infections and infestations dr iain henderson gp scotstoun hospital practitioner, western infirmary...
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Infections and Infestations
Dr Iain HendersonGP Scotstoun
Hospital Practitioner, Western Infirmary
Basic Dermatology Day
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Infections• Bacterial
– Staphylococci – Streptococci – Other bacteria
• Viral– Herpes – Warts– Pox viruses– Others
• Fungal – Tinea– Candida– Pityriasis Versicolor
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Skin Functions
• Mechanical barrier• Regulates body temp• Sensory• Immunological • Regenerates itself • Protects against trauma,
chemicals, viruses, bacteria and UV damage
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Skin Infections
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Bacterial
Staphylococci• Folliculitis (hair follicle infections)• Impetigo (school sores) • Boils (Carbuncles and Furunculosis)• Cellulitis (but more often due to
streptococcus) • Secondary infection in eczema • Ecthyma (crusted ulcers) • Scalded skin syndrome
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Folliculitis
Can be due to trauma – epilation, occupational due to tar or oils or application of greasy ointments to skin. Pseudomonas from jacuzzis and whirlpools.
Need swabs, Usually Staph if infective. Can have nasal carriage.
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Impetigo
• Common infection• Can be due to staph or strep• Usually staph in this country• Face usual site• Develops small vesicles that rupture and then
develop a yellow crust • Can spread easily to others• Bullous Impetigo is usually due to staph
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Boils (furuncles)
• An abscess centred on one or more hair follicles
• Usually due to Staph• Commonest sites face, neck, axillae,
buttocks arms and legs• When developed points and pus is
discharged• Carbuncle is multiple abscesses coming
together – less common – occurs on neck in men over 40
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Secondary Infection
• Staph and Strep are the most likely organisms
• Eczema doesn’t have to look that bad to be infected
• Swabs very useful
• Can see if Fucidic Acid resistance
• Eczema sufferers have a higher rate of carriage of staph
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Ecthyma
• Infection of the full thickness of the epidermis and dermis by Staph aureus or sometimes Beta Haemolytic Strep
• Presents as round painful punched out ulcer with thick crust on top
• Usually children. Commoner in hot humid climates
• Needs oral Rx as deep and will heal with scarring.
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Staphylococcal Scalded Skin Syndrome
• Toxin induced
• Staph infection may not be obvious
• Severity varies from localised blisters to complete skin involvement with de-roofed bullae
• Raw red moist skin
• Niklolsky’s sign is positive
• Needs antibiotics, analgesic, fluids and temperature regulation. Nursed as for burns
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Staph Scalded Skin Syndrome
• Usually affects small children esp neonates Red blistered skin like burns or scalds
• Tissue paper wrinkling, then large fluid filled blisters in armpits, groins and around ears and nose
• Then top layer peels off leaving raw skin• Causes by exotoxins from certain strains of
staph• Mortality low but needs intensive care
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Staph Scalded Skin Syndrome
• Usually affects small children esp neonates Red blistered skin like burns or scalds
• Tissue paper wrinkling, then large fluid filled blisters in armpits, groins and around ears and nose
• Then top layer peels off leaving raw skin• Causes by exotoxins from certain strains of
staph• Mortality low but needs intensive care
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BacterialStreptococci
• Impetigo (some cases)• Ecthyma (some cases)• Erysipelas• Cellulitis• Scarlet fever• Septicaemia• Erythema Nodosum• Guttate Psoriaisis• Necrotising Fasciitis
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Erysipelas
• Erysipelas is an infection of the dermis and superficial subcutis
• Starts suddenly with inflammation, pain swelling. High temperature and ill
• It usually has palpable edge
• Beta Haem Strep is usual cause
• Bug enters though minor break in skin
• Face and lower legs are commonest sites
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Cellulitis• Usually caused by Strep• Similar but deeper and more diffuse than
erysipelas• Can be very acute with high fever,
vomiting and can be delirious • If leg involved it can lead to permanent
oedema of leg• Fungal infections of feet can be the portal
of entry – look for portal of entry• Need high does of antibiotics to control it
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Necrotising fasciitis• Early signs
– Pain is more than you would expect for appearance of lesion – agonising pain
– CRP is way up 200 - 400
– often history of taking NSAI drugs like Ibuprofen
– Personal/family history of strep infection – throat, impetigo, erysipelas or cellulitis
– Group A Strep NF has higher death rate than meningococcal disease – up to 23%
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Swabs
Accurate prescribing of antibiotics
Picking up antibiotic resistance
Finding community acquired MRSA
Patients and parentsinformation WET SWAB
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Fusidic Acid • Resistance to fusidic acid is rising
• Was less than 10% is now 50%
• The resistance is not stable and will fade if drug stopped
• Fusidic acid must be used for short courses and stopped and not used regularly. Can be used for 2 week courses every 6-12 weeks.
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MRSA (Methicillin resistant staphylococcus aureus)
• More resistant to treatment but not impossible to treat
• Most MRSA in the UK is contracted in hospital – open sores, operation wounds, catheter site and I/V sites
• Well people with intact skin are not likely to contract MRSA
• MRSA can also cause infections in people outside hospital, but much less commonly – have been outbreaks in sports teams in USA
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Treatment of Skin Infections• Staph – Oral Flucloxacillin or Erythromycin 250mg – 500mg qds
• Strep – Penicillin V or Erythromycin 250mg – 500mg qds
• Cellulitis – Benzyl penicillin i/m or i/v or if milder Pen V with Flucloxacillin or Erythromycin alone if pen allergic
but double doses - 1g qdsSwab for sensitivities
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Fish Tank Granuloma
• Caused by atypical mycobacterial infection• Recreational or occupational exposure to
contaminated freshwater or saltwater• Affects elbows, knees, feet, knuckles or fingers • Often single lump which causes crusty sore or
abscess• Other lumps on course of lymphatic drainage• More widespread if immuno-compromised • Treated with long course of minocycline or co-
trimoxazole 6-12 weeks
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ErythrasmaHyperpigmented, non scaly plaque in axilla
Due to infection with Corynebacterium
Common in diabetes
Coral – red fluorescence with Wood’s light
Treated with Fucidin, imidazoles (not Ketaconazole) and oral Erythromycin
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Lyme Disease• Borrelia burgdorferi• A spirochaete - infected Ixodes ticks are
often found on deer• Erythema chronicum migrans – an annular
erythema expanding outward from the tic bite• Have had outbreaks in the New Forest• If not rx promptly long term serious sequelae
– neurological, cardiac and arthritic• Doxycycline for 2-3 weeks, Amoxicillin for
children and pregnant women
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Warts• Most resolve spontaneously• First Line
– Salicylic acid, Glutaraldehyde, Silver Nitrate, Formaldehyde soaks and Duct Tape
• Second Line – Cryotherapy - painful avoid in young children
• Third line– Surgery, Curette, Efudix, Topical retinoid,
Imiquimod, Laser and PDT
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Molluscum • Flesh coloured, dome shaped papules • Central dimpling• One of the pox viruses • Can be 1mm to 1cm• Multiple lesions are usual – eczema sufferers get more• Occasional there is just one lesion• An individual lesion lasts 2 months but gets new ones• Lasts 9 months to 15 months• Rarely get it again• If has eczema – moisturise and ease off the topical
steroids in the affected areas
• Worth trying Crystacide – hydrogen peroxide 1%
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Orf
Human lesions are caused by direct inoculation of infected material. Orf recovers spontaneously in 3 to 6 weeks. No specific treatment is necessary in most cases.
Orf is a parapox virus infection of the skin contracted from young sheep and goats.
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Herpes• Herpes simplex very common • Initial infection in childhood is usually trivial but
can be cause of acute gingivostomatis and be very ill
• Recurrent herpes simplex are common• Herpes is the commonest recognised cause of
Erythema Multiforme• Sometimes frequent recurrences needs an
extended course of oral antivirals
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Eczema Herpeticum
• Regular polygonal often crusted lesions
• Often a family history of recent herpes if you take a careful history
• Can go rampant if has widespread eczema
• Can be life threatening
• It is a ring the dermatologist at the time scenario – Emergency
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Herpes Zoster
If very widespread think about diabetes, underlying malignancy or immuno –
suppression
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Candida• Angular Chelitis in patients with dentures• Red patches on palate in pts with dentures• Intertrigo – small satellite lesions• Candida Paronychia and sub-ungal
infection• Finger web problems in those doing wet
work• Severe oral thrush in the immuno-
compromised
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Fungal Infection
• Fungal infections usually have a well defined edge – unlike eczema
• Tinea Incognito is common with widespread use of topical steroids
• Eczema of one hand or foot is likely to be fungal
• Scrapings can help but fungus can be difficult to culture
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Scalp Ringworm
• Affects children • Rare in adults• Plaque of short broken hairs with greyish scale –
patchy hair loss• Microsporum Canis (cats and dogs) is the
commonest• T.Tonsurans has been imported from the USA
and is commonest amongst Afro- Caribbean boys – hair gel and clippers
• Toothbrush scrapings are useful to get diagnosis
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Fungal Treatments
• Topicals – for localised fungal infections• – Miconazole, clotrimazole etc • Apply twice daily for two to four weeks,
including a margin of 2-3cm of normal skin• Continue for 1-2 weeks after rash has cleared
• Oral – for extensive, severe, in hair bearing areas, resistant to topical and nail treatment
• Terbinafine and Itraconazole
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Pityriasis Versicolor • Superficial yeast infection of torso - malassezia• Commensal which becomes pathogenic in warm,
humid conditions• Macules of various shapes and sizes• Brown - on pale skin• White on tanned/ pigmented skin• Fine scale• Gets mistaken for vitiligo• Topical azoles e.g ketonconazole or selenium• Treat with a week of Itraconazole – colour fades
slowly – more effective if takes before exercise• Can recur
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Scabies
• Scabies in babies and toddlers usually affects feet and hands – often with blisters
• Can be mistaken for eczema
• In women affects nipple area
• In men affects the genitals • In the elderly and immuno-compromised it can
be very widespread
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Distribution of Scabies
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Scabies Treatment • 25% Benzyl benzoate lotion applied daily for 3 days or• 5% Permethrin cream left on for 8-10 hours or• 0.5% Aqueous malathion lotion left on for 24 hours • Apply whole body from the chin to soles – all body in
under 2years – need to prescribe enough• Special care between fingerwebs, flexures and behind
fingernails • The itch will continue 4-6 weeks• Repeat treatment one week later – overuse will cause
dermatitis• Oral Ivermectin is now considered treatment of choice
for crusted scabies and other resistant cases.
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Lice
• Head lice endemic in school children• Can get severe eczema on scalp from
scratching• Red spots on back of neck = head lice• Need big quantities of clear up an infection• Vaseline will clear lice in eyelashes• Combing wet or dry daily for 2 weeks• Hedrin – dimeticone lotion – new non
insecticide treatment for head lice
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Larva Migrans • Hookworm larvae
• Infests cats and dogs
• Infected by walking barefoot on sandy beaches or moist soft soil
• Also known as creeping eruption
• Causes itchy red lines/tracks – that move
• Treat with topical thiabendazole or oral albendazole or Ivermectin
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Leishmaniasis
• From bite of sand fly• Common in the Middle East • Does occur in Mediterranean countries• Lesion is firm papule or nodule which
ulcerates and crusts• Do heal spontaneously but can scar • Pentavalent antimonials intralesionally
treatment of choice e.g. sodium stibogluconate
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Leprosy• Leprosy caused by Mycobacterium leprae• Found in tropics and subtropics• A spectrum of disease depending on host• Tuberculoid gives skin lesions that are
raised, asymmetrical, anaesthetic and do not sweat
• Can be pale - mimicing vitiligo or a patch of eczema
• It is in the UK