Skin lesions, solar damage, cancers, skin infections Flashcards
What are the risk factors for cutaneous candida infection?
Broad spectrum antibiotics
Diabetes
General Debility
Immunodeficiency
Obesity
Immobility
What type of skin environment leads to candida infection on the skin?
Usually conditions that make the skin moist or macerated predispose to candida infection
What are 4 treatment steps for this? If drugs are used, please provide dosing.
This is a candida infection
- Keep Skin dry
- Apply a barrier cream like white parafin or zinc oxide
- 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
- 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
What is folliculitis and what are the two main groups of causes ?
It is any inflammation of the hair follicle that presents as a papule or pustule with an erythematous base
Non-infective causes
Infective Causes
What are the infective agents that cause folliculitis?
(Up to 6)
Mostly Staphylococcus Aureus
Sometimes Pseudomonas Aeruginosa (from spas/hot tubs)
Sometimes Malassezia yeasts
Dermophytes
Dermodex mites
Herpes Simplex virus
List non antibiotic management advice for infective folliculitis?
(4)
Warm compressors
Antiseptic wash- benzoyl peroxide or whatever is in Dettol (chloroxylenol)
Clean sharp razors when shaving
Advise patients to avoid triggers
What to do for treatment of folliculitis, thought to be due to Staphylococcus Aureus?
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
What is this?
How would you describe it?
This is perioral impetigo
Showing perioral honey coloured crusts
Caused by Staphylococcus Aureus
What are the complications of impetigo?
(7)
Widespread cellulitis
Staphylococcal Scalded Skin syndrome
Scarlet Fever
Post-strephtococcal Glomerulonephritis
Streptococcal Toxic shock syndrome
Post inflammatory pigmentation
Scarring
What is the treatment for Impetigo in ENDEMIC settings?
i.e remote communities in central and northern Australia dosing not required.
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
Difference between impetigo and bullous impetigo?
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.
What is this?
How do you treat it?
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.
Which virus is responsible for this?
Herpes Simplex virus
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 _______
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
What does human papillomavirus cause on the skin?
warty papules or plaques on the skin.
What are common warts, how are they treated?
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
- 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
- Liquid nitrogen cryotherapy, 2 x 20 second freezes per wart, that might need to be repeated weekly
What are plantar warts?
They are also common warts caused by HPV virus, only they occur on the bottom of the foot and usually require more aggressive treatment
What are plane warts?
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
How do you prevent spread of this? - advice for parents
Found in a child, not painful or itchy
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
Treatments available for Molloscum?
They usually resolve so it is not needed
There isn’t much evidence to support treatments but
- topical imiquimod cream for many lesions
-tedious and expensive though - Curettage
- Cryotherapy
- 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.
What is pityriasis versicolour caused by and what is the treatment?
A. Malassezia yeasts.
B. ketoconazole 2% shampoo topically, once daily (leave for 3 to 5 minutes and wash off), for 5 days
General Household Measures to consider when treating scabies?
- 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.
- 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)
- If possible put all mattresses, pillows and blankets into the sun
- Vacuum the entire house
- NO body contact with items that cannot be washed or put in the sun for at least 3 days
(alternatively pack
When can a child return to school after having scabies?
After being treated twice, which is usually a week apart.
Treatment of scabies in children > 6months and in adults
(2)
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
If Ivermectin and Permethrin are not tolerated (e.g. allergy or side effects) then what else can be used to treat scabies?
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
What is recommended to treat children < 6 months with Scabies?
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
How can you instruct parents to detect/diagnose head lice?
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
Treatment options for headlice?
When to use the wetcombing
- Wet combing itself ( but only has a 40% success rate)
- 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
- 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.
Headlice are becoming resistant to some of the topical treatments, what can you do?
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
How do you treat body lice and public lice?
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
what is ringworm? is there a worm involved?
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.
When should you test for, and how do you test for tinea infections?
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
When is topical anti-fungal therapy indicated and what is used?
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
What situations would you use oral anti-fungal therapy for this?
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.
First line treatment for this?
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
First line treatment for this? First noticed 3 days prior to your consult.
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
