Diagnostics and Therapeutics Flashcards
What is the cause of oral thrush?
Fungal infection from candida
- antibiotic use can cause
- incorrect inhaler technique can cause
- cancer patients and other immunocompromised groups
Symptoms of oral thrush?
Red mouth with white patches
Can cause nappy rash in babies
Is oral thrush contagious?
It is not contagious from oral to oral transmission but babies can pass it on the the nipple of breastfeeding mothers
How to treat oral thrush?
First line: Miconazole gel 1.25ml QDS for seven days (2.5ml in two years plus)
Nystatin 100,000 units if miconazole not indicated
Why would miconazole gel be contraindicated?
Licensed for 4 months plus, or 5/6 months plus in preterm. Choking risk in younger babies, so nystatin may be preferred.
Liver dysfunction
Drug interactions e.g. warfarin
How to prevent oral thrush?
Good dental hygiene
Inhaler advice if appropriate
What if oral thrush hasn’t resolved after seven days of miconazole?
If there was some response continue miconazole for a further seven days
If no response offer seven day course of nystatin
If still no response seek specialist advice
What is the cause of hand, foot and mouth disease?
Coxsackie virus usually the A16 strain
Symptoms of hand, foot and mouth disease?
Sore throat
Possible fever
Tender lesions in mouth and rash on body
How it hand, foot and mouth disease spread?
Contact with nasal/throat secretions Contact with fluid from blisters Faeco-oral transmission Can spread from mother to foetus Transmissible immediately before and during acute stage of illness
How to treat hand, foot and mouth disease?
Usually self limiting
Maintain fluids as dehydration can occur due to pain in mouth
Advise on possible soft diet with no salty, spicy, hot or acidic foods
Advise on analgesics- paracetamol/ibuprofen
How to prevent hand, foot and mouth disease?
Good hand hygiene
Cover mouth and nose when sneezing
Take care when handling nappies
Do not share cups, utensils, clothes or bedding
Do not pierce blisters as fluid is infectious
Other advice for hand, foot and mouth disease?
Avoid close contact with pregnant women
Children do NOT need to be excluded from school/nursery
What is the cause of threadworms?
A parasitic worm called enterobius vermicularis which infests the human gut
Symptoms of threadworms?
Perianal itching, usually worse at night
Worms may be seen on skin or in faeces
How is threadworm spread?
Faeco-oral route when eggs are ingested
Once ingested eggs mature to adult worms in one to two months in the small intestine
Adult female worms migrate to the anus to lay thousands of eggs, usually at night
Threadworms survive for six weeks
Treatment for threadworms?
Mebendazole 100mg stat for all of the household and two weeks or rigorous hygiene measures unless pregnant or under six months of age.
If mebendazole contraindicated then rigorous hygiene measures must be used for six weeks
What rigorous hygiene measures are needed during threadworm treatment?
Good hand hygiene Cut fingernails regularly Shower each morning Change bed linen and night wear daily for several days after treatment- do not shake these items as may spread eggs around room Wash on a hot cycle Throughly dust and vacuum
Do children need to be excluded from school/nursery if they have threadworms?
No
What causes head lice?
Parasitic insects called pediculus humanus capitis infect hairs on the head and feed on blood from the scalp
Life cycle of head lice?
Eggs are laid close to scalp surface, take 7-10 days to hatch
Baby lice hatch from eggs and take 7-10 days to mature to adult
Female lice lay 50-150 eggs a day
Lice have a 30-40 day life span
How is head lice spread?
Crawling between hair shafts of hosts
Head lice symptoms?
Itching on head
White spots in hair (empty eggs)
Sight of lice
Head lice treatment?
Physical insecticides- silicone or fatty acid ester based products that coat the lice and suffocate them
Chemical insecticides- poisons lice (resistance can occur)
Wet combing- to remove the lice
Treatment depends on needs of the individual patient but dimeticone 4% lotion and wet combing are recommended first line for pregnant/breast feeding, ages 6 months to 2 years and patients with asthma or eczema
Other advice for patients with head lice?
No need to be excluded from school/nursery
What causes chickenpox?
Virus called varicella-zoster
What are the symptoms of chickenpox?
Fever Rash (spots) all over body Itchy Crusting of spots within 5 days of the rash, crusts fall off in 1-2 weeks Nausea Headache Tiredness Loss of appetite
How is chickenpox spread?
Personal contact or droplet spread, very infectious as 90% of susceptible contacts contract disease
Incubation period of 1-3 weeks
Infectious from 1-2 days before rash appears until spots have crusted over
Chickenpox treatment?
Paracetamol for pain and pyrexia (licensed for three months plus) Avoid NSAIDs- can cause skin complications Calamine lotion to relieve itching Chlorphenamine for ages 1 year plus 1-2 years: 1mg BD 2-6 years: 1mg 4-6h max 6mg daily 6-12 years: 2mg 4-6h max 12mg daily 12 years plus: 4mg 4-6h max 24 mg daily
Other advice to patients with chickenpox?
Exclude from school until blisters crust over
Also avoid pregnant women, babies less than 4 weeks old and the immunocompromised
Adequate fluid intake
Dress to avoid overheating or shivering
Smooth, cotton fabrics
Keep nails short
Advise on complications: bacterial superinfection, dehydration
What causes slapped cheek?
Parvovirus B19
Symptoms of slapped cheek?
Low-grade fever Nasal discharge Headache Nausea Diarrhoea Rash on cheeks Rash may also be present on trunk, back and limbs
How is slapped cheek spread?
Droplet spread through respiratory secretions
Incubation period of 14-21 days
Only infectious for a few days before rash appears
Slapped cheek treatment?
Adequate fluids
Paracetamol or NSAID if needed
Do children with slapped cheek need to be excluded from school/nursery?
No
What causes measles?
A morbillivirus of the paramyxovirus family
Symptoms of measles?
Non-vaccinated Cough and cold symptoms Conjunctivitis Fever of 39°C or more Rash Koplik’s spots: on buccal mucosa. 2-3mm red spots with blue/white centres
How is measles spread?
Airborne via respiratory tract- almost all susceptible contacts with contract disease
Incubation period of 10 days
Infectious when symptoms appear (four days BEFORE rash appears) and four days after the onset of the rash
Treatment for measles?
Adequate fluids
Paracetamol/ ibuprofen for symptomatic relief
Other advice for patients with measles?
Excludes from school/nursery until at least 4 days after rash appears Avoid contact with susceptible people Urgent medical advice if: Shortness of breath Uncontrolled fever Convulsions Altered consciousness
What causes impetigo?
Staphylococcus aureus or staphylococcus pyogenes. Some is metacillin resistant
How is impetigo spread?
Close contact with infected person or contaminated object
Incubation period of 4-10 days
Infectious until lesions are crusted over
Symptoms of impetigo?
Lesions usually on face around mouth/nose. Usually have yellow crust Itchy Systemic symptoms may occur: Fever Diarrhoea Weakness
How to treat localised impetigo?
1) Hydrogen peroxide cream 1% cream apply two/three times a day for five days
2) if not appropriate use fusidic acid 2% cream three times a day for five days
3) if fusidic acid resistant use mupirocin 2% three times a day for five days
How to treat wide-spread impetigo?
1) fusidic acid 2% three times a day for five days
2) if resistant use flucloxacillin QDS for five days (dose depends on age/weight)
3) if allergic or unsuitable use clarithromycin BD for five days
4) if unsuitable use erythromycin QDS for five days
For systemic infections higher doses may be required
Other advice for impetigo patients?
Good hygiene
Wash affected areas with soap and water
Avoid scratching
Avoid sharing towel, clothes, utensils etc
Exclude from school/nursery until lesions healed or 48 hours after starting antibiotics
What causes ringworm?
Fungal infection usually caused by trichophyton rubrum of interdigitale
How is ringworm spread?
Direct contact with infected human
Direct contact with infected animal
Indirect contact through objects
Contact with soil (rare)
Symptoms of ringworm?
Itchy, scaly skin
Red ring shaped patches
Ringworm treatment?
In mild prescribe terbinafine or imidazole cream
Consider hydrocortisone 1% cream if inflammation
In severe disease prescribe oral anti fungal such as terbinafine
Topical anti fungal treatment for ringworm?
Terbinafine 1% cream (over 12 years): apply once or twice a day for up to 1-2 weeks
Clotrimazole 1% cream: apply two to three times a day and continue for at least 4 weeks
Miconazole 2% cream: apply twice a day continuing for 10 days after lesions have healed
Econazole 1% cream: apply twice a day until skin lesions heal
Oral anti fungal treatment for ringworm?
Terbinafine 250mg OD for four weeks
Contraindicated in hepatic impairment and severe renal impairment
Make sure to check LFTs
Itraconazole 100mg OD for 15 days or 200mg OD for 7 days
Contraindicated in ventricular dysfunction or heart failure
Other advice for ringworm?
Wear loose fitting clothes to keep moisture away from skin
Maintain good hygiene
Dry thoroughly after washing
Avoid scratching as this will cause spread
Do not share towels
Children do NOT need to be excluded from school/nursery
What causes scabies?
Infestation of a parasite called sarcoptes scabiei
Symptoms of scabies?
Pruritus particularly at night
Wavy, thread-like white/grey lines 2-10mm in length which may have a small vesicle with a black dot at the end
How is scabies spread?
Close skin contact with an infected person
Symptoms via shared clothes and towels
Symptoms begin 3-6 weeks after primary infestation
Therefore contagious before rash develops
Usually linked to overcrowded living conditions
How is scabies treated?
For ages over 2 months:
1st line: permethrin 5% cream
2nd line: malathion aqueous 0.5% if permethrin contraindicated or not tolerated
May also prescribe anti-pruritic cream such as crotamiton 10% cream and a sedating antihistamine such as chlorphenamine or hydroxyzine
Other advice for scabies?
Product should usually be applied to the whole body chin downwards however the immunosuppressed, children and the elderly may also have to apply to the face and scalp
Second application required a week after the first
All household members and sexual partners from the last month should be treated
Bedding, clothes and towels should be decontaminated by washing at 60°C and drying in a hot dryer or by sealing in a plastic bag for at least 72 hours
Itching may persist for up to two weeks after successful treatment
Isolate from school or work for until 24 hours after first treatment
What is urticaria?
Superficial swelling of the skin that results in red raised, and intensely itchy rash
Angioedema is a deeper form of urticaria with swelling of the deeper layers
What causes urticaria?
Release of histamine and other inflammatory mediators from activated mast cells
Acute: less than six weeks, usually self-limiting. Can be spontaneous or in response to a trigger such as a viral infection or allergic reaction
Chronic: has the same causes but lasts longer than six weeks
How to treat urticaria?
Identify triggers if appropriate
Non-sedating antihistamine for up to six weeks
If severe offer a short course of steroids
Refer to specialist if appropriate
Paediatric warning symptoms? (13)
Loss of appetite More than 24 hours without a wet nappy Loss of weight Persistently raised temperature Breathing problems Significant earache Discharge from only one nostril Temperature and sore throat Persistent night cough Blood loss from any orifice Neck stiffness Photophobia Rash which does not blanch on pressure
What are three types of eczema in early years?
Atopic eczema Seborrhoeic eczema (cradle cap/dandruff) Nappy rash (contact dermatitis)
Symptoms of atopic eczema?
Usually starts before first birthday
Children can grow out of it
Skin becomes irritated, itchy, red, cracked and inflamed. It can be weeping, crusting and bleeding in severe cases
What cause atopic eczema?
The protect barrier is reduced
Increased moisture loss from the skin
Bacteria/irritants pass through easier
What is atopy?
Genetic tendency to develop allergic disease, capacity to produce IgE in response to common environmental proteins
What is flexural eczema?
Atopic eczema in sites of creases and skin folds
Common trigger factors of atopic eczema?
Soap and detergents Skin infection House-dust mites and their droppings Animal dander and saliva Pollen Overheating Rough clothes
Treatments for atopic eczema?
Mainly emollients and corticosteroids
What are emollients?
Topical treatments to help soothe, smooth, protect and hydrate the skin
Indicated for all dry disorders
They make the skin waterproof
Reduce itching/scratching to reduce secondary infection
Forms of emollients?
Creams Ointments Gels Bath/shower oils Sprays
Positives of aqueous cream?
Useful as a leave on emollient
Negatives of aqueous cream?
Can cause skin reactions
Causative agent may be the stabiliser and cleansing agent sodium lauryl sulphate (SLS)
Also contains other ingredients that may cause a reaction: chlorocrescol, cetostearyl alcohol and parabens
How should emollients be applied?
Liberally
As often as possible but at least three/four times a day
Apply immediately after bath or shower to trap in the maximum amount of moisture
Apply in downwards motion following the direction of the hairs
Do not rub as can lead to irritation from friction
Warnings with emollients?
Some are SLS contains so irritating
Paraffin containing are flammable
Advice for bath/shower oils?
Do not have the water too hot as this can exacerbate itching
Use a bath mat to prevent slipping
Following the directions
Pat skin dry after use
What is complete emollient therapy?
A way of keeping your skin properly moisturised at all times by using a combination of products liberally and frequently
Do not stop suddenly once things get better as they can quickly get worse again
What does a standard complete emollient therapy include?
Emollient-based cleanser or soap substitute
Creams for any time application
Ointment which are usually preferred at night
How to know how much emollient should be prescribed?
Use section in BNF
How do topical corticosteroids work for eczema?
Suppress production of inflammatory mediators
Forms of topical corticosteroids?
Creams Lotions Gels Mousses/foams Ointments Tapes
Four potencies of topical corticosteroids?
Mild
Moderate
Potent
Very potent
How often to apply topical corticosteroids?
Once or twice a day for one to two weeks to control flare ups
No benefits of applying more often
What is a finger tip dosage unit?
Length of cream/ointment from a tube squeezed from the tip of an adult index finger to the crease
Approximately 0.5g
How much does one finger tip dosage unit cover?
Two adult palms including the fingers
Advice for topical corticosteroid application?
Apply thinly to affected areas only
Apply no more than twice a day
Use least potent formulation that gives full effect
Apply up to 20 minutes after application of emollient
What does topical corticosteroid potency mean?
The degree of vasoconstriction they produce in the skin
Why should an emollient be applied up to 20 minutes before a topical corticosteroid?
Hydrates the skin and highlights areas of redness to make it easier to see where to apply corticosteroid
Removes scales which can affect corticosteroid absorption
Also plumps you the skin to increase the surface area for absorbing corticosteroid
Symptoms of seborrhoeic eczema?
Greasy, yellow or brown scaly patches
Usually on the scalps of young babies but can be face, ears, neck, nappy area, armpits and behind the knees of both children and adults
Usually does not itch or cause discomfort
Not contagious
Affects oily skin
Cause of seborrhoeic eczema?
Unclear but not poor hygiene or allergy
May be high levels of sebum on affected areas
Reaction to yeast called malassezia on the skin
Advice for seborrhoeic eczema?
Common in first two months of babies life and clears up in weeks to months without treatment
Do not pick the scales as can cause infection
Hair loss may occur but this will grow back
Scales can be soften overnight with baby oil, white petroleum jelly, olive or vegetable oil and shampoo in the morning
Gently brush with a soft brush
If this doesn’t work an emollient can be tried
When to refer a patient with cradle cap?
Itchy scalp
Swollen scalp
Bleeding scalp
Spreads to the face or body
What is nappy rash?
When the skin around a babies nappy area becomes irritated
Contact dermatitis caused by urine and faeces
Nappy rash causes?
Mainly prolonged exposure to urine or faeces
Can be a result of infection, trauma or rare skin condition
How to prevent nappy rash?
Keep babies skin clean and dry
Use a barrier cream if needed
Trigger factors for nappy rash?
Weaning Common cold Teething Antibiotics First sleeping through the night Change in diet Diarrhoea
Symptoms of a secondary bacterial infection from nappy rash?
Marked redness with exudate
Vesicular and pustular regions
Pus-like drainage or yellowing coloured crusting
Treatment of a secondary bacterial infection from nappy rash?
Advise on skin care
Apply barrier cream every change
Refer to a doctor for oral antibiotics
Do not use talcum powder, vitamin A, topical antibiotics or oral antifungals
Symptoms of a secondary fungal infection from nappy rash?
Severe bright red patches with fine peripheral scale in nappy region
Especially in skin folds
No exudate
Sometimes co-exists with oral thrush
Treatment of a secondary fungal infection from nappy rash?
Advise on skin care
Antifungal cream such as clotrimazole
No barrier creams until infection has settled
When to refer a patient with nappy rash?
Spreading to other areas
Getting worse or refractory to treatment
Bacterial infection present or suspected
Fungal infection that co-exists with oral thrush
Systemic symptoms
Anaemia definition?
A haemoglobin level two standard deviations below the normal for age and sex. Men: below 130g/l Women: below 120g/l Ages 12-14: below 120g/l Pregnant women: 110g/l Postpartum: 100g/l
What serum ferritin level confirms iron deficiency?
Less than 30mcg/l
Causes of iron deficiency anaemia?
dietary deficiency (rarely a cause on its own as it can take eight years to develop)
Malabsorption (coeliac, gastrectomy, H. Pylori infection)
Increased loss mainly from GI or uterus (NSAID use, colonic carcinoma, gastric carcinoma, gastric ulceration, menorrhagia)
Increased requirement (pregnancy)
Other causes (blood donation, self-harm, haematuria, nose bleeds, medication)
What is the most common type of anaemia?
iron deficiencycy
Complications of iron-deficient anaemia?
Cognitive and behavioural impairment in children
Impaired muscular performance
Heart failure
Adverse effects on the immune system
Complications of iron deficiency anaemia in pregnant women?
Increased morbidity (both mother and child)
Possible low birth weight
Preterm delivery
Maternal postpartum fatigue
Iron deficiency in infant for first three months of life
Symptoms of iron deficiency anaemia?
Dyspnoea Fatigue Headache Cognitive dysfunction Restless leg syndrome Serious symptoms such as ankle oedema, worsening of pre-existing angina pain can occur if level less that 70g/l
Signs of iron deficiency (without anaemia?)
fatigue Lack of concentration Irritability Pallor Atrophic glossitis Dry, rough skin and hair Alopecia Ulceration of corners of the mouth Nail changes (ridges, spoon-like)
How to treat iron deficiency anaemia?
address any underlying causes
Prescribe ferrous sulfate, fumarate or gluconate (all equipment to 65mg iron) OD
Continue for three months after the iron deficiency is corrected to allow stores to replenish
If not tolerate changed to alternate-day dosing or consider alternative preparation
Consider parenteral iron if oral not tolerated, contraindicated or ineffective
Information to give patients taking iron supplements?
adverse effects usually settle down with time
Usually taken on an empty stomach, but if GI disturbances occur, then can try taking with or after food (but lowers absortion) or taking on alternate days
Explain monitoring requirements
Safe storage as overdose can be fatal
Side effects of iron supplements?
constipation Diarrhoea Epigastric pain Faecal impaction GI irritation Nausea Black stools
When may ongoing iron supplementation be appropriate?
recurring anaemia (elderly) and further investigations not indicated Iron poor diet (vegan) Malabsorption (coeliac disease) Monnorhagia Patient with gastrectomy Pregnant women Patients in hemodialysis
Oral iron supplements can reduce the absorption of?
Tetracyclines
Quinolones
Bisphosphonates
Zinc
What can reduce the absorption of oral iron?
Zinc Magnesium Calcium Tannins (in tea, coffee, cocoa) Phytates (cereal grains, legumes, nuts and seeds)
Common oral iron supplement interactions?
methyldopa (reduces antihypertensive effect)
Levodopa (bioavailability may be reduced)
Levothyroxine (effects of thyroxine may be reduced)
Penicillamine (absorption can be reduced by up to two thirds)
What is MCV?
mean corpuscular volume
Average size of the red blood cells
Typing anemia due to MCV?
microcytic (<80fl)
Normocytic (80-100fl)
Macrocytic (>100fl)
Types of microcytic anemia?
iron deficiency
Chronic inflammatory disease
Thalassemia
What are reticulocytes?
premature RBCs
Types of normocytic anaemia with a high reticulocyte count?
Haemolytic anaemia
Blood loss
Types of normocytic anaemia with a low reticulocyte count?
bone marrow disorder (aplastic anaemia)
What are megaloblasts?
large immature RBCs
Types of macrocytic anemia with megalobasts?
Vitamin B12 deficiency
Folate deficiency
Drug-induced (methotrexate etc.)
Types of macrocytic anemia without megalobasts?
alcohol abuse
Hypothyroidism
Pregnancy
Types of anaemia caused by decreased RBC production?
Aplastic anemia CKD due to decreased erythropoietin Hypothyroidism Vitamin B12 deficiency Iron deficiency Chronic inflammatory disease
Types of anaemia caused by increased destruction of red blood cells?
Disseminated fragmented coagulopathy (DIG)
Thrombotic thrombocytopenic purpura (TTP)
Hemolytic uremic syndrome (HUS)
Mechanical heart valves
Hypersplenism
Inherited haemolytic anaemia (sickle cell)
Malaria
Bloods test results in hemolytic anaemia?
increased lactate dehydrogenase
Increased reticulocyte count
Increased bilirubin
Low haptoglobin levels
What are red blood cells broken down to?
lactate dehydrogenase Globin Free haemoglobin Unconjugated bilirubin Iron
What is MHC?
mean haemoglobin concentration
a measure of the concentration of haemoglobin
27-32pg is the normal range
What is a low MHC called?
hypochromic
What types of anemia have a low MHC?
Iron deficiency
Chronic disease
Thalassemia
What is aplastic anaemia?
when the bone marrow fails to produce RBC, WBC and platelets
Blood test results for aplastic anaemia?
low Hb
Low platelets
Low neutrophils
Causes of aplastic anaemia?
Congenital (very rare) Idiopathic Infections Exposure to toxins Drugs Pregnancy Sickle cell Genetic factors
What drugs can cause aplastic anaemia?
chloramphenicol, sulfonamides, gold, penicillamine, indometacin, diclofenac, naproxen, piroxicam, phenytoin, carbamazepine, carbimazole, thiouracil, dosulepin, phenothiazines, chlorpropamide, chloroquine
Aplastic anaemia symptoms?
pallor Headache Palpitations Dyspnoea Fatigue Ankle oedema Skin/mucosal haemorrhage Retinal haemorrhage Petechial rashes
Aplastic anaemia treatments?
remove any underlying causes Haemopoietic stem cell transplant immunosuppressive drug therapies include: ATG (anti-thymocyte globulin) combined with cyclosporin Alemtuzumab Eltrombopag
What is AIHA?
autoimmune hemolytic anaemia
What is autoimmune haemolytic anaemia?
when the body produces antibodies again RBCs, so they are destroyed by the immune system
What causes autoimmune haemolytic anaemia?
idiopathic Infections Cancer Autoimmune conditions Certain drugs
Symptoms of autoimmune haemolytic anaemia?
dyspnoea Fatigue Palpitations Chest pain Headache Pallor Jaundice Dark urine Gallstones Splenomegaly
What do blood test results show in AIHA?
raised bilirubin
Raised lactate dehydrogenase
A Coombs test is used to detect antibodies that act against the surface of your red blood cells
Treatments for AIHA?
treat underlying causes if secondary AIHA (drug-induced, cancer)
Steroids
Rituximab
IVIG
Other immunosuppressive drugs (azathioprine, mycophenolate, ciclosporin, cyclophosphamide)
Splenectomy
What is hematocrit?
percentage of a sample of whole blood occupied by intact red blood cells
Norma hematocrit ranges?
males 40-52%
Females 37-47%
What is RDW?
RBC distribution width
(Standard deviation of RBC volume/ mean cell volume) x 100
Normal range for RDW?
11-15%
What does a high RDW show?
Large variability in sizes of RBCs
How does CKD cause anaemia?
Damaged kidneys means a reduced amount of erythropoietin produces
Patients with CKD also use more iron to make the same amount of haemoglobin as others
Treatment options for CKD associated anaemia?
Use of erythropoietin stimulating agents such as epoetin or darbepoetin
IV iron supplementation
Both of these can be given during dialysis
What is a food allergy?
An abnormal reaction of the immune system to a particular food. It can be IgE mediated or non-IgE mediated
What is a food intolerance?
When the body has difficulty digesting certain substances in food or because certain substances directly affect the body somehow. The immune system is not involved
Time of onset of food allergy?
IgE mediated is immediate
Non-IgE mediated is delayed
Time of onset of food Intolerance?
usually a few hours after eating the food
How much food do you need to experience intolerance symptoms?
Substantial amount
How much food do you need to experience allergy symptoms?
Even a tiny amount
Through kissing
Through eating food that has touched the allergen
What antibodies cause some food allergies?
IgE
Food allergy symptoms due to IgE reactions?
Tingling in mouth Swelling of lips, tongue or throat Rash and itching Wheezing and breathlessness Vomiting and nausea Diarrhoea Sneezing and runny nose Itchy and watery eyes Swelling of the face Feeling lightheaded
Food allergy symptoms due to non-IgE reactions?
atopic eczema Vomiting Diarrhoea Constipation Blood/mucus in stools Redness around anus Fatigue Pallor Poor growth
Symptoms of food intolerance?
bloating and abdominal pain Diarrhoea Skin rashes and itching Runny nose Fatigue Headaches
Top 14 foods that cause the most allergies?
Celery Cereals containing gluten Crustaceans Egg Fish Lupin Milk Molluscs Mustard Peanuts Sesame Soya Sulphites Tree nuts
How to diagnose a food intolerance?
Keep a food diary
Trial elimination diet
How to treat food intolerances?
Stop eating the food for a while
A gradual introduction of small amounts of the food
What percentage of children in the UK have a peanut allergy?
2%
The two types of food allergy?
IgE mediated
Non-IgE mediated
How to test for IgE mediated food allergy?
Skin prick test/blood test for specific IgE against the particular allergen
How to treat a cows milk allergy?
Avoid milk in ALL products
Prescribe a milk substitute
Gradual reintroduction through a specialist
Types of milk substitutes for lactose intolerance?
Lactose-free formula such as SMA LF or aptamil lactose free
Main types of medication used for food allergies?
antihistamines
Adrenaline for anaphylaxis
Emerade and jext dosing for a child less than 15kg?
150mcg followed by 150mcg after 5-15 minutes as required
Emerade and jext dosing for a child between 15kg and 30kg?
150mcg followed by 150mcg after 5-15 minutes as required
Although some children may require 300mcg
Emerade and jext dosing for a child and adults above 30kg?
300mcg followed by 300mcg after 5-15 minutes as required
Emerade dosing for ages 12 plus?
500mcg followed by 500mcg after 5-15 minutes as required
EpiPen dosing for a child below 15kg?
150mcg followed by 150mcg as required
EpiPen dosing for a child between 15 and 25kg?
150mcg followed by 150mcg as required
Some children may require 300mcg
EpiPen dosing for a child above 26kg?
300mcg followed by 300mcg after 5-15 minutes as required
EpiPen dosing for an adult?
300mcg followed by 300mcg after 5-15 minutes as required
Advice to give patients prescribed an adrenaline auto-injector?
Two devices should be carried at all times
An ambulance should be called after every administration
The individual should lie down with their legs raised (unless they have breathing difficulties and should sit up) and not be left alone
Should pregant or breastfeeding women avoid peanuts?
no, there is no evidence this will cause the child to develop an allergy
What is lactose intolerance?
a lack of the enzyme lactase to break down lactose in food
Milk substitutes for both IgE mediated and non-IgE mediated cows milk allergy?
First line: hydrolysate formulas such as alimentum, aptamil pepti
Second line: amino acid-based formulas such as neocate, SMA alfamino
In IgE mediated allergy, if a child has severe symptoms such as anaphylaxis, oral angioedema or severe skin rashes, then amino-acid based formulas should be used first-line
What is a normal Hb level during the first trimester of pregnancy?
> 110g/L
What is a normal Hb level during the second and third trimesters of pregnancy?
> 105g/L
What is a normal Hb level postpartum?
> 100g/L
What is a normal Hb level for men aged over 15?
> 130g/L
What is a normal Hb level for women aged over 15?
> 120g/L
What is a normal Hb level for children aged 12-14?
> 120g/L
Why is anaemia more common in pregnancy?
Increased use of iron
An increase in plasma volume that is disproportionate to the red cell mass
When should pregnant women be screened for anaemia?
At their first booking visit and at 28 weeks
Risk factors for developing anaemia in pregnancy?
Low iron stores pre-pregnancy Preexisting blood conditions Inflammatory disorders of the gut Multiple births Aged > 20 Previous birth less than 12 months ago
Why is iron important in pregnancy?
Maintain a healthy immune system
Decrease the impact of blood loss during delivery
Improve postnatal recovery
Avoid a decreased breast milk supply
How to prevent anaemia in pregnancy?
Provide dietary advice to maximise oral iron intake
Why are modified release iron preparations not recommended?
The iron is absorbed slowly through the GI tract and carried to the duodenum where absorption may be poor
Why is iron recommended to be given in divided doses?
The absorption is reduced as the dose increases
When may parenteral iron be used?
When oral therapy is unsuccessful
After 36 weeks of pregnancy
What are the four main types of drug dyscrasias?
Haemolytic anaemia
Thrombocytopenia
Agranulocytosis/neutropenia
Aplastic anaemia
Main two mechanisms for drug-induced haemolytic anaemia?
Immune-mediated
Oxidant injury
Cause of drug-dependent immune-mediated haemolytic anaemia?
The drug binds to the RBC cell surface and becomes part of the antigen which the antibodies bind to
Types of drug-dependent immune-mediated haemolytic anaemia?
Penicillin type
Immune complex type
Passive absorption
What is penicillin type drug-dependent immune-mediated haemolytic anaemia?
The drug remains present on the RBC surface and is needed for antibody binding
What is immune complex type drug-dependent immune-mediated haemolytic anaemia?
the drug causes formation of immune complexes that bind to the RBCs and cause complement activation
What is passive absorption type drug-dependent immune-mediated haemolytic anaemia?
IVIGs frequently contain alloantibodies that react with the recipient’s RBC antigens producing haemolysis
Drugs that can cause immune-mediated haemolytic anaemia?
Cefalosporins Penicillins Anti cancer drugs NSAIDs Many others
How can oxidative injury cause haemolysis?
Oxidant injury can cause hemolysis via oxygen radical damage to RBC membrane components and cellular proteins
This damaged blood cells are the destroyed
Risk factors for developing oxidative injury related haemolytic anaemia?
G6PD deficiency
Haemoglobin H disease
What is G6PD deficiency?
A lack of glucose-6-phosphate dehydrogenase
How can G6PD deficiency increase the risk of drug induced haemolytic anaemia?
Red blood cells are normally protected from oxidant injury by several enzymatic systems including glutathione and NADPH
generation of NADPH requires G6PD
Individuals with G6PD deficiency have increased susceptibility to oxidant drugs
Common drugs that can cause oxidative damage haemolysis?
Nitrofurantoin
Flouroquinolones
Dapsone
How to test for immune-mediated hemolytic anaemia?
Coombs test to test for antibody coating RBCs and circulating antibodies directed against RBCs
What is drug-induced neutropenia?
Neutrophil count of less than 1500/microlitre
Risk factors for drug-induced neutropenia?
women
Impaired drug excretion
Drugs associated with neutropenia?
NSAIDs Antithyroid drugs Macrolides Penicillins Cefalosporins Vancomycin Clozapine Valproate Carbamazepine Phenytoin ACE inhibitors Propranolol Digoxin Diuretics Dapsone Isotretinoin
Symptoms of drug-induced neutropenia?
sore throat
Malaise
Fever
Weakness
What are the four mechanisms for immune-mediated drug-induced neutropenia?
Hapten-type reaction
Innocent bystander phenomenon
Protein carrier mechanism
Auto antibody production
What is the hapten-type reaction associated with immune-mediated drug-induced neutropenia?
drug adsorped to neutrophil membrane
Drug-membrane complex acts as a hapten and stimulates antibody formation
Antibody attached to drug-membrane complex
Complement activation destroys WBC
Usually causes by penicillin
What is the innocent bystander phenomenon associated with immune-mediated drug-induced neutropenia?
The drug combines with a drug-specific antibody which absorbs to neutrophil membrane
Complement activated to destroy the cell
Such as quinidine
What is the protein carrier mechanism reaction associated with immune-mediated drug-induced neutropenia?
Protein carrier combines with drug and then attaches to neutrophil
Antibodies form which attach to complex and activate complement to kill cell
What is the autoantibody reaction associated with immune-mediated drug-induced neutropenia?
drug alter neutrophil membrane
Formation of antibodies that attach to neutrophil and destroy cell
Types of drug induced neutropenia?
immune mediated
Toxic mechanism
Combination of both
Treatment of drug-induced neutropenia?
remove offending agent
Antimicrobial if infection present
GM-CSF and G-CSF
Types of drug-induced thrombocytopenia?
Drug-induced immune thrombocytopenia
Non-immune drug induced thrombocytopenia
Heparin induced thrombocytopenia
What is immune drug induced thrombocytopenia?
caused by drug-dependent antibody-mediated platelet destruction
Drugs that can cause immune drug induced thrombocytopenia?
Beta-lactams Carbamazepine Quinine Rifampicin Phenytoin Co-trimoxazole Vancomycin Tirofiban
What is non-immune drug-induced thrombocytopenia?
Many drugs used as chemotherapy cause thrombocytopenia by bone marrow suppression. Other drugs can also cause moderate thrombocytopenia in some patients by suppression of platelet production.
Drugs that can cause non-immune drug-induced thrombocytopenia?
Daptomycin
Linezolid
Valproic acid
Valaciclovir
What is heparin induced thrombocytopenia?
unique drug reaction in which antibodies against complexes of platelet factor 4 and heparin cause both thrombocytopenia and platelet activation, resulting in venous and/or arterial thrombosis.
Management of drug-induced thrombocytopenia?
remove offending agent
Symptomatic treatment
Corticosteroids in severe cases
Possibly platelet transfusion
What is DITMA?
drug-induced thrombotic microangiopathy
What causes drug-induced thrombotic microangiopathy?
resulting from exposure to a drug that induces formation of drug-dependent antibodies or causes direct tissue toxicity that results in the formation of platelet-rich thrombi in small arterioles or capillaries.
Drugs that can cause DITMA?
Quinine Anticancer drugs Co-trimoxazole Immunosuppressants Valproic acid Quetiapine Clopidogrel Ticlopidine
How to manage DITMA?
remove offending agent
Some evidence for acetylcysteine
How to tell between DITMA AND TTP?
ADAMTS13 enzyme activity is normal in DITMA but reduced in TTP
What is drug-induced a plastic anemia?
the drug acts on the pluripotent stem cells causing pancytopenia
What drugs can cause aplastic anaemia?
chloramphenicol
anticancer drugs
How to treat drug-induced aplastic anaemia?
remove offending drug Treat infections Blood/platelet transfusions Bone marrow transplant (if severe) Immunosuppression ATG, corticosteroids, cyclosporin
Why is otitis media more common in children?
The eustachian tube is shorter in children, which allows easy entry of bacteria and viruses
Facilitates direct extension of infections from the nasopharynx
Risk factors for otitis media?
Passive smoking Air pollution Breastfeeding for less than four months as the immunity will not be passed on Infected or enlarged adenoids Recent cold, flu, sinus or ear infection Drinking whilst laying down in infants Dummy use
Aetiology of otitis media?
Male Caucasian Poverty Familial clustering demonstrated Depressed immune system Anatomic abnormalities Vitamin deficiencies Obesity Other infections
Presentation of otitis media?
Earache Pulling and rubbing the ear Cough and runny nose Eardrum red/yellow or cloudy on examination The eardrum may be bulging
What is the tympanic membrane?
Eardrum
What bacteria can cause otitis media?
Streptococcal pneumoniae
Haemophilus influenza
Moxarella catarrhalis
Most common antibiotic for otitis media?
Amoxicillin
Why are macrolides only used for penicillin-allergic patients with otitis media?
Less effective against Haemophilus influenza
What is the dose of amoxicillin for otitis media in children?
1-11 months: 125mg TDS
1-4 years: 250mg TDS
5-17 years: 500mg TDS
For 5-7 days
Amoxicillin mechanism of action?
Inhibition of cell wall biosynthesis but is susceptible to degradation by B-lacatamases
Broad spectrum against gram positive and negative
What is the VD of amoxicillin?
0.2-0.4l/kg
What time does peak concentration of amoxicillin occur?
~2 hours
What is the half life of amoxicillin?
~1 hour
When should be amoxicillin be taken?
Spread out evenly through the day
Food has no importance
How is amoxicillin excreted?
Renal
What are the common side effects of amoxicillin?
Skin rash, diarrhoea and nausea
Types of impetigo?
Bullous and non-bullous
What is the most common type of impetigo?
Non-bullous
Symptoms of bullous impetigo?
Fluid-filled blisters without redness on the surrounding skin
Face less commonly affected, usually in skin folds
Symptoms of non-bullous impetigo?
Crusts form
Usually on the face but can spread to any area of the body
Who is most likely to have impetigo?
Children
Adults with other skin conditions
Risk factors for impetigo?
Crowded conditions Warm weather Contact sport Broken skin Immunosuppression
Does impetigo leave scarring?
Not usually unless scratched
Complications of impetigo?
Ecthyma can develop, this is when the infection goes deeper into the skin
Symptoms of ecthyma?
Painful blisters
Blisters turn into deep open sores
Thick crusts develop often with redness on the surrounding skin
May leave scars
Differential diagnosis of impetigo?
Herpes Scabies Oral thrush Eczema Insect bites Drug reactions
What bacteria causes impetigo?
Staphylococcus aureus
Staphylococcus pyogenes
Oral antibiotics for impetigo?
Flucloxacillin
Macrolide if penicillin allergy
Topical antibiotic for impetigo?
Fusidic acid
Features of fusidic acid?
Bacteriostatic Protein synthesis inhibitor Narrow spectrum Gram-positive Mainly active against staphylococcus aureus but also effective against streptococci, corynebacteria, Neisseria
How is fusidic acid excreted?
Mainly in bile
Although minimal systemic absorption from topical treatment
Fusidic acid dose for impetigo?
Apply three-four times a day for seven days
Why should fusidic acid and not be used for longer than 10 days?
Development of resistance
Flucloxacillin mechanism of action?
Inhibits cell wall synthesis Narrow spectrum Not inactivated by B-lactamases Staphylococcus aureus Streptococcus
How is flucloxacillin excreted?
Renal
Possible side effect for up to two months after stopping flucloxacillin?
Cholestatic jaundice
Hepatitis
Risk factors: administration for more than two weeks, increasing age
BNF warning labels for flucloxacillin?
Label 9: space doses evenly throughout the day. Keep taking this medicine until the course is finished, unless you are told to stop.
Label 23: take this medication when your stomach is empty. This means an hour before food or two hours after food.
What is the conjunctiva?
A thin covering that covers the white part of the eye and the underside of the eyelids
What can cause conjunctivitis?
Allergens Viruses Bacteria Contact lens use Chemicals Fungi
Most likely cause of hyper-acute conjunctivitis?
Chlamydia
Gonorrhoea
What is acute conjunctivitis?
Less than three weeks
What is chronic conjunctivitis?
More than three weeks
Viruses that can cause conjunctivitis?
Adenovirus
Rubella
Rubeola
Herpes
How is viral conjunctivitis mainly spread?
Hand-to-eye contact by hands or objects Infectious tears Eye discharge Faecal matter Respiratory discharges/droplets
How to treat viral conjunctivitis?
Usually clears itself in 7-14 days
Antivirals may be prescribed for more serious infections such as herpes simplex or varicella zoster
What bacteria can cause conjunctivitis?
Staphylococcus aureus
Haemophilus influenzae
Streptococcus pneumoniae
Symptoms of hyperacute conjunctivitis?
More severe and develops more rapidly
Often eyelid swelling, pain and decreased vision
Large amount of thick purulent discharge that returns even after wiping away
Vision loss if not treated promptly
Usually unilateral
What is ophthalmia neonatorum?
Conjunctivitis caused by chlamydia in neonates
Mother passes on
Symptoms develop 5-12 days after birth
May also have chlamydia elsewhere on the body
Ways to treat bacterial conjunctivitis?
Good hygiene Don't wear contact lenses Lubricant drops Clean with warm water Can use antibiotic drop Systemic antibiotics but only if very severe
Chloramphenicol features?
Bacteriostatic
Broad-spectrum
Gram-positive and negative
Inhibits protein synthesis
Chloramphenicol eye drop dosing for conjunctivitis?
One drop every two hours then reduce the frequency as infection is controlled and continue for 48 hours after healing
For most infections three to four times a day is sufficient
Chloramphenicol eye ointment dosing for conjunctivitis?
Apply three to four times a day OR once at night if using alongside eye drops
Usual treatment length for bacterial conjunctivitis?
Five days
What is cancer?
It occurs when abnormal cells begin to grow uncontrollably. These cells may spread into other tissues
What is the primary tumour?
The site where are growing in an uncontrolled manner
What are the two types of tumours?
Benign
Malignant
What are the five main categories of cancer?
Carcinoma cancer Sarcoma Leukaemia Lymphoma CNS cancer
What are carcinoma cancers?
Begin in skin cells
What are sarcomas?
Begin in connective tissue
What is leukaemia?
Cancer of the blood
What is lymphoma?
Begins in the immune system
What is CNS cancer?
Begins in the CNS
Features of cancer cells?
Reproduce even if not needed
Spread causing metastases
Do not specialise as they are immature cells
Do not repair themselves or die when damaged
Abnormal appearance
What is a proto-oncogene?
Genes that regulate the cell cycle
Operate by stimulating cell growth and division
What is an oncogene?
Mutation in proto-oncogenes
Cause upregulation of the cell cycle, thereby causing cancer
What is a tumour suppressor gene?
Restrict cell growth and division and induce apoptosis
Inhibit cell cycle progression; they are involved in the maintenance of cell cycle checkpoints and initiate apoptosis
How to pass the G2 checkpoint?
Chromosomes successfully replicated
DNA is undamaged
Activated MPF is present
How to pass the G1 checkpoint?
Cell size is adequate Nutrients are sufficient Social signals are present DNA is undamaged Mature cells do not pass this checkpoint as they enter the G2 state
How to pass the metaphase checkpoint?
All chromosomes are attached to spindle apparatus
What determines the maximum growth rate of a tumour?
The cell cycle
How is cancer classified?
Type of tissue
Abnormality of cells
Extent if disease
Cancer treatment options?
Surgery Radiotherapy Chemotherapy Hormone therapy Biological therapy
How does radiotherapy work?
By damaging DNA in cells in a targeted area
How does chemotherapy work?
By killing dividing cells
What parts of the body are commonly affected by cytotoxic drugs?
Hair follicles
Gut
Bone marrow
Why are multidrug regiments usually used for chemotherapy?
Each drug has a different mode of action
Allows for lower doses
Reduces drug resistance
Pharmacokinetic resistance to chemotherapy?
Distribution of drug (e.g. Angiogenesis in the tumour)
Efflux pump
Inactivation or metabolism
Pharmacodynamic resistance to chemotherapy?
Mutation to P53 gene Sensitivity to apoptosis Changes to binding site Improve DNA repair after cytotoxic exposure Adverse extracellular environment
What is neoadjuvant chemotherapy?
Given before surgery
What is adjuvant chemotherapy?
Given after surgery
What is palliative chemotherapy?
Symptom control
Risk factors for childhood cancers?
Inherited diseases such as Down syndrome Foetal development Infections Radiation exposure Previous cancers
Childhood cancers?
Acute leukaemia Lymphomas CNS tumours Neuroblastoma Retinoblastoma Renal tumours Soft tissue tumours Bone tumours
Sings and symptoms of acute lymphoblastic leukaemia?
Flu like symptoms Pale skin Tiredness Breathlessness Unusual bleeding Raised temperature Night sweats Bone and joint pain Swollen lymph nodes Abdominal pain due to swollen liver or spleen Unexplained weight loss and appetite Unexplained seizures Vision changes Behaviour changes
How to diagnose acute lymphoblastic leukaemia?
FBC
Bone marrow biopsy
Lumbar puncture with CSF analysis
Peripheral blood smears
Treatment for acute lymphoblastic leukaemia?
Chemotherapy
Blood transfusions
Platelet transfusion
Antibiotics
Phases of acute lymphoblastic leukaemia treatment?
Remission induction (4 weeks): get rid of all cancer cells Consolidation: stop cancer cells from returning Maintenance: helps keep in remission
Systemic anti cancer drugs for acute lymphoblastic leukaemia?
Cyclophosphamide Cytarabine Daunorubicin Dexamethasone Vincristine Intrathecal methotrexate Oral methotrexate Mercaptopurine Pegaspergase
How to diagnose acute myeloid leukaemia?
Blood test
Lumbar puncture
Bone marrow biopsy
Chest X-ray
Treatment for acute myeloid leukaemia?
Mainly chemotherapy
Radiotherapy
Stem cell transplant
Phases of acute myeloid leukaemia treatment?
Remission: get rid of all cancer cells to put patient in remission
Consolidation: stop cancer from returning
Drugs used for acute myeloid leukaemia?
Cytarabine
Daunorubicin
Etoposide
Fludarabine
Side effects of cytarabine?
Tiredness Soreness at injection site Risk of infection Bruising Anaemia
Side effects of daunorubicin?
Allergic reaction Rash Itching Lip swelling Face swelling Extravasation
Where do most CNS tumours begin?
Glial cells (called gliomas)
Examples of gliomas?
Astrocytoma
Ependymomas
Oligodendrogliomas
Signs and symptoms of CNS tumours?
Vomiting Poor coordination Abnormal eye movements Behaviour change Lethargy Seizures Abnormal head position Increasing head circumference Reduced consciousness Excessive drinking Abnormal growth Persistent headache Blurred vision Delayed puberty
How to diagnose CNS tumours?
CT scan MRI scan Lumbar puncture Biopsy Blood tests
Aims of surgery for CNS tumours?
Biopsy
Relieve intracranial pressure
Remove tumour
Side effects of surgery for CNS tumours?
Brain damage
Side effects of radiotherapy?
Hair loss
Tiredness
Nausea
Poor appetite
Cytotoxic drugs used to treat CNS tumours?
Cyclophosphamide Vincristine Cisplatin Etoposide Carboplatin High dose methotrexate
How common is a sore throat?
Very
6% of GP consultations but many do not actually have a consultation
Causes of a sore throat?
Viral
Bacterial
Non-infectious causes
Viral causes of a sore throat?
Rhinovirus, coronavirus, parainfluenza (25%)
Influenza (4%)
Herpes simplex (2%)
Bacterial causes of sore throat?
Streptococcal pyogenes (GABHS Group A Beta-haemolytic Streptococcus) (15-30% in children, 10% in adults)
Another name for glandular fever?
infectious mononucleosis
What usually causes infectious mononucleosis?
Epstein-Barr virus
How is glandular fever spread?
Saliva contact, sexual contact, blood
Age range glandular fever is most common in?
15-24 year olds
Symptoms of glandular fever?
Fever Lymphadenopathy Sore throat Possible whitewash exude on tonsils Possible pharyngeal inflammation Possible palatal petechiae Fatigue Splenomegaly Hepatomegaly Moderate bradycardia
How to diagnose glandular fever?
FBCs
Monospot test (heterophile antibodies)
Likely if monospot test is positive or FBC shows more than 20% reactive lymphocytes or lymphocyte count is more than 50% of total white cell count
How to treat glandular fever?
Admit to hospital if: stridor, swallowing difficulty or dehydration, serious complications
Analgesia: paracetamol or ibuprofen
Corticosteroids may be prescribed for persistent inflammation
Exclude from school with glandular fever?
No
Why should amoxicillin not be used in secondary infection in patients with glandular fever?
A non-specific rash usually occurs
Non-infectious causes of sore throat?
Irritation
Hayfever
ADR: Stevens-Johnson syndrome, oral mucositis after chemotherapy, blood dyscrasia from drugs such as carbimazole or clozapine
Sore throat complications?
Sinusitis
Otitis media
Quinsy
What is quinsy?
Peri-tonsillar abscess
Collection of pus beside the tonsil in the peritonsillar space
Quinsy symptoms?
Severe pain Fever Dysphagia Drooling Hot potato voice
How to diagnose tonsillitis?
3 or 4 on Centor criteria (40-60% chance)
What are the Centor criteria?
Presence of tonsillar exude
Lymphadenopathy
Fever
Absence of cough
When to refer a sore throat?
Epiglottitis (999 ambulance transfer) Hospital admission: Breather difficulty Clinical dehydration Quinsy Sepsis Possible hospital admission: DMARD Carbimazole Immunocompromised
How to treat viral sore throat?
Self-limiting 3-7 days Analgesia Fluid intake Medicated lozenges Difflam Poor evidence for anything else
Antibiotic prescribing for tonsillitis?
Phenoxymethylpenicillin QDS for 5-10 days
1-11 months: 62.5mg
1-5 years: 125mg
6-11 years: 250mg
12 years +: 500mg
Clarithromycin BD for 5 days, dose depends on body weight mainly
Mainly delayed Rx unless other risk factors
Effectiveness of prescribing antibiotics in tonsilitis?
Reduction of 1 days illness, slightly more if higher centor score
Another name for ringworm?
Tinea
What causes ringworm?
Dermatophytes
How is ringworm transmitted?
Direct contact with infected person, direct contact with infected animal, indirect contact with fomites, contact with soil (rare)
Risk factors for ringworm?
Hot, humid climate Tight-fitting clothing Obesity Hyperhidrosis Immunocompromised Very young or very old African-Caribbean (scalp) Type 1 diabetic Past fungal infections Atherosclerosis Poor circulation, particularly venous insufficiency
Symptoms of ringworm on the body?
Single or multiple, red or pink, flat or slightly raised ring-shaped patches of varying size
Red, scaly edge with a clear central area
Symptoms of ringworm on the groin?
Skin lesions that are usually red to red-brown, flat or slightly raised plaques with active borders
Uniform scale without a clear centre
Typical scaly edge may be lost in moist flexures
Self-care management for fungal infections?
Wear loose-fitting clothing made of cotton
Wash affected areas daily
Dry thoroughly after washing
Avoid scratching as it can spread
Do not share towels
Wash towels, clothes and bed linen frequently
Exclude from school for ringworm?
No
Treatment for ringworm?
Topical antifungal, can use topical corticosteroids for inflammation but NOT alone
Oral antifungal
Application of topical antifungals for ringworm?
Terbinafine 1%: Thinly to the affected area once or twice a day for up to 1-2 weeks
Clotrimazole 1%: apply to affected area two-three times a day for at least 4 weeks. Half a centimetre strip is enough to treat size of a hand
Miconazole 2%: apply to affected area BD and continue 10 days after lesions heal
Econazole 1%: apply to affected area BD until lesions heal
Licensed age range for topical antifungals?
Terbinafine 1% 12 years plus
All others for adults and children
Topical miconazole and econazole drug interactions?
Oral anticoagulants
Monitor during concurrent use
Oral antifungal dosing for ringworm?
Terbinafine 250mg OD for 4 weeks for body infections, 2-4 weeks for groin infections
Itraconazole 100mg OD for 15 days, alternatively 200mg OD for 7 days
Griseofulvin 500mg OD increase to 1g if necessary. Continue for at least two weeks after lesions heal
Oral terbinafine contraindications?
Hepatic impairment
Severe renal impairment
Monitoring for oral terbinafine?
LFTs 4-6 weekly
Stop if deranged
Mechanism of action of clotrimazole?
Fungistatic: inhibition of sterol synthesis for the cell membrane.
Fungicidal: at higher concentrations, calcium and potassium channels are inhibited
Why can’t clotrimazole be given orally?
High first pass metabolism
Clotrimazole side effect?
irritation or burning
Name of ringworm of the scalp?
Tinea capitis
Name of ringworm of the body?
Tinea corporis
Name of ringworm of the groin?
Tinea cruris
Name of ringworm of the nail?
Tinea unguium/ onychomycosis
Treatment for tinea capitis?
Oral antifungal: terbinafine or itraconazole
Topical antifungal: ketoconazole
Treatment for onychomycosis?
Topical amorolfine 1%: apply once or twice a week (6 months for finger, 9-12 months for toe)
Oral terbinafine: 250mg OD 6/52 to 3/12 for fingers, 3-6/12 for toes
Oral itraconazole: 200mg OD 3/12 or more 200mg BD 7/7 and retreat after 21 days. Two courses for fingers, three courses for toes
