nerve pathway issues or middle-ear disease.
Psychological stress – visible skin marks and health worries can affect self-esteem. nfed.orgmy.clevelandclinic.orgpubmed.ncbi.nlm.nih.gov

Diagnostic Tests and What They Show

Physical-Exam–Based Tests

Full-body skin inspection – reveals stage-specific lesions and their Blaschko pattern.
Neurological reflex check – looks for asymmetry, hyper- or hyporeflexia signaling brain injury.
Developmental milestone assessment – tracks sitting, walking, speech to flag delays.
Direct ophthalmoscopy – detects retinal bleeding or vessel closure early.
Snellen visual-acuity chart – quick screen for vision loss in older children.
Comprehensive oral exam – counts teeth, notes shape and enamel quality.
Nail and hair inspection – finds ridged nails or alopecia patches.
Growth parameter charting – head circumference, weight, length to spot failure to thrive. dermnetnz.orgmy.clevelandclinic.org

Manual (Bedside) Tests

Cover–uncover eye test – identifies hidden eye misalignment.
Rinne tuning-fork test – screens for conductive hearing loss.
Weber tuning-fork test – picks up unilateral sensorineural loss.
Light-touch and pin-prick mapping – checks peripheral nerve integrity.
Manual muscle strength grading (MRC scale) – rates power from 0–5.
Deep-tendon reflex percussion – exaggerated reflexes hint at central damage.
Doll’s-eye maneuver – crude check of vestibulo-ocular reflex in infants.
Fontanelle palpation – bulging soft spot may point to intracranial pressure. ncbi.nlm.nih.gov

Lab & Pathological Tests

IKBKG exon 4–10 deletion assay – gold-standard genetic test (~80 % positive).
Sanger sequencing of IKBKG – finds rare point mutations.
Multiplex ligation-dependent probe amplification (MLPA) – detects small deletions/duplications.
Next-generation sequencing ectodermal-dysplasia panel – scans many related genes at once.
X-inactivation (HUMARA) assay – measures skewing that predicts severity.
Skin-biopsy histology – early lesions show eosinophilic spongiosis; later show melanin clumping.
Complete blood count with differential – may reveal eosinophilia during blistering stage.
Cytokine profile (TNF-α, IL-6) – elevated markers of NF-κB pathway stress in severe cases. pubmed.ncbi.nlm.nih.govfrontiersin.org

Electro-diagnostic Tests

Electroencephalogram (EEG) – records seizure activity or background slowing.
Visual evoked potentials (VEP) – measure optic-nerve conduction.
Brainstem auditory evoked response (BAER) – screens infant hearing pathways.
Somatosensory evoked potentials (SSEP) – map signal travel in spinal cords.
Electroretinography (ERG) – gauges retinal photoreceptor function.
Electro-oculography (EOG) – tracks eye-movement-related potentials.
Nerve-conduction velocity (NCV) – checks peripheral nerves for demyelination.
Electromyography (EMG) – evaluates muscle electrical activity for weakness origin. pubmed.ncbi.nlm.nih.gov

Imaging Tests

Brain MRI with angiography – finds strokes, vessel narrowing, or malformations.
Diffusion-weighted MRI – highlights acute brain injury minutes after onset.
Fundus photography – documents retinal hemorrhages and neovascular growth.
Optical coherence tomography (OCT) – provides cross-section “microscopy” of retina.
Fluorescein angiography – shows leaking or blocked retinal vessels.
Panoramic dental X-ray (OPG) – maps missing, unerupted, or cone-shaped teeth.
Cone-beam CT of jaws – high-detail 3-D view for dental planning.
High-frequency skin ultrasound – measures thickness, cysts, and scarring in lesions. nfed.org

Non-pharmacological management

Below are 30 evidence-based, drug-free strategies divided into four groups. Each paragraph explains what the therapy is, why it matters, and how it works inside the body.

A. Physiotherapy & electrotherapy

Neonatal positioning care – Skilled therapists teach parents to keep fragile newborn skin off hard surfaces, reducing blisters and scarring by lowering mechanical shear on poorly protected epidermis. pubmed.ncbi.nlm.nih.gov
Passive range-of-motion (PROM) – Gentle limb movements prevent contractures in babies who cannot move well after brain injury. PROM preserves joint nutrition by cycling synovial fluid.
Bobath neuro-developmental therapy – Hands-on facilitation of normal movement patterns in infants with spasticity retrains immature motor pathways through repetitive, goal-directed practice.
Constraint-induced movement therapy – Temporarily casting the stronger arm forces use of the weaker side, driving cortical rewiring and improving grasp skills.
Treadmill gait training with body-weight support – A harness lets children rehearse stepping long before they can stand unassisted, stimulating central pattern generators in the spinal cord.
Hydrotherapy – Warm-water exercise unloads joints and soothes itchy or inflamed skin; hydrostatic pressure also boosts venous return, easing limb swelling.
Balance-board practice – Standing on wobble boards improves ankle proprioception and reduces fall risk once walking begins.
Sensory-integration play – Textured mats, swings, and weighted blankets help the brain process touch and motion cues, calming sensory defensiveness common in neuro-cutaneous disorders.
Low-level laser therapy (LLLT) – Red-light irradiation (650–830 nm, ≤5 J/cm²) speeds epidermal repair by triggering cytochrome-C oxidase inside mitochondria, boosting ATP for cell growth.
Transcutaneous electrical nerve stimulation (TENS) – Mild surface currents gate pain signals and may ease neuropathic itch during the blister and verrucous stages.
Neuromuscular electrical stimulation (NMES) – Stronger pulses recruit weak muscles, preventing disuse atrophy while neural control improves.
Postural training with elastic taping – Kinesio-tape supports spinal alignment, reduces scoliosis progression, and gives cutaneous feedback for trunk control.
Orthoptic eye exercises – Patching the dominant eye and performing convergence drills promotes binocular fusion, critical where retinal scarring causes amblyopia.
Vestibular rehabilitation – Head-motion tasks recalibrate inner-ear balance circuits damaged by vascular events in IP.
Phototherapy (narrow-band UV-B) – Controlled ultraviolet doses dampen over-active skin immune cells, shortening flare duration without systemic drugs.

B. Exercise therapies

Progressive resistance training – Age-appropriate bands build muscle around dystrophic bones, reducing fracture risk. Micro-tears activate osteoblasts through mechanotransduction.
Cycling ergometry – Stationary bikes offer aerobic conditioning without loading fragile skin on feet, improving cardiovascular fitness and neurotrophic factor release.
Aquatic Pilates – Core-centric poses in chest-deep water stabilise the spine safely while engaging deep abdominal and paraspinal muscles.
Yoga for kids – Simple poses plus breathing lower cortisol and improve body-awareness, reducing stress-triggered eczema flares.
Interval walking programs – Alternating brisk and slow bouts raises growth-hormone pulses that aid dermal collagen repair.

C. Mind-body interventions

Mindfulness-based stress reduction (MBSR) – Guided meditation curbs the NF-κB inflammatory cascade by lowering sympathetic overdrive.
Cognitive-behavioural therapy for itch and pain – CBT rewires catastrophic thought loops, teaching distraction and sensory re-labelling.
Biofeedback for migraine-like headaches – Surface EMG devices train relaxation of pericranial muscles, cutting trigeminovascular triggers.
Therapeutic music and rhythmic drumming – Co-regulated heart-rate variability fosters parasympathetic tone, easing anxiety during dressing changes.
Art therapy – Externalising fears through drawing improves adherence to complex care routines.

D. Educational & self-management tools

Genetic counselling sessions – Families learn inheritance patterns, prenatal testing choices, and early warning signs, empowering proactive surveillance. ncbi.nlm.nih.gov
Parent-delivered skin-care workshops – Hands-on lessons cover gentle cleansing, emollient layering, and prompt blister hygiene to ward off bacterial infections.
Dental-hygiene coaching – Special brushes, fluoride varnish, and speech drills limit decay around peg-shaped teeth and support clear speech.
Interactive seizure-first-aid training – Video modules teach safe positioning and timing of fits, improving emergency responses and reducing injury.
Online peer-support forums – Community sharing fights isolation, boosts resilience, and spreads real-world tips faster than clinic visits.

Pharmacological care

IP has no single cure, so drugs are chosen to tackle specific complications. The doses given are typical starting points for otherwise healthy children; all require individual medical supervision.

Prednisolone syrup 1–2 mg/kg/day (systemic corticosteroid) – Short bursts calm severe blister flares or cerebral vasculitis by suppressing NF-κB‐driven cytokines; taper within two weeks to limit growth suppression. emedicine.medscape.com
Topical mometasone 0.1 % ointment once daily (medium-potency steroid) – Reduces weeping and itch in stage-1 plaques; limit to 14 days per site to avoid skin thinning.
Levetiracetam 10 mg/kg twice daily (broad-spectrum anti-epileptic) – First-line for neonatal or infantile seizures; minimal drug interactions, common side effect: irritability.
Phenobarbital 3 mg/kg at bedtime (barbiturate anti-epileptic) – Useful where intravenous access is poor; watch for respiratory depression.
Valproate 20 mg/kg/day in two doses (GABA enhancer) – For refractory myoclonic jerks; monitor liver enzymes and platelets.
Cephalexin 25 mg/kg every 8 h for 7 days (first-generation cephalosporin) – Treats secondary bacterial cellulitis around ruptured blisters; GI upset is common.
Acyclovir 20 mg/kg IV every 8 h (antiviral guanosine analogue) – Empirical cover during extensive vesicles when neonatal herpes is a concern; continue 10 days if HSV confirmed.
Bevacizumab 0.625 mg intravitreal single dose (anti-VEGF monoclonal) – Stops sight-threatening retinal neovascularization; repeat only if leakage recurs; risk: transient arterial constriction. pubmed.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov
Ranibizumab 0.2 mg intravitreal monthly × 3 (anti-VEGF fragment) – Alternative with shorter systemic exposure; monitor for intra-ocular pressure spikes.
Timolol 0.25 % eye-drops twice daily (topical β-blocker) – Controls secondary glaucoma by lowering aqueous humour production; caution in asthma.
Nepafenac 0.1 % eye-drops thrice daily (topical NSAID) – Relieves post-laser photocoagulation inflammation; may delay corneal healing if overused.
Infliximab 5 mg/kg IV at weeks 0, 2, 6 (TNF-α inhibitor) – Off-label for refractory vasculitic brain lesions; screen for tuberculosis.
Adalimumab 20 mg subcut every other week (>15 kg) (TNF-α blocker) – Option where infliximab unavailable; injection-site pain is common.
Intravenous immunoglobulin (IVIG) 2 g/kg over 48 h – Modulates auto-antibody activity in fulminant infant encephalopathy; watch for aseptic meningitis.
Oral zinc sulfate 1 mg elemental/kg/day (trace mineral) – Supports skin barrier enzymes and immune defence; metallic taste possible.
Cetirizine 0.25 mg/kg at night (second-generation antihistamine) – Eases itch without drowsiness; dose adjust in renal impairment.
Acetaminophen 15 mg/kg every 6 h PRN (analgesic antipyretic) – Safe pain reliever for dressing changes; keep under 60 mg/kg/day.
Prednisolone acetate 1 % eye-drops four-times daily (ocular steroid) – Shortens post-surgical retinal inflammation; taper to avoid cataract.
Baclofen 5 mg orally three times daily (GABA-B agonist) – Relieves painful spasticity when physiotherapy alone is insufficient; may cause dizziness.
Gabapentin 10 mg/kg at night (neuropathic pain modulator) – Targets chronic burning sensations from healed but hypersensitive skin.

Dietary molecular supplements

Omega-3 fish-oil 1 g EPA + DHA daily – Converts into anti-inflammatory resolvins that cool NF-κB signalling, easing eczema-like flares and aiding retinal perfusion. pmc.ncbi.nlm.nih.govpubmed.ncbi.nlm.nih.gov
Vitamin D₃ 1000 IU daily – Enhances cathelicidin peptides that fight skin infection and supports bone mineralisation that may be weakened by chronic inflammation.
Vitamin E (α-tocopherol) 400 IU daily – Lipid-soluble antioxidant shields cell membranes from free-radical damage, slowing pigment loss.
Vitamin C 500 mg twice daily – Water-soluble antioxidant recycles oxidised vitamin E and is co-factor for collagen cross-linking, strengthening dermis.
Lutein/Zeaxanthin 10 mg/2 mg daily – Carotenoids build macular pigment, filtering blue light and reducing oxidative retinal injury. aaojournal.orghealthline.com
Coenzyme Q10 100 mg daily with meals – Supports mitochondrial ATP generation in rapidly renewing epidermal cells.
Alpha-lipoic acid 300 mg daily – Dual water- and fat-phase antioxidant regenerates vitamins C and E, improving nerve blood flow.
Zinc gluconate 10 mg elemental daily – Co-factor for DNA repair enzymes and innate immunity.
Selenium 55 µg daily – Required for glutathione peroxidase that neutralises hydrogen-peroxide in melanocytes.
Probiotic L. rhamnosus GG 10⁹ CFU daily – Alters gut-skin axis cytokine balance, reducing systemic inflammation and atopic symptoms. jaci-inpractice.org

Advanced bone & regenerative agents

Alendronate 0.7 mg/kg once weekly (oral bisphosphonate) – Binds bone hydroxy-apatite, blocking osteoclast acid pumps and preventing vertebral compression.
Zoledronic acid 0.05 mg/kg IV once yearly (potent bisphosphonate) – Single infusion raises lumbar bone density; monitor renal function.
Risedronate 1 mg/kg monthly (bisphosphonate) – Useful where weekly adherence is difficult.
Denosumab 60 mg subcut every 6 months (RANKL antibody) – Stops osteoclast formation; reversible and handy if bisphosphonates fail.
Teriparatide 20 µg daily (recombinant PTH 1-34, regenerative anabolic) – Stimulates osteoblasts in adults with severe osteoporosis; limit to two years.
Bone morphogenetic protein-7 (BMP-7) graft paste during surgery – Induces local stem cells to form new cortical bone bridges.
Platelet-rich plasma (PRP) intra-dermal injection every 4 weeks × 3 – Concentrated growth factors (PDGF, VEGF) accelerate dermal-epidermal junction repair.
Hyaluronic-acid ocular gel (1 drop QID) – Viscosupplement coats cornea, reducing dry-eye pain after retinal laser.
Umbilical cord-derived mesenchymal stem-cell topical gel (investigational) – Paracrine cytokines modulate dermal fibroblasts, evening pigment.
Autologous hematopoietic stem-cell transplant (single procedure) – In early trials for catastrophic CNS vasculopathy; aims to repopulate immune cells without NF-κB flaws.

Surgical & procedural options

Retinal laser photocoagulation – Burns avascular retina, starving rogue vessels of oxygen and preventing tractional detachment; vision preserved in >90 %. ojrd.biomedcentral.com
Pars-plana vitrectomy – Removes scarred vitreous gel so the retina can lie flat; restores sight if done before macular involvement.
Retinal cryotherapy with scleral buckle – Freezes and indents eyeball wall, sealing tears in cases where laser access is blocked by haemorrhage. pubmed.ncbi.nlm.nih.gov
Dental implants & crowns – Titanium posts anchor prosthetic teeth, improving chewing, speech, and self-esteem in adolescence.
Orthognathic jaw surgery – Realigns under-developed maxilla, preventing obstructive sleep apnoea and facial asymmetry.
Spinal rod fixation – Corrects progressive scoliosis due to hemivertebrae, freeing lung expansion.
Cochlear implantation – Bypasses cochlear nerve damage, giving usable hearing when neurovascular injury causes deafness.
Dermabrasion with split-skin graft – Resurfaces thick, warty plaques unresponsive to medical care.
Neurosurgical decompression (ventricular shunt) – Relieves hydrocephalus from cerebrovascular accidents.
Targeted excimer laser for verrucous lesions – 308 nm UV-B breaks keratin bonds, flattening stubborn plantar plaques with little collateral damage.

Everyday prevention tips

Early genetic testing in future pregnancies enables prenatal diagnosis and planned neonatal monitoring.
Sun-smart clothing & SPF 50+ protect pigment-altered skin from burns that trigger blister relapse.
Stay up-to-date on vaccines; skin breaks heighten infection risk.
Prompt treat fevers to lower seizure threshold risk.
Yearly eye exams from birth to catch silent retinal changes early. ojrd.biomedcentral.com
Twice-yearly dental visits keep fragile enamel intact.
Avoid harsh soaps and wool; choose pH-balanced cleansers and cotton.
Moisturise within 3 min of bathing (“soak-and-seal”) to lock in water.
Use child-safe helmets & pads—bone fragility means minor falls may fracture.
Teach itch-scratch alternative (press rather than rub) to avert skin tears.

When should you see a doctor urgently?

See your paediatrician or specialist immediately if your baby develops any of the following:

A new seizure or unexplained staring spell
Rapid eye movements, wandering eye, or sudden vision loss
Bulging fontanelle or vomiting suggesting brain pressure
Blisters that spread in streaks with fever or yellow pus
Black “floaters,” flashes of light, or curtain-like shadow in vision
Sudden limping, back pain, or unequal limb length
Persistent tooth pain or abscess

Regular 3- to 6-month check-ups with dermatology, neurology, ophthalmology, and dentistry remain essential even when the skin looks calm. ncbi.nlm.nih.gov

What to do & what to avoid

Do moisturise twice daily; avoid alcohol-based lotions that sting.
Do keep nails trimmed; avoid scratching blisters.
Do dress in layered cotton; avoid overheating that provokes sweat blisters.
Do practise daily eye-tracking games; avoid screen time without breaks.
Do follow your seizure action plan; avoid skipping anti-epileptic doses.
Do use fluoride toothpaste; avoid hard-bristle brushes.
Do gentle resistance exercise; avoid high-impact sports until bone density confirmed.
Do log skin changes with photos; avoid self-treating with over-the-counter steroids longer than 2 weeks.
Do eat antioxidant-rich foods; avoid ultra-processed, high-sugar snacks that fuel inflammation.
Do connect with patient groups; avoid isolation—shared stories inspire practical solutions.

Frequently asked questions

Is IP contagious?
No. It is a genetic condition inherited or caused by a new mutation; you cannot “catch” it.
Will the dark swirls fade?
Most pigment streaks lighten after puberty, but subtle ghost lines may remain.
Can boys survive IP?
Yes—if they have mosaic (patchy) mutations or an extra X chromosome (Klinefelter 47,XXY).
Does every child get eye disease?
Roughly one-third develop retinal vascular problems, but early laser can save vision. ojrd.biomedcentral.com
Are seizures lifelong?
Many infants outgrow them; about 10 % need long-term medication.
Why are teeth affected?
Enamel-forming cells share the faulty NF-κB pathway, leading to peg-shaped or missing teeth.
Can I breast-feed?
Yes—the gene defect is not in milk, and breast-feeding supplies immune factors that protect fragile skin.
Is there a cure yet?
Currently no; treatment is supportive. Stem-cell and gene-editing research is underway.
Does diet really help?
Balanced omega-3, antioxidants, and low sugar reduce systemic inflammation, supporting skin healing. pmc.ncbi.nlm.nih.gov
Can vaccines trigger flares?
Transient redness can occur at injection sites but the benefits outweigh minimal risk.
Will my child’s hair grow normally?
Some children have sparse scalp patches; topical minoxidil may help, but evidence is limited.
Is school PE safe?
Yes, with protective gear and teacher awareness of seizure precautions.
Can girls with IP have healthy babies?
Absolutely—50 % chance each pregnancy; prenatal testing or IVF with genetic screening can be offered.
Why do blisters follow lines?
They trace embryonic “lines of Blaschko,” paths of skin cell migration.
Where can I find support?
National Foundation for Ectodermal Dysplasias (NFED) and Incontinentia Pigmenti International Foundation provide resources, webinars, and family networks. nfed.org

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.