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Skin Infections

Screening and education

Offer full skin check with routine annual health assessment Check skin opportunistically in all children when they attend the clinic Encourage daily washing, swimming regularly in salt water or pool; early treatment and care for skin sores See NT Healthy Skin flip chart: http://www.lowitja.org.au/ files/crcah_docs/Healthy-Skin-Flipchart-Aug09.pdf · ·

Box 1

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Treat for 4 weeks then review progress: If clearing, continue treatment for 2 weeks after rash has disappeared, usually need longer course (6-8 weeks) with tinea capitis and with extensive infections If no progress, discuss with doctor: review lab results, send specimens if not already done, consider alternative diagnosis, if confident this is tinea consider changing to terbinafine (see dosing table below) If there are any signs of secondary bacterial infection, treat according to protocol on next page for Bacterial Skin Infections

HoW to do a SKin Scraping

Use a disposable scalpel. Scrape the raised edge of the scaly patch and collect flakes of the skin in a plastic specimen jar (more flakes the better). Avoid bleeding - scraping should be firm but along the surface of the skin, not into the skin Send for Fungal Microscopy and Culture.

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S K i n i n F e c t i o n S

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tinea / ringWorM

Tinea is a fungal infection which may affect almost any areas of the skin: Tinea capitis: scalp infection · may appear as scaly patches with hair loss / stumps of broken hair; in more severe cases, may appear as a large boggy patch Tinea corporis: infection on main areas of the body often round, scaly patches with raised edges (hence "ring"worm); may grow into extensive patches covering large areas of the body Tinea unguium or Onychomycosis - infection of the nails usually no symptoms, but nails appear thickened, often darkened, cracking / fissuring, may become distorted

Management

Tinea can spread from one person to another encourage family members to attend for a skin check avoid sharing towels etc while infection is active

3. Nail infections / onychomycosis

· · · Always discuss first with doctor Take nail clippings / scrapings and consider treatment with terbinafine as first line Usually requires 6 weeks treatment for fingernails, 1216 weeks for toenails

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1.For small areas of tinea on the skin:

Ketoconazole 2% topically twice daily until infection has cleared, then continue for another week

tinea VerSicolor

Tinea versicolor is caused by a "yeast" type of fungal infection. It appears as light patches on dark skin and dark patches on light skin, with a very fine scale on the rash It is usually found on the upper trunk but can occur on other parts of the body. There may be a slight itch, but often there are no symptoms. It is not contagious

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2.For large areas on the body or for tinea on the scalp:

· Griseofulvin - see dosing table below Weight (KGs) 10 - 15 16 - 20 21 -25 > 25 <20 20-40 >40 · Daily Dose of griseofulvin (griseovin (r)) 125mg daily (1 x 125mg tablet) 187.5mg daily (1 1/2 of the the 125mg tablets) 250mg daily (2 x 125mg tablets) 500mg (1 x 500mg tablet) 62.5mg daily 125mg daily 250mg daily

diagnosis

Diagnosis can often be made just by looking Take skin scrapings (see box 1) if: · · · Unsure of the diagnosis All scalp infections Infection is recurrent, persistent or extensive

Management

Treatment may not be needed if the person is not bothered by symptoms or by the appearance of the rash. If treatment is needed: · Selsun Gold (R) (selenium sulfide 2.5%) shampoo applied topically to wet skin, leave on for at least 60 minutes, overnight if possible Repeat this daily for 7 days; Consider maintenance treatment for people with recurrent infections continue to apply Selsun Gold 1-2 times per week Explain that skin colour may take months to return to

For all cases of onychomycosis / nail infection: take nail clippings / scrapings from under the nail, send in a dry jar to lab for microscopy and culture. Lab results may take many weeks - commence treatment while waiting if fungal infection is likely

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Advise women and men of child bearing age about risks if pregnancy occurs while taking griseofulvin, discuss with doctor and weigh up benefits vs risks

·

© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

VC - Last Modified: May 23, 2011 8:26 AM

Skin Infections

normal after treatment. If skin still has not returned to normal after 3 months, take a skin scraping (see box 1), 1), re-treat with Selsun Gold as above while awaiting results, and refer to doctor motes - lactic acid or salicylic acid cream applied daily; 3. Eradication of scabies mite: Permethrin 5% cream - apply twice weekly for 2 weeks, then once a week for a further 4 weeks Ivermectin - Seek specialist advice for dose schedule / management Discuss with family re notification of local environmental health officer for assistance with household eradication to antibiotics we commonly use to treat skin infections, including flucloxacillin. It is important (1) to collect specimens to send to the lab for testing when patients present with skin infections; and (2) to know what bugs are in your area, including patterns of resistance. Weight (KGs) >20 10.1 - 20 5.1 - 10 <5 1. 2. Dose of la bicillin (r) 900mg / 2.3mg 2.3mls 1.2mls 0.75mls Discuss with Doctor Collect pus or fluid from boil / sores - liquid specimens are best. Send these in a sterile jar to the lab for MC&S Swab the wound / sore if there is no liquid specimen to collect. Use a charcoal swab, send for MC&S

ScaBieS

Scabies is caused by a parasitic mite that spreads from person to person. The body reacts to the presence of the scabies mite, resulting in itchy small lumps appearing almost anywhere on the body, commonly on the trunk, wrists, elbows, knees. Infants may develop blistering lesions on the hands and feet. Scratching may cause disruption of the skin and secondary infection with bacteria - impetigo and scabies commonly occur together

S K i n i n F e c t i o n S

BoilS and SKin SoreS

Bacterial skin infections in the Kimberley contribute to significant short term illness, including severe sepsis. In addition, skin infections in childhood are a particular concern, given the association with both kidney disease and Acute Rheumatic Fever / Rheumatic heart disease. Screening for skin infections includes; · · Offering full skin check annually with routine health check Checking skin opportunistically in all children when they attend the clinic

Management

Under 2 months old - discuss with doctor before treating; cortamiton 10% (Eurax) cream for 3 days is recommended Over 2 months: · · Treat secondary bacterial infection - see next page. Once sores healing / crusting: Apply permethrin (Lyclear (R)) 5% cream topically to whole body (avoid eyes) once after bath / shower; leave on overnight Repeat application one week later Offer same treatment simultaneously to any other household members with symptoms or signs of scabies If itch is intense, offer antihistamine until settling. Advise patient that itch may persist up to 2 weeks after scabies has been successfully treated

Management

For boils: Lance, drain, debride, clean and dress - this is the most important aspect of treatment. Often boils can be managed without antibiotics, provided pus can be drained For skin sores: soak, remove scabs, clean and dress

presentation

Bacterial infections of the skin usually present as: 1. "Impetigo" - Superficial skin sores which may be crusted or open and weeping / oozing pus. These are commonly caused by either Streptococcal (strep) or Staphylococcal (staph) bacteria "Boils" or abscesses - localised collections of pus. These are mostly commonly caused by Staph infections Could this be infected scabies? Could this be infected tinea? Recurrent presentations of skin infections: Could there be an underlying illness such as diabetes? Is there a resistant bug? (see below)

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use antibiotics if any of the following are present:

1. 2. 3. Multiple boils / sores; Any local spread including cellulitis; Any systemic signs of infection (e.g. high fever, tachycardia, unwell)

2.

Always consider possibility of underlying triggers including: · · ·

Severe, crusted ("norwegian") scabies:

This is a severe and serious form of scabies usually indicating underlying medical illness / immunosuppression Always discuss with doctor Management is directed at: 1. 2. Finding and addressing any underlying conditions Reducing the thickened keratin layers of the skin to enable penetration to, and treatment of, the scabies

choice of antibiotics (ask first about any allergies) A. Mild infection/not recurrent:

If allergic to penicillin, discuss with doctor, otherwise give: 1. Flucloxacillin orally for 6 days - see dosing table below

Specimen collection

In the Kimberley, cMRSA - Community-acquired Methicillin Resistant Staph Aureus - is becoming increasingly common. These are Staph bacteria that have developed resistance

© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

VC - Last Modified: May 23, 2011 8:26 AM

Skin Infections

Weight (KGs) > 25 15.1 25 10.1 15 <5 Dose of flucloxacillin 500mg tablets - 1 tablet QID 250mg/5mls: Give 5mls (250mg) QID 250mg/5mls: Give 4mls (200mg) QID Discuss with Doctor · · Don't forget to think of underlying triggers · Think scabies - particularly if sores are recurrent and / or widespread, other household members may also have scabies and/ or sores. Think tinea - look for typical "ringworm" lesions, scalp infection Once infection is settling / open sores are crusting, offer treatment - see page 1 of this protocol 5. If possible to achieve, some household manoevres including washing bed linen and towels every few days

S K i n i n F e c t i o n S

2. If adherence to with an oral schedule will be difficult, offer LA Bicillin IM as a single dose - see dosing table below

Follow up

Review regularly until skin infection is improving; recall for follow up after completion of antibiotics. Provide education for patient and family about skin care, and prevention and early management of skin infections Check other members of the household · · Ask about other household members who may also have skin infections Encourage the individual and family members to attend the clinic for a check up if they develop skin infections

B. recurrent or more severe infection: discuss first with doctor, who will guide therapy as follows: Without laboratory results:

1. 2. ADULTS: clindamycin 300mg o tds for 7 days CHILDREN (under 30kg): give sulfamethoxazole / trimethoprim 10mg / 2mg per kg per dose BD for 7 days - follow dosing table below: Dose of sulfamethoxazole / trimethoprim (bactrim® 200mg / 40mg per 5mls) 5mls (200mg / 40mg) orally BD 4mls (160mg / 32mg) orally BD 3mls (120mg / 24mg) orally BD 2mls (80mg/16mg) orally BD Admission IV Vancomycin may be indicated if infection is severe and patient is being admitted

Weight (KGs)

If MRSA found on swabs: Offer decolonization treatment

Consider "decolonisation" treatment for those who is willing to give it a go - the aim is not community-wide eradication, but you may help reduce the risk of recurrence for the individual and their family. Particularly encourage a person if this is a recurrent infection, and / or if there is an underlying chronic condition which places them at higher risk of sepsis with a recurrence - e.,g. diabetes, renal disease. Although a 10 day course is "ideal", a minimum of a 5 day program is a reasonable compromise with likelihood of some benefit for those unable to complete the full 10 days. 1. 2. 3. 4. Make sure skin is being treated and infection is under control before starting, then: Mupirocin (Bactroban) ointment applied inside each nostril tds Chlorhexidine body wash daily Explain the importance and technique of hand-washing

VC - Last Modified: May 23, 2011 8:26 AM

20-30kg 15.1 - 20 10.1-15 5.1-10 <5 3.

If MRSA is confirmed and sensitivities are available:

If resistant to erythromycin, AVOID CLINDAMYCIN as resistance will also develop rapidly · · treat adults with doxycycline 100mg o BD for 7 days treat children with sulfamethoxazole / trimethoprim (see previous dosing table)

© Kimberley Aboriginal Medical Services Council (KAMSC) and WA Country Health Service (WACHS) Kimberley

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