Management of common skin infection

Natta Rajatanavin,MD.Div. of Derm, Dep. Of Medicine

Ramathibodi hospital,Mahidol university8th July 2010

Skin VS. EnvironmentSkin VS. Environment

Photosensitivity and 1 year after Tx

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

Overview

• Infestation insect, parasite.• Infection fungus

bacteria virus

• Management

Insect bite reactionInsect bite reaction

•• Itch and inflammationItch and inflammation•• ManagementManagement•• Cold Cold •• AntihistamineAntihistamine•• Topical steroidTopical steroid

moderatemoderateto high potencyto high potency

Insect bite in cover areaInsect bite in cover area

linear pruritic papules. linear pruritic papules.

‘‘breakfast, lunch and breakfast, lunch and dinner signdinner sign’’ ––

Dz presented with itchDz presented with itch

•• Flea Flea หมัดหมัด bite bite

Bite Bite

Tick bite (rickettsia, lyme Dz.)Tick bite (rickettsia, lyme Dz.)

Management of Tick biteManagement of Tick bite((เห็บเห็บ))

•• Lyme dz.Lyme dz.•• Doxycyclin 200 mg/d Doxycyclin 200 mg/d

21 day.21 day.•• Amoxicillin 500x3/d Amoxicillin 500x3/d

21 day.21 day.

Dz presented with itchDz presented with itch

•• Insect bite reactionInsect bite reaction•• FleaFlea•• Tick;systemic dzTick;systemic dz

•• Mite Mite

burrowburrow

scabiesscabies

•• Scabies mites burrow, Scabies mites burrow, or tunnel, under the or tunnel, under the outer layer of skinouter layer of skin. . This produces pimpleThis produces pimple--like irritations known like irritations known as the scabies rashas the scabies rash. . These mites lay eggs These mites lay eggs under the skin and under the skin and feed on bloodfeed on blood. .

scybala

Common sitesCommon sites

Norwegian scabiesNorwegian scabies

Diagnostic TestsDiagnostic Tests::Skin scrapings after application of Skin scrapings after application of

mineral oil to look for eggs under the mineral oil to look for eggs under the microscopemicroscope. . Deep scraping.Deep scraping.

TreatmentTreatment

•• Eradicate mitesEradicate mites•• Control rash and itch.Control rash and itch.•• Prevent spreading. Prevent spreading.

•• Topical/oralTopical/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 10-

14 days.• Pediculosis days1,2 and 10• Wt 15-24kg 3 mg single dose• 25-35 6• 36-50 9• 51-65 12

TreatmentTreatment

•• Eradicate mitesEradicate mites•• Control rash and itch.Control rash and itch.•• Prevent spreading. Prevent spreading.

•• Topical/oralTopical/oral•• Topical steroid and Topical steroid and

antihistamine.antihistamine.•• All contact cases.All contact cases.

Head /Body louseHead /Body lousePubic louse (crab)Pubic louse (crab)

Rx

Dz presented with itchDz presented with itch

•• Insect bite reactionInsect bite reaction•• FleaFlea•• TickTick

•• Mite Mite •• ScabiesScabies•• Head /Body louseHead /Body louse•• Pubic lousePubic louse

ดวงกนกระดก (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 enzymesrequired to penetrate the basement membrane to invade the dermis.

Larva migran

• Thiabendazole; topical 10-15% suspunder occlusive *4x7d

• 25-50 mg/kg/d PO divided q12h for 2-5 dnot to exceed 3 g/dalbendazole, mebendazole, and ivermectin

Overview

• Infestation insect, parasite.• Infection fungus

bacteria virus

• Management

Tinea corporis กลาก

Fungal infectionFungal infectionTinea facei/corporis Tinea facei/corporis

KOH;dermatophyteKOH;dermatophyte

• Clotrimazole• Miconazole• Gently massage into

affected area and surrounding skinareas bid for 4 wk

• Ketoconazole 2-4 wk• Terbinafine

qd for 1-4 wk

Tinea versicolor เกลื้อน

KOH KOH เกลื้อน

• 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 เกลื้อน

• Ketoconazole; single-dose 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(กลาก)• Endogenous Tinea versicolor(เกลื้อน)

Candidiasis-immune status

Antifungal topical

• imidazoles (eg, clotrimazole, miconazole, econazole, ketoconazole)

• Terbinafine กลาก

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 crurismay need systemic antifungal therapy

Drugs Dosage (tab/day)

Duration (days)

Rx Cost (baht)

efficacy

Griseofulvin (500mg)*

2 21-28 130 ~70%

Ketoconazole (200mg)*

1 14 252 79%

Itraconazole (100mg)

1 14 616 88%

Terbinafine (250mg)

1 14 1162 87%

Systemic antifungal therapy

Original vs local madeDrugs Dosage

(tab/wk)Duration (weeks)

Rx Cost (Baht)

Efficacy(%)

Diflucan (150mg)

1 4 813 88

Fluconazole (200mg)*

1 6 24 ?

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

Oraparn Techaritpitak ,Natta Rajatanavin 2007

7079

88 87 88

0102030405060708090100

Griseofluvin Ketoconazole Itraconazole Terbinafine Diflucan Fluconazole

Percent

Efficacy comparison

85 %

(our study)

130252

616

1162

813

240

200

400

600

800

1000

1200

1400

Griseofluvin Ketoconazole Itraconazole Terbinafine Diflucan Fluconazole

Baht

Price comparison

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 bathKetoconazole 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

Mee’s 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 RxWhich medication?

Antifungal drug for onychomycosis

• Topical ineffective• Nail lacquer• Oral grisiofulvin ineffective

ketoconazol hepatotoxicitraconazole expensive

(1,960-3,920 baht)terbinafine 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 ชันต ุ;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 insect, parasite.• Infection 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 แตไดacyclovir

•• Ass. Prof. Amornsri Ass. Prof. Amornsri ChunharajChunharaj

Impetigo

• Mupirocin topically three times a day for 7days.

• 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 Ass. Prof. Amornsri ChunharajChunharaj

Scarlet feverSand paper rashStrawberry tongue

desquamation

Ass. Prof. Amornsri ChunharajAss. 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 dicloxacillinor cephalexin.

Erysipelas

Mycobacteria

Tuberculosis & leprosyAtypical mycobacterium

Tuberculosis

continuous propagation

of infection from an underlying

structure, most commonly

lymph node or bone.

Tuberculosisverrucosa cutis (wart like)

โรคเรื้อนประเภทเชื้อนอย (Paucibacillary Leprosy - PB)

• ผื่นเปนวง สีจางหรือเขมกวา ผิวหนังปกติ ผิวแหงมีอาการชา

Sensory loss is a typical feature of leprosy.

• ประชาชนสวนใหญจะมีภูมิตานทานตอโรคเรื้อน เมื่อไดรับเชื้อโรคเรื้อน โอกาสที่จะปวยเปนโรคมีเพียงประมาณรอยละ 5 เทานั้น

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

ผูปวยโรคเรื้อนประเภทเชื้อนอย(PB)

• กินยา Rifampicin 600 มิลิกรัม กินตอหนาหรือตามคําแนะนําของเจาหนาที่ เดือนละครั้ง และยา Dapsone 100 มิลิกรัม ทุกวัน ระยะเวลากินยานาน 6 เดือน

• การหยุดยาและจําหนายจากทะเบยีนการรักษา ระยะเฝาระวัง(การติดตามหลังจากหยุดยา)ตรวจรางกายปละครั้งเปนเวลา 3 ป ในผูปวยชนิดเชื้อนอย

โรคเรื้อนประเภทเชื้อมาก (Multibacillary Leprosy - MB)

โรคเรื้อนประเภทเชื้อมาก (Multibacillary Leprosy - MB)

ผื่นนูนแดงหนาหรือตุม มีจํานวน มาก กระจายตามสวนตาง ๆของรางกาย พบเชื้อ

ผูปวยโรคเรื้อนประเภทเชื้อมาก

• กินยา Rifampicin 600 มิลิกรัม และ Clofazimine(Lamprene) 300 มลิิกรัม กินตอหนาหรือตามคําแนะนําของเจาหนาที่ เดือนละครั้ง และยา Dapsone 100 มลิิกรัม และ Clofazimine(Lamprene) 50 มิลิกรัม ทุกวัน ระยะเวลากินยานาน 2 ป

• การหยุดยาและจําหนายจากทะเบียนการรักษา ตรวจรางกายและตรวจเชื้อปละครั้งเปนเวลา 5 ปในผูปวยชนิดเชื้อมาก แลวจึงจําหนายจากการเฝาระวัง

Atypical mycobacterium

Atypical mycobacterium Sweet syndrome

Overview of lecture

• Infestation insect, parasite.• Infection fungus

bacteriavirus

HZV

H.simplex

Herpes

vesicle

Erosive ulcer

crust

Recurrent

Herpes zoster

Management

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

Verrucae vulgaris / warts

<>

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 contagiosumหูดขาวสุก

Rx ;currettage + EMLA

Conclusion

• Infestation insect, parasite.• Infection fungus

bacteria,mycobactrium virus

• Management

• Thank you

AcknowledgementAcknowledgementAss. Prof. Amornsri ChunharajAss. Prof. Amornsri ChunharajAll dermatology staffs and residentsAll dermatology staffs and residents

Div. Of DermatologyRamathibodi Hospital

Question&AnswerQuestion&Answer

Adverse drug reaction ADR

Recurrent dusky red patches

• Dx Acneiform drug eruptionStriae due to steroid

Staphylococcal scalded skin syndrome

Nikolsky sign

Impetigo

Scarlet fever