Management of common skin infection

Natta Rajatanavin,MD.
Div. of Derm, Dep. Of Medicine Ramathibodi hospital,Mahidol university 8th July 2010

Skin VS. Environment

Photosensitivity and 1 year after Tx

Skin is the only organ that can itch. Pruritus =itch =scratch

Overview
Infestation Infection insect, parasite. fungus bacteria virus

Management

Insect bite reaction

Itch and inflammation Management Cold Antihistamine

Topical steroid moderate to high potency

Insect bite in cover area

linear pruritic papules. breakfast, lunch and dinner sign

Dz presented with itch

Flea bite

Bite

Tick bite (rickettsia, lyme Dz.)

Management of Tick bite()

Lyme dz. Doxycyclin 200 mg/d 21 day. Amoxicillin 500x3/d 21 day.

Dz presented with itch

Insect bite reaction Flea Tick;systemic dz

Mite

burrow

scabies
Scabies mites burrow, or tunnel, under the outer layer of skin. This produces pimplelike irritations known as the scabies rash. These mites lay eggs under the skin and feed on blood.

scybala

Common sites

Norwegian scabies

Diagnostic Tests: Skin scrapings after application of mineral oil to look for eggs under the microscope. Deep scraping.

Treatment
Eradicate mites Control rash and itch. Prevent spreading. Topical/oral

Topical Scabies Rx
Permethrin 5% 8-12hrs 2-10% sulphur ointment safest applied to all body surfaces for 2-3 nights

Topical Scabies Rx
Benzyl benzoate 10-25% applied 3 consecutive times below neck for 24 hrs, age>2 yrs. Gamma benzene hexachloride 1% >50 kg , CNS toxic

Oral Scabies Rx
Ivermectin(6 mg/tab) Children >15 kg 200 mcg/kg as a single dose, may repeat at 1014 days. Pediculosis days1,2 and 10 Wt 15-24kg 3 mg single dose 25-35 6 36-50 9 51-65 12

Treatment
Eradicate mites Control rash and itch. Prevent spreading. Topical/oral Topical steroid and antihistamine. All contact cases.

Head /Body louse Pubic louse (crab)

Rx

Dz presented with itch

Insect bite reaction Flea Tick Mite Scabies Head /Body louse Pubic louse

 (Rove beetle:Paederus fuscipes)

kissing lesion

Acute irritant contact; kissing lesion

Rx

Overview
Infestation insect, parasite.

Larva migran
Humans are accidental hosts, and the larvae are believed to lack the collagenase enzymes required to penetrate the basement membrane to invade the dermis.

Larva migran
Thiabendazole; topical 10-15% susp under occlusive *4x7d 25-50 mg/kg/d PO divided q12h for 2-5 d not to exceed 3 g/d albendazole, mebendazole, and ivermectin

Overview
Infestation Infection insect, parasite. fungus bacteria virus

Management

Tinea corporis

Fungal infection Tinea facei/corporis

KOH;dermatophyte
Clotrimazole Miconazole Gently massage into affected area and surrounding skin areas bid for 4 wk Ketoconazole 2-4 wk Terbinafine qd for 1-4 wk

Tinea versicolor

KOH
Selenium sulfide lotion is liberally applied to affected areas of the skin daily for 2 weeks; at least 10 minutes prior to being washed off. Ketoconazole shampoo

Tinea versicolor
Ketoconazole; singledose 400-mg fluconazole, single150-300 mg/wk 2-4 wk itraconazole 200 mg/d x 7days

Recurrences
1 tablet a month of ketoconazole, fluconazole, and itraconazole has been used successfully to prophylactically prevent recurrences

Candidiasis ;immune status

Management
Cause Topical or oral azole Not terbinafine 10-mg troches: Hold in mouth and allow to dissolve over a single 15- to 30-min period 5 times/d

Fungal infection
Exogenous Tinea;dermatophyte() Endogenous Tinea versicolor() Candidiasis-immune status

Antifungal topical
imidazoles (eg, clotrimazole, miconazole, econazole, ketoconazole) Terbinafine

Antifungal oral
triazoles (eg, fluconazole, itraconazole) Diazoles (eg, ketoconazole) have more effect on mammalian cytochromes than do triazoles and tend to have more severe adverse effects.

 Widespread Tinea corporis and Tinea cruris may need systemic antifungal therapy

Systemic antifungal therapy

Drugs Griseofulvin (500mg)* Ketoconazole (200mg)* Itraconazole (100mg) Terbinafine (250mg) Dosage (tab/day) 2 1 1 1 Duration (days) 21-28 14 14 14 Rx Cost (baht) 130 252 616 1162 efficacy ~70% 79% 88% 87%

Original vs local made

Drugs Diflucan (150mg) Dosage (tab/wk) 1 Duration (weeks) 4 Rx Cost (Baht) 813 Efficacy (%) 88

Fluconazole (200mg)*

24

Once weekly oral doses of Generic Fluconazole 200mg in the treatment of Tinea corporis and Tinea cruris Oraparn Techaritpitak

,Natta Rajatanavin 2007

Efficacy comparison
100 Percent 90 80 70 60 50 40 30 20 10 0 Griseofluvin Ketoconazole Itraconazole Terbinafine Diflucan
(our study)

88 79

87

88

85 %

70

Fluconazole

Price comparison
1400 1200 1000 800 600 400 200 0 Griseofluvin Ketoconazole Itraconazole Terbinafine Diflucan Fluconazole 130 24 252 616

Baht
1162

813

Conclusion
Fluconazole 200mg (local made)once weekly for 6 weeks is cost-effective and safe regimen in the treatment of Tinea corporis and Tinea cruris. Efficacy 85%,cost 24 bath Ketoconazole has higher risk of hepatitis.

* Ramathibodi Phototherapy Research Fund

onychomycosis

Paronychia

onychomycosis /Paronychia

onychomycosis

White superficial onychomycosis swo

Proximal subungual onychomycosis

Proximal white onychomycosis

is a fungal infection which occurs by inversion into the proximal nailfold and growth under the nailplate. It is strongly associated with HIV infection.

Leuconychia striata

Mees line

psoriasis

Trachyonychia (Twenty-nail dystrophy)

Lichen Planus (pterygium)

Onychomycosis Dx
KOH + Nail clipping for PAS Culture + +

Nail clipping picture

Sensitivity of different methods

Wilsmann-Theis etal. JEADV 2010

Onychomycosis Dx and Rx
2-12 months Rx Which medication?

Antifungal drug for onychomycosis

Topical Nail lacquer Oral grisiofulvin ketoconazol itraconazole terbinafine ineffective ineffective hepatotoxic expensive (1,960-3,920 baht) very expensive (3,360-6,720 baht)

J Am Acad Dermatol 1998;38:S77-86

diagram

Paronychia
Chronic irritation avoid wet work and topical steroid +/antifungal

T. capitis ;Hair loss + itch

T. capitis

 A discrete patch of alopecia in the scalp of a child where the skin is covered with scale, pustules and/or black dots is typical of tinea capitis

Tinea capitis

Children Grisiofulvin Kerion ;antibiotic

Moth-eaten alopecia of secondary syphilis

secondary syphilis

alopecia areata

Trichotillomamia

Antifungal
imidazoles (eg, clotrimazole, miconazole, econazole, ketoconazole) triazoles (eg, fluconazole, itraconazole) Diazoles (eg, ketoconazole) have more effect on mammalian cytochromes than do triazoles and tend to have more severe adverse effects. Oral Rx ;nail,hair;grisiofulvin

Overview
Infestation Infection insect, parasite. fungus bacteria virus

Impetigo

Impetigo is a superficial skin infection with honey-colored crusting caused by streptococci, staphylococci, or both.

Impetigo

 The face is a common location for impetigo. The area below the nose is particularly prone, presumably because staphylococci often colonize the nose. Any nasal drainage promotes infection. Mupirocin topically =3 times /day for 7 days.

Impetigo acyclovir

Ass. Prof. Amornsri Chunharaj

Impetigo
Mupirocin topically three times a day for 7 days. S. aureus nasal carriage

Impetigo
widespread involvement, an oral antibiotic (e.g. cephalexin, dicloxacillin, or erythromycin.

Bullous impetigo,4S,scarlet
Systemic antibiotic.

4S

Ass. Prof. Amornsri Chunharaj

Scarlet fever
Strawberry tongue Sand paper rash

desquamation

Ass. Prof. Amornsri Chunharaj

Folliculitis(hairy area,bacterial)

Hot Tub Folliculitis

Folliculitis/abcess

Precipitating causes
Trauma Chronic friction Occlusive clothing Occlusive chemicals Excessive sweating Exposure to water

Folliculitis

Pityrosporum folliculitis

Lab, gram stain

 Furuncle diagram

Furuncle(boil)/Carbuncle

 Carbuncle on the nape of a diabetic man. This is a staphylococcal infection of several contiguous hair follicles.

 Mild cases of folliculitis and small furuncles may heal on their own with good hygiene and wound care. More extensive furuncles and all carbuncles need to be treated with antibiotics such as dicloxacillin or cephalexin.

Erysipelas

Mycobacteria
Tuberculosis & leprosy Atypical mycobacterium

Tuberculosis

continuous propagation of infection from an underlying structure, most commonly lymph node or bone.

Tuberculosis verrucosa cutis (wart like)

 (Paucibacillary Leprosy - PB)

Sensory loss is a typical feature of leprosy.

5

Transmission
The principal means of transmission is by aerosol spread from infected nasal secretions to exposed nasal and oral mucosa. Leprosy is not generally spread by means of direct contact through intact skin

(PB)
Rifampicin 600 Dapsone 100 6 ( ) 3

 (Multibacillary Leprosy - MB)

 (Multibacillary Leprosy - MB)


Rifampicin 600 Clofazimine(Lamprene) 300 Dapsone 100 Clofazimine(Lamprene) 50 2 5

Atypical mycobacterium

Atypical mycobacterium Sweet syndrome

Overview of lecture
Infestation Infection insect, parasite. fungus bacteria virus

HZV

H.simplex

Herpes

vesicle crust

Erosive ulcer

Recurrent

Herpes zoster

Management
Acyclovir 1,000 -4,000 mg/d*7days Herbal medicine , phrayayor cream None prevent recurrent

Verrucae vulgaris / warts

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Genital wart

Management
Topical; cold water,occlusion salicylic cream 5-10% wart solution irritation imiquimod activates immune cells through the toll-like receptor 7 ;penetration, irritation and price. Surgical;cryo,electro,laser- surgery,

Molluscum contagiosum

Rx ;currettage + EMLA

Conclusion
Infestation Infection insect, parasite. fungus bacteria,mycobactrium virus

Management Thank you

Acknowledgement Ass. Prof. Amornsri Chunharaj All dermatology staffs and residents Question&Answer

Div. Of Dermatology Ramathibodi Hospital

Adverse drug reaction ADR

Recurrent dusky red patches

 Dx Acneiform drug eruption Striae due to steroid

Staphylococcal scalded skin syndrome

Nikolsky sign

Impetigo

Scarlet fever