Skin lesions, solar damage, cancers, skin infections

Question 1

What are the risk factors for cutaneous candida infection?

Answer 1

Broad spectrum antibiotics

Diabetes

General Debility

Immunodeficiency

Obesity

Immobility

Question 2

What type of skin environment leads to candida infection on the skin?

Answer 2

Usually conditions that make the skin moist or macerated predispose to candida infection

Question 3

What are 4 treatment steps for this? If drugs are used, please provide dosing.

Answer 3

This is a candida infection

1. Keep Skin dry
2. Apply a barrier cream like white parafin or zinc oxide
3. Topical anti-fungal cream
   Clotrimazole 1% cream, applied topically, twice daily until skin is clear

Or miconazole 2% cream same instructions. This is safer for breast candida if breast feeding

4. If there is pruritus then you can use a topical steroid such as hydrocortisone 1% cream applied twice daily for 2 weeks

Oral Anti-fungal therapy is not usually needed

Question 4

What is folliculitis and what are the two main groups of causes ?

Answer 4

It is any inflammation of the hair follicle that presents as a papule or pustule with an erythematous base

Non-infective causes

Infective Causes

Question 5

What are the infective agents that cause folliculitis?

(Up to 6)

Answer 5

Mostly Staphylococcus Aureus
Sometimes Pseudomonas Aeruginosa (from spas/hot tubs)
Sometimes Malassezia yeasts
Dermophytes
Dermodex mites
Herpes Simplex virus

Question 6

List non antibiotic management advice for infective folliculitis?

(4)

Answer 6

Warm compressors

Antiseptic wash- benzoyl peroxide or whatever is in Dettol (chloroxylenol)

Clean sharp razors when shaving

Advise patients to avoid triggers

Question 7

What to do for treatment of folliculitis, thought to be due to Staphylococcus Aureus?

Answer 7

Treat as impetigo

In non endemic settings

For localised lesions
mupirocin 2% ointment or cream topically to crusted areas, 8-hourly for 5 days.

For widespread lesions
Flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 7 days. Stop therapy earlier if infection has resolved.

Dicloxacillin or Cephalexin can be used instead, with the exact same dosing

Question 8

What is this?
How would you describe it?

Answer 8

This is perioral impetigo

Showing perioral honey coloured crusts

Caused by Staphylococcus Aureus

Question 9

What are the complications of impetigo?

(7)

Answer 9

Widespread cellulitis

Staphylococcal Scalded Skin syndrome

Scarlet Fever

Post-strephtococcal Glomerulonephritis

Streptococcal Toxic shock syndrome

Post inflammatory pigmentation

Scarring

Question 10

What is the treatment for Impetigo in ENDEMIC settings?
i.e remote communities in central and northern Australia dosing not required.

Answer 10

benzathine benzylpenicillin intramuscularly as a single dose

FYI
adult: 1.2 million units (2.3 mL)

child less than 10 kg: 0.45 million units (0.9 mL)

child 10 kg to less than 20 kg: 0.6 million units (1.2 mL)

child 20 kg or more: 1.2 million units (2.3 mL)

Or

trimethoprim+sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly for 3 days

While the bactrim may be easier to administer, if there is a risk of not following up then give the IM penicillin

Question 11

Difference between impetigo and bullous impetigo?

Answer 11

non bullous starts with a macule, and might develop a pustule or vesicle, this ruptures usually leaving a honey coloured crust. There is minimal surrounding erythema. Patients are usually well otherwise.

Bullous impetigo have quickly appearing thin walled small or large bullae that spontaneously rupture and ooze a yellow discharge. More likely to cause systemic features. Can affect any part of the body.

Question 12

What is this?

How do you treat it?

Answer 12

Erythrasma

caused by Corynebacterium minutissimum.

Treat with
fusidate sodium 2% ointment topically, twice daily for 14 days - not actually sure this is available in australia

But can also use
Clarithryomycin 1gram as a single oral dose.

Question 13

Which virus is responsible for this?

Answer 13

Herpes Simplex virus

Question 14

Coldsores are commonly caused by _____ _____ ____ and they can be treated with _______________ which is available ____________.

If the outbreak is severe you can use ____________ in an __________.

Children who do not have control over their secretions should be ________ from _______

Answer 14

Herpes Simplex virus

benzydamine 1% gel (adult and child 6 years or older), topically to the lesions, 2- to 3-hourly as necessary.

Over the counter

famciclovir 500 mg orally, 12-hourly for 7 days

adult

excluded, from, school or childcare

Question 15

What does human papillomavirus cause on the skin?

Answer 15

warty papules or plaques on the skin.

Question 16

What are common warts, how are they treated?

Answer 16

They are known as verruca vulgaris, and usually present in children on their extremities- hands feet and extensor surfaces.

They can resolve spontaneously or can be treated with

1. salicylic acid up to 40% w/v, with or without lactic acid, topically, once daily until wart has cleared or for up to 3 months.

or

2. Liquid nitrogen cryotherapy, 2 x 20 second freezes per wart, that might need to be repeated weekly

Question 17

What are plantar warts?

Answer 17

They are also common warts caused by HPV virus, only they occur on the bottom of the foot and usually require more aggressive treatment

Question 18

What are plane warts?

Answer 18

they are caused usually by a different subset of HPV, and instead of a raised warty papule they cause small plaques.

They usually spontaneously resolve in 6-12 months

If treatment is desired

on the face: tretinoin 0.05% cream topically, once daily for at least 3 months. –avoid tretinoin in pregnancy!

Treat as common warts on other parts of the body

Question 19

How do you prevent spread of this? - advice for parents

Found in a child, not painful or itchy

Answer 19

This is Molluscum Contagiosum

Give the child a shower not a bath

after a shower Dry areas of infection last so it doesn’t spread

Wash and dry bath toys after use

Do not share towels, face washers or clothing

Wash your hands thoroughly after touching your child’s spots

Question 20

Treatments available for Molloscum?

Answer 20

They usually resolve so it is not needed

There isn’t much evidence to support treatments but

1. topical imiquimod cream for many lesions
   -tedious and expensive though
2. Curettage
3. Cryotherapy
4. Adhesive tape therapy- that’s right apply adhesive tape to the lesions for 24 hours then rip off quickly. The more adhesive the better it helps irritate the lesions.
   -beware of exacerbating any surrounding dermatitis or if the patient has a contact dermatitis to adhesive.

Question 21

What is pityriasis versicolour caused by and what is the treatment?

Answer 21

A. Malassezia yeasts.

B. ketoconazole 2% shampoo topically, once daily (leave for 3 to 5 minutes and wash off), for 5 days

Question 22

General Household Measures to consider when treating scabies?

Answer 22

1. Wash all of the infected person’s clothing, towels and bedding in a hot cycle 60 dC + and or put into a hot clothes drier.
2. Wash all of the clothes ,towels and bedding of the infected person’s family/household contacts in a hot cycle or put into a hot clothes drier

(alternatively pack the clothing/towels/bedding into a sealed plastic bag and leave it for 8 days)

3. If possible put all mattresses, pillows and blankets into the sun
4. Vacuum the entire house
5. NO body contact with items that cannot be washed or put in the sun for at least 3 days

(alternatively pack

Question 23

When can a child return to school after having scabies?

Answer 23

After being treated twice, which is usually a week apart.

Question 24

Treatment of scabies in children > 6months and in adults

(2)

Answer 24

Topical

permethrin 5% cream, applied over the entire body, neck down. Then apply gently to face a scalp. leave for 8 hours. Can repeat this initially in 24 hours if its obvious there is treatment failure otherwise repeat the application in 7 days.

Oral treatment
ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food. Repeat treatment in 7 days

Question 25

If Ivermectin and Permethrin are not tolerated (e.g. allergy or side effects) then what else can be used to treat scabies?

Answer 25

benzyl benzoate 25% emulsion

child 6 months to 2 years: dilute with 3 parts of water;
child 2 to 12 years: dilute with equal parts of water) topically to dry skin from the neck down, paying particular attention to hands and genitalia.

Apply under the nails using a nailbrush. In specific patient

Leave it on for 24 hours and repeat in 7 days

Question 26

What is recommended to treat children < 6 months with Scabies?

Answer 26

Still to use permethrin 5% cream applied from the neck down, left on for 8 hours and then repeated 7 days later.

However while recommended it’s not approved for use.

So technically what is approved for use is

Sulfur

< 2months old Sulfur 10% in white soft paraffin topically, once daily for 3 days

> 2 months old Sulfur 5% in white soft paraffin topically, once daily for 3 days

Question 27

How can you instruct parents to detect/diagnose head lice?

Answer 27

wet combing

Wet the hair
Apply generous amounts of conditioner to the hair (this stuns the lice for about 20 minutes)
Divide the scalp into sections
Detangle the hair
Run a fine toothed comb through the sections of scalp
Wipe the conditioner onto a towel or cloth and inspect for lice

Question 28

Treatment options for headlice?

When to use the wetcombing

Answer 28

1. Wet combing itself ( but only has a 40% success rate)
2. Occlusive Insecticide like benzyl alcohol 5% lotion (adult and child older than 6 months) topically, leave for 10 minutes. Repeat treatment in 7 and 14 days
3. Neurotoxic insecticide: e.g. malathion 0.5% lotion (adult and child older than 6 months) topically, leave for 12 hours. Repeat treatment in 7 days

B. Wetcomibing
NB: use the wetcombing method the day after each treatment to check.

In between treatments, use the wet combing method twice, removing all eggs less than 1.5 cm from the scalp with the fine-toothed comb or by pulling them off with fingernails. The presence of eggs more than 1.5 cm from the scalp indicates previous, not active, infestation.

Wet combing should be repeated weekly for several weeks after cure to detect recurrence.

Question 29

Headlice are becoming resistant to some of the topical treatments, what can you do?

Answer 29

If you find lice on combing after correctly applied treatment then switch to another topical treatment.

If the lice still don’t respond/die after mutliple trials of topical treatments then use

ivermectin (adult and child 15 kg or more) 200 micrograms/kg orally with fatty food, as a single dose. Repeat dose in 7 days

Question 30

How do you treat body lice and public lice?

Answer 30

Apply the same medications to the affected areas.

In sensitive areas like eyelashes, use thick white parafin, twice a day for 8 days.

Also wash clothes etc in a hot cycle AND machine dry

Question 31

what is ringworm? is there a worm involved?

Answer 31

Ring worm is a tinea (fungal) infection.

There is no worm, it only gets its name from the shape of lesion’s it leaves behind.

Question 32

When should you test for, and how do you test for tinea infections?

Answer 32

Always confirm diagnosis of tinea with microscopy and culture PRIOR to starting any treatment.

Can do
-skin scrappings if on the skin
-subungal debris (under the nail)
-nail clippings if nail affected
-plucked hair if hair line involved

Question 33

When is topical anti-fungal therapy indicated and what is used?

Answer 33

Only for RECENT and local lesions that are not on the scalp, palms or soles.

First line
terbinafine 1% cream or gel topically, once or twice daily for 7 to 14 days

Second line
clotrimazole 1% cream topically, two to three times daily for 2 to 4 weeks

Question 34

What situations would you use oral anti-fungal therapy for this?

Answer 34

This is a tinea infection

You would use oral antifungals over topical in the following situations:
- not responding to topical
- extensive spread
- recurs soon after treatment
- been initially inappropriately treated with a steroid
- on the scalp, palms or soles
- is is inflammatory, hyperkeratotic, vesicular or pustular.

Question 35

First line treatment for this?

Answer 35

This is ring worm in the scalp

Because of being in the scalp it requires oral antifungal

First line is terbinafine 250 mg (child less than 20 kg: 62.5 mg; child 20 to 40 kg: 125 mg) orally, once daily for 2 weeks

Question 36

First line treatment for this? First noticed 3 days prior to your consult.

Answer 36

This is tinea on the body, since it is recent and localised a topical antifungal is appropriate

e.g. terbinafine 1% cream or gel topically, once or twice daily for 7 to 14 days

second line is

clotrimazole 1% cream topically, two to three times daily for 2 to 4 weeks