Skin and Soft Tissue Infections

Impetigo

Impetigo is a superficial bacterial skin infection most often caused by Streptococcus pyogenes or Staphylococcus aureus. Lesions may sometimes be bullous or have a “honey crust”.

Antimicrobial

All impetigo should be treated with soap and water and antiseptic solution topically TID to soften crusts.

For moderate to severe disease:

Cloxacillin 500mg (child 15mg/kg) PO QID

Alternative:

Co-trimoxazole 160 / 800mg (child 4/20 mg/kg) PO BID

Benzathine penicillin 1.2 million IU (900mg) (child <20kg 0.6 million IU (450 mg)) IM, 1 dose (do not use for bullous impetigo)

Comments and Duration of Therapy

Swab exudate for culture if moderate-severe infection, or if patient is not improving on first line therapy.

Nonbullous impetigo arises on the face especially around the nares, or the extremities. It starts as erythematous papules which become vesicles, and then pustules that rupture and lead to honey-coloured crusted lesions on an erythematous base.

Bullous impetigo is characterized by the progression of vesicles to flaccid bullae which rupture easily, then become crusted. It is usually caused by Staphylococcus aureus. Adults with bullous impetigo should be tested for HIV.

Duration:

Treat for 5 days

Folliculitis, Boils, Carbuncles and Skin Abscesses

Folliculitis is the infection of a hair follicle with purulent inflammatory exudate. A boil (or furuncle) is a simple subcutaneous abscess. Carbuncles are deeper and wider lesions with interconnecting tracts from neighbouring hair follicles.

The main pathogens are Staphylococcus aureus and Streptococcus pyogenes.

Antimicrobial

For abscesses < 5cm antibiotics are not always necessary.

After adequate incision and drainage, if persistent cellulitis, give:

Cloxacillin 500mg (child 15mg/kg) PO QID

Alternative:

Cotrimoxazole 160/800 mg (child 4/20 mg/ kg) PO BID

Clindamycin 450 mg (child 10mg/kg) PO TID

If patient is systemically unwell treat as per Cellulitis.

Comments and Duration of Therapy

Incision and drainage is key to the treatment of boils and carbuncles. Send pus for culture and if systemically unwell send blood cultures.

Duration:

If patient is systemically well treat for 5-7 days

See Staphylococcus aureus bacteraemia in Chapter 12: Sepsis and Directed Therapy for Blood Stream Infections if this is present.

Cellulitis

Cellulitis is a common infection of the deep dermis and subcutaneous tissue most often caused by Streptococcus pyogenes and Staphylococcus aureus. It presents as erythema, swelling, warmth, and pain, and may be purulent with associated pustules or abscesses.

Water exposure increases the risk of certain organisms such as Aeromonas (fresh/ brackish water) or Vibrio (salt water).

In patients with septic shock treat as Necrotising Soft Tissue Infection.

In patients with cellulitis involving or surrounding an eye, see Orbital and Pre-Orbital Cellulitis in Eye Infections chapter.

Antimicrobial

Mild infection:

Cloxacillin 500mg (child 15mg/kg) PO QID

Alternative:

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID

Clindamycin 450 mg (10mg/kg) PO TID

Moderate to severe infection:

Cloxacillin 2g (child: 50mg/kg) IV QID

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

Clindamycin 600mg (child 15mg/kg) IV TID

Vancomycin IV, dose according to Vancomycin dosing section

If there is water exposure, ADD:

Ciprofloxacin 500mg (child 10mg/kg) PO BID

Comments and Duration of Therapy

If there are abscesses, incision and drainage is important, if there are signs of necrotizing fasciitis treat for this. Consider MRSA if cellulitis is purulent. Send blood cultures if systemically unwell, send swab of pus for culture if this is present.

Predisposing factors for cellulitis such as tinea infection of the feet, lymphoedema and fissured dermatitis if present should be treated to prevent recurrence.

Rest and elevation of the affected area improves clinical response.

Duration:

Mild infection: Treat for 5-7 days
Moderate to severe infection: Change to oral antibiotics when clinically improving. Treat for a total of 7-10 days.

See Staphylococcus aureus bacteraemia in Chapter 12: Sepsis and Directed Therapy for Blood Stream Infections if this is present.

Bite wounds

Bite wound infections are caused by bacteria associated with human skin (Staphylococcus aureus), and animal oral flora (Pasteurella spp., Capnocytophaga canimorsus, Streptococcus spp., anaerobic bacteria). Marine bite infections are associated with Aeromonas spp., Shewanella putrefaciens, and Vibrio spp.

Antibiotics are required for infected bites. For bites that are not infected, antibiotics are required if the wound is high risk.

If patient is in septic shock treat as Necrotising Soft Tissue Infection. See Necrotising Soft Tissue Infection (Necrotising fasciitis, myonecrosis, gas gangrene, Fournier’s gangrene) in Chapter 13: Skin and Soft Tissue Infections

Antimicrobial

Consider tetanus prophylaxis for all bite wounds. See Tetanus Prophylaxis in Antibiotic Prophylaxis chapter.

For Human (clenched fist) / Cat / Dog bites:

Prophylaxis for high risk wounds, or mild infection:

Amoxicillin/Clavulanic acid 500/125mg (child 25/6.25 mg/kg) PO TID

Alternative:

Doxycycline 100 mg (child ≥8 years: 2mg/ kg) PO OD

PLUS

Metronidazole 500mg (child 12.5mg/kg) PO BID

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID

PLUS

Metronidazole 500mg (child 12.5mg/kg) PO BID

Moderate to severe infection:

Ceftriaxone 2g (child 25mg/kg) IV OD

PLUS

Metronidazole 500mg (child 12.5mg/kg) IV/ PO BID

For marine bites and water contaminated wounds:

Prophylaxis for high risk wounds, or mild infection:

Cloxacillin 500mg (child 15mg/kg) PO QID

PLUS

Ciprofloxacin 500mg (child 12.5mg/kg) BID

Moderate to severe infection:

Cloxacillin 2g (child: 50mg/kg) IV QID

PLUS

Ciprofloxacin 400mg (child 10mg/kg) IV TID

Comments and Duration of Therapy

If there is evidence of infection, swab wound for culture. If systemically unwell, perform blood cultures. If wound is debrided send tissue for culture.

Bite wounds are high risk for infection if any of the following are present:

Delayed presentation for debridement (>8hours)
Puncture wound that cannot be adequately debrided
Wound on hands, feet, or face
Wound involving bones, joints, or tendons
Immunocompromised patient
Cat bite wound

Duration:

Prophylaxis or mild infection: If no signs of infection treat for 3 days. If signs of infection treat for 5-7 days depending on clinical response.

Moderate to severe infection: Change to oral antibiotics when clinically improving. Treat for a total of 10-14 days.

Traumatic Wound Prophylaxis and Infection

Antibiotic prophylaxis is not routinely required for traumatic wounds but may be considered in wounds that require surgical management, or which are heavily contaminated.

See Prophylaxis for Open Fractures in Bone and Joint Infections if this is present.

If patient is in septic shock treat as Necrotising Soft Tissue Infection.

See Necrotising Soft Tissue Infection (Necrotising fasciitis, myonecrosis, gas gangrene, Fournier’s gangrene) in Chapter 13: Skin and Soft Tissue Infections

Antimicrobial

Consider tetanus prophylaxis for all wounds. See Tetanus Prophylaxis in Antibiotic Prophylaxis chapter.

Thorough debridement and cleaning is essential.

For prophylaxis of heavily contaminated wounds that do not require surgery, and for mild infection use:

Cloxacillin 500mg (child 15mg/kg) PO QID.

Alternative:

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID

Clindamycin 450 mg (child 10mg/kg) PO TID

For prophylaxis of wounds that require surgery, and for moderate to severe infection use:

Cefazolin 2g (child 50mg/kg) IV TID

Alternative:

Cloxacillin 2g (child 50mg/kg) IV QID

Clindamycin 600mg (child 15mg/kg) IV TID

Vancomycin IV, dose according to Vancomycin dosing section

If wound is heavily contaminated or penetrating to hollow viscous ADD:

Metronidazole 500mg (child 12.5mg/kg) IV/ PO BID

Comments and Duration of Therapy

If there is evidence of infection, swab wound for culture. If there are systemic features of infection, send blood cultures.

Duration:

Prophylaxis of heavily contaminated wounds that do not require surgery: Treat for 24 - 72 hours.

Prophylaxis of wounds that require surgery: Stop antibiotics ≤ 24 hours after wound closure. Stop antibiotics at 72 hours if wound closure is not achieved earlier.

Mild infection: Treat for 5-7 days depending on clinical response.

Moderate to severe infection: Change to oral antibiotics when clinically improving. Treat for a total of 10-14 days.

Surgical Site Infection

This refers to a post-operative patient who has developed infection at the operation site either in the ward or after discharge home.

The most common pathogens are Staphylococcus aureus and other Staphylococcal spp., Streptococcal spp., and Enterococcus.

If patient is in septic shock treat as Necrotising Soft Tissue Infection.

Antimicrobial

Cloxacillin 2g (child 50mg/kg) IV QID

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

Clindamycin 600mg (child 15mg/kg) IV TID

If gram negative infection is suspected (e.g. grossly contaminated wound that communicates with gastrointestinal or urinary tract) consider ADDING:

Gentamicin 4-5mg/kg (child <10 years old 7.5mg/kg) IV OD

See Aminoglycoside dosing section.

Comments and Duration of Therapy

Swab wound for culture. If systemic features of infection, send blood cultures.

Debride wound if necrotic tissue or deep collection is present. Send tissue for culture.

Duration:

Change to oral antibiotics when clinically well. Treat for 7-14 days depending on the severity of infection.

Diabetic foot infection

Diabetic foot infections may involve skin and soft tissue or extend deeper to underlying muscle and bone. These infections are often mixed, involving aerobes and anaerobes, Gram-positive and Gram-negative organisms., however Staphylococcus aureus and streptococci are the most common cause of acute diabetic foot infections in patients who have not received recent antibiotics.

If patient is in septic shock treat as Necrotising Soft Tissue Infection.

Antimicrobial

Always obtain surgical opinion for the possibility of debridement.

Mild:

Amoxicillin/Clavulanic acid 500/125mg PO TID

Alternative:

Cloxacillin 500mg PO QID

PLUS

Metronidazole 500mg PO BID

Co-trimoxazole 160/800mg BID

PLUS

Metronidazole 500mg PO BID

Moderate-Severe:

Cloxacillin 2g IV QID

PLUS

Ciprofloxacin 500mg PO BID (or 400mg IV TID)

PLUS

Metronidazole 500mg PO/IV BID

Alternative:

Clindamycin 600mg IV TID

PLUS

Ciprofloxacin 500mg PO BID (or 400gm IV TID)

Comments and Duration of Therapy

Tissue culture obtained by biopsy or aspiration may help guide antibiotic therapy. Superficial wound swab cultures need to be interpreted in the clinical context, as organisms isolated may be colonizing rather than infecting the wound. Take blood cultures if systemically unwell.

Diabetic foot infections are often worse than they appear. Complications which need to be considered include osteomyelitis, and necrotising soft tissue infection. Proper wound care and dressings are as important as antibiotics.

Duration:

Mild infection: Treat for 5-7 days

Moderate to severe infection: If there is no osteomyelitis change to oral antibiotics when clinically improving and treat for a total of 10-14 days.
If infected limb is amputated with clear margins, stop antibiotics 2-5 days following surgery.

See Acute Osteomyelitis in Chapter 2: Bone and Joint Infections, and Chronic Osteomyelitis in Chapter 2: Bone and Joint Infections for treatment duration if this is present.

Necrotising Soft Tissue Infection (Necrotising fasciitis, myonecrosis, gas gangrene, Fournier’s gangrene)

Clinical features that suggest a necrotising infection of the skin and deeper tissues include: severe constant pain, bullae, skin necrosis or discolouration, wooden hard subcutaneous tissue, gas in the soft tissue, oedema beyond the margin of erythema, rapid spread, systemic toxicity plus fever, delirium, renal failure and a high white cell count. Consider this diagnosis in any patients who are critically unwell with skin and soft tissue infection.

Give antibiotics within 1 hour of presentation. Urgent surgical debridement is essential.

Antimicrobial

Meropenem 1g (child 20mg/kg) IV TID

PLUS

Vancomycin 25-30mg/kg loading dose IV, then dose according to Vancomycin dosing section

PLUS

Clindamycin 600mg (child 15mg/kg) IV / PO TID

Alternative:

Replace meropenem in the above regime with:

Piperacillin/Tazobactam 4/0.5g (child 100/12.5 mg/kg) IV QID

Replace meropenem in the above regime with: Amikacin 28mg/kg IV OD as a first dose in patients with creatinine clearance >60ml/minute. Use 16-20mg/kg if creatinine clearance <60ml/minute. For subsequent doses see Aminoglycoside dosing section.

Child 15mg/kg IV OD.

Replace vancomycin in the above regime with:

Cloxacillin 2g (child: 50mg/kg) IV QID

If the wound has been immersed in water ADD:

Ciprofloxacin 400mg (child 10mg/kg) IV TID

Ciprofloxacin 500mg (child 12.5mg/kg) PO BID to three drug regime above.

Comments and Duration of Therapy

Send blood cultures prior to antibiotics. Send tissue specimens from operative theatre for culture.

Change to directed antibiotics as soon as culture results are available.

Clindamycin is included in the empiric regime for its theoretic anti-toxin effects. It should be continued in addition to a beta-lactam if Streptococcus pyogenes, Staphylococcus aureus, or Clostridium spp. are found to be the causative organisms.

Duration:

Change to oral antibiotics when further debridement is no longer necessary, there has been clinical improvement, AND patient has been afebrile for 48 to 72 hours. At this point if patient is still on clindamycin, stop this. Continue oral antibiotics until infection has resolved but not necessarily until the wound has healed.

See Staphylococcus aureus bacteraemia in Chapter 12: Sepsis and Directed Therapy for Blood Stream Infections if this is present.

Streptococcus pyogenes Necrotising Soft Tissue Infection

Antimicrobial

Benzylpenicillin 4 million IU (2.4g) (child 80 000 IU (50mg)/kg) IV Q4H

PLUS

Clindamycin 600mg (child 15mg/kg) IV TID / PO

Alternative:

Ampicillin 2g (child 50mg/kg) IV Q4H

PLUS

Clindamycin 600mg (child 15mg/kg) IV TID / PO

When oral therapy is appropriate change to:

Amoxicillin 1g (child 25mg/kg) PO TID

Comments and Duration of Therapy

Duration:

Change to oral antibiotics when further debridement is no longer necessary, there has been clinical improvement, AND patient has been afebrile for 48 to 72 hours. At this point stop clindamycin. Continue oral antibiotics until infection has resolved but not necessarily until the wound has healed.

Clostridium spp. Necrotising Soft Tissue Infection (Gas gangrene)

Antimicrobial

Benzylpenicillin 4 million IU (2.4g) (child 80 000 IU (50mg)/kg) IV Q4H

PLUS

Clindamycin 600mg (child 15mg/kg) IV TID / PO

Alternative:

Ampicillin 2g (child 50mg/kg) IV Q4H

PLUS

Clindamycin 600mg (child 15mg/kg) IV TID / PO

Comments and Duration of Therapy

Duration:

Change to oral antibiotics when further debridement is no longer necessary, there has been clinical improvement, AND patient has been afebrile for 48 to 72 hours. Continue oral antibiotics until infection has resolved but not necessarily until the wound has healed

MRSA Necrotising Soft Tissue Infection

See Staphylococcus aureus bacteraemia in Chapter 12: Sepsis and Directed Therapy for Blood Stream Infections if this is present.

Antimicrobial

Vancomycin 25-30mg/kg loading dose, then dose according to Vancomycin dosing section

PLUS

Clindamycin 600mg (child 15mg/kg) IV TID / PO

Comments and Duration of Therapy

Duration:

Burns

Antibiotic prophylaxis is not indicated for patients with burns that do not require immediate debridement surgery. For patients who require debridement use routine surgical prophylaxis (see Surgical Prophylaxis in Antibiotic Prophylaxis chapter). There is no evidence to support the use of systemic prophylactic antibiotics after debridement. Monitor patients closely for evidence of infection and treat if this occurs.

Antimicrobial

Consider tetanus prophylaxis for all burns. See Tetanus Prophylaxis in Antibiotic Prophylaxis chapter.

Minor:

Sterilised gauze dressing impregnated with white soft paraffin

Moderate to severe with signs of infection:

Silver Sulfadiazine 1% cream (this cream does not penetrate eschar)
Give systemic antibiotics if signs of surrounding cellulitis. See Cellulitis in Skin and Soft Tissue Infections chapter.

Comments and Duration of Therapy

For all burn cases, proper debridement and/ or escharotomy is paramount.

Superficial wound swab cultures can be helpful to direct therapy when infection is present, however they should be interpreted in the clinical context, as organisms isolated may be colonizing rather than infecting the wound. Send blood cultures if systemically unwell. Send tissue cultures from debridement if infection is present.

Mastitis

Acute mastitis is usually associated with lactation and is frequently due to Staphylococcus aureus.

Antimicrobial

Mild:

Cloxacillin 500mg (child: 15mg/kg) PO QID

Alternative:

Cotrimoxazole 160/800 mg (child 4/20 mg/kg) PO BID

Clindamycin 450 mg (10mg/kg) PO TID

Moderate to severe:

Cloxacillin 2g (child: 50mg/kg) IV QID

Alternative:

Cefazolin 2g (child 50mg/kg) IV TID

Clindamycin 600mg (child 15mg/kg) IV TID

Comments and Duration of Therapy

Take blood cultures if systemically unwell. Send wound swab, pus or operative specimens for culture if available.
Change antibiotics according to susceptibility results.

Duration:

Mild infection: Treat for 5-7 days
Moderate to severe infection: Step down to oral antibiotics when improving. Treat for a total of 7-10 days.

See Staphylococcus aureus bacteraemia in Chapter 12: Sepsis and Directed Therapy for Blood Stream Infections if this is present.

Herpes Simplex

Common in children and adults. Primary episode generally occurs in childhood and may be associated with fever and lymphadenopathy. Lesions are usually preceded by pain, burning, or tingling for several hours to days. The lesions begin as macules and rapidly become papular, with vesicles appearing within 48 hours and scabs within 3-4 days.

Antimicrobial

Mild:

Symptomatic management only

Moderate-Severe:

Acyclovir 400mg (child 10mg/kg) PO 5 times a day

Long-term suppression:

Acyclovir 400mg (child 10mg/kg) PO BID

Comments and Duration of Therapy

Treatment is effective if initiated within 48 hours of a lesion appearing. Long-term suppression may be considered in patients with frequent disabling recurrences, erythema multiforme, or in immunocompromised patients

Duration:

Moderate to severe: Treat for 7 days

Long-term suppression: Treat for up to 6 months

See also Encephalitis in Chapter 4: Central Nervous System Infections, Dendritic corneal ulceration caused by Herpes Simplex virus in Chapter 7: Eye Infections, Genital Herpes simplex virus in Chapter 8: Genital Infections, and Neonatal Herpes simplex in Chapter 11: Paediatric Infections (Neonates, Infants and Children)

Eczema Herpeticum

Widespread Herpes skin infection complicating active or recently healed atopic dermatitis. Presents with an acute eruption of vesicles or multiple crusted erosions in an area of dermatitis. May be associated with fever, lymphadenopathy, and malaise.

Antimicrobial

Acyclovir 400mg (child 10mg/kg) PO 5 times a day

If secondary bacterial infection is present treat as Cellulitis.

Comments and Duration of Therapy

Duration:

Treat for 7-10 days. Extend duration if lesions have not healed or crusted by day 10.

See Herpes Simplex in Chapter 13: Skin and Soft Tissue Infection

Herpes Zoster / Shingles

Caused by reactivation of Varicella Zoster virus (chicken pox virus). Characterised by unilateral dermatomal pain, with a vesicular rash on an erythematous base in a dermatomal distribution. More common in older adults and immunocompromised patients. May be complicated by post-herpetic neuralgia. Management of this complication is more likely to be successful if analgesia is commenced early.

Antimicrobial

If treatment is indicated (see comments) use:

Acyclovir 800mg (child 20mg/kg) PO 5 times a day

For immunocompromised patients with disseminated diseases:

Acyclovir 10mg/kg (child < 5 years 20mg/kg, 5-12 years 15mg/kg, >12 years use adult dosing) IV TID

If secondary bacterial infection is present treat as Cellulitis.

For post-herpetic neuralgia consider:

Amitriptyline 25 – 50mg nocte

Comments and Duration of Therapy

Treatment is indicated for adults and adolescents who present within 72 hours of rash onset, and for all immunocompromised patients regardless of duration of rash. Most children with herpes zoster don’t require treatment. Treat if immunocompromised, or if severe or rapidly progressing.

Test for HIV in disseminated disease.

Duration:

Treat for 7 days
Immunocompromised patients with disseminated diseases: Change to oral therapy when clinically improving. Treat for total of 10-14 days.

See Neonatal Varicella Zoster Virus Prophylaxis / Treatment in Chapter 11: Paediatric Infections (Neonates, Infants and Children)

See Neonatal Varicella Zoster Virus Prophylaxis / Treatment in Chapter 11: Paediatric Infections (Neonatesm Infants and Children), and, Varicella infection (chickenpox) in Chapter 14: Special Infections

Tinea

Caused by dermatophytes. The typical rash is annular, itchy, and scaly with a definite edge and central clearing.

Tinea capitis Dermatophyte infection of hair and scalp.

Tinea corporis Dermatophyte infection of skin excluding palms, soles, groin, and face.

Tinea cruris Dermatophyte infection of inguinal area and crural fold.

Tinea pedis Dermatophyte infection of feet.

Tinea manuum Dermatophyte infection of hand.

Antimicrobial

Miconazole 2% cream BID

Alternative:

Ketoconazole shampoo 2% OD to twice a week

Ketoconazole gel 2% topical OD

Clotrimazole 1% cream topical BID

Terbinafine 1% cream BID

If oral therapy is indicated (see comments) use:

Fluconazole 150mg - 200mg PO weekly

Comments and Duration of Therapy

If diagnosis is uncertain perform fungal skin scraping and send to laboratory for microscopy and culture, prior to antifungal treatment.

Oral therapy is indicated if the following

Widespread or established infection
Failure of topical therapy
Rapid recurrence after topical therapy

In tinea pedis keep feet dry, particularly between toes, and dry footwear in the sun.

Duration:

Topical therapy: Treat for 2-6 weeks
Oral therapy: Treat for 6 weeks. Monitor liver function weekly.

Cutaneous Candidiasis

Presents as patches of moist confluent erythematous macules with overlying curd-like material. Usually occurs on mucosal surfaces or in skin folds (e.g. under breasts, in inguinal fold). Most commonly occurs in patients with predisposing factors such as therapy with broad-spectrum antibiotics, or diabetes.

Antimicrobial

Clotrimazole 1% cream topical BID

Alternative:

Miconazole 2% cream topical BID

Nystatin 100 000 units cream topical BID

A mild steroid cream can be added to the anti-fungal cream if required to relieve itching.

Comments and Duration of Therapy

Consider performing potassium hydroxide (KOH) bedside test. If diagnosis remains unclear, swab area for culture.

Duration:

Continue until 2 weeks after symptom resolution.

See also Vulvovaginal candidiasis, Oral thrush (Candidiasis), Candida oesophagitis, and Candidaemia
See Oral thrush (Candidiasis) in Chapter 9: Gastrointestinal infections, Candida Oesophagitis in Chapter 9: Gastrointestinal infections, and Vulvovaginal Candidiasis in Chapter 17: Women’s Health

Pityriasis versicolour

Caused by Malassezia yeasts. Most commonly seen in adolescents and young adults. Presents with patches of hypopigmentation or hyperpigmentation, with fine scale. Usually on the neck, chest, back, and upper arms. Rash is usually asymptomatic.

Comments and Duration of Therapy

Consider performing potassium hydroxide (KOH) bedside test. If diagnosis remains uncertain perform fungal skin scraping and send to laboratory for microscopy and culture, prior to antifungal treatment.

While the condition does not leave scars, pigmentary changes may take several months to return to normal.

Duration:

Shampoo: Single application may be adequate

Cream: Treat for 1-3 weeks

Head lice (Pediculosis capitis)

These are crawling insects that live on the scalp and lay eggs on hair. Bites may produce erythematous macules, papules, excoriations, and scaling, with accompanying with pruritus.

Antimicrobial

40% of cases can be cured by wet combing alone.

If insecticide is required use:

Permethrin 1 % cream topically to damp hair and scalp. Leave for 20 minutes before washing out.

Comments and Duration of Therapy

Wash pillowcases, combs, and brushes in hot water. Family and close physical contacts should be examined.

Duration:

Repeat application 7 days after first treatment.

Body lice (Pediculosis corporis)

Caused by Pediculus humanus humanus, lice that live in clothing. Patients complain of pruritus, and present with excoriations, often linier, primarily on the neck, shoulders, back, and wrist. In chronic cases patients may have hyperpigmentation macules.

Antimicrobial

Permethrin 1 % cream topically to body. Leave on for 20 minutes before washing off

Alternative:

Ivermectin 200mcg/kg single dose (not in children <15kg or pregnant women)

Comments and Duration of Therapy

Clothing and bedding should be discarded or washed in hot water and sealed in closed plastic bags for 30 days.

Pediculus humanus humanus can be a vector for typhus and trench fever (Bartonella quintana)

Duration:

Repeat application or dose 7 days after first treatment.

Pubic lice (Pediculosis pubis)

Caused by Phthirus pubis, lice that live in pubic, axillary, beard, and other body hair. The main symptom is itch. Eggs are visible on hairs. Examine all hair-baring surfaces.

Antimicrobial

Permethrin 1% cream topically to hair. Leave for 20 minutes before washing out.

Alternative:

Ivermectin 200mcg/kg single dose (not in children or pregnant women)

Shaving hair may be helpful.

Comments and Duration of Therapy

Pediculosis pubis commonly transmitted by sexual or close contact, examine contacts.

Duration:

Repeat application or dose 7 days after first treatment.

Scabies (non-crusted)

Scabies caused by the mite Sarcoptes scabei var. Hominis, a human pathogen that is spread by close physical contact. An allergic reaction to the mite causes inflammation and itch particularly at night. Excoriations appear in the interdigital webs, sides of fingers, wrists, lateral palms, elbows, axillae, scrotum, penis, labia and areola mammae in women. Scaly burrows in the finger web spaces as pathognomonic. In infants, elderly, and immunocompromised individuals, all skin surface are susceptible.

Antimicrobial

Permethrin 5% cream topically to dry skin from the neck down (including hands, under nails, and genitals). Leave on for 8-14 hours. Reapply to hands if they are washed.

Alternative:

Ivermectin 200mcg/kg single dose (not in children <15kg or pregnant women)

Benzyl benzoate 25% emulsion (apply as per Permethrin)

Comments and Duration of Therapy

Send skin scraping from multiple sites for microscopy if diagnosis unclear, however due to the low mite burden in scabies this may be falsely negative.

All family members, and close contact should be treated simultaneously

Treated individuals should wear clean clothing, and all clothing, pillows, towels, and bedding used during the previous week should be washed in hot water and dried at high heat.

Itch may initially worsen with treatment and may take 3 weeks to resolve after treatment completion.

Duration:

Repeat application or dose 7 days after first treatment.

Crusted Scabies / Norwegian Scabies

In crusted scabies the mite population on the patients is very high due to inadequate host immune response. It occurs in immunocompromised patients and presents as hyperkeratotic plaques. There may be associated thickening and dystrophy of the toenails and fingernails.

Refer to Dermatology and Infectious Diseases if available

Antimicrobial

Ivermectin 200mcg/kg PO OD (not in children <15kg or pregnant women)

PLUS

Topical scabicide:

Permethrin 5% cream topically to dry skin from the neck down (including hands, under nails, and genitals). Leave on for 24 hours. Reapply to hands if they are washed.

Alternative:

Benzyl benzoate 25% emulsion (apply as per Permethrin).

PLUS

To topical scabicide ADD Keratolytic:

Salicylic acid 5-10% in sorbolene cream after washing on alternate days when scabicide is not used.

Alternative:

Whitfield’s solution (3% salicylic acid and 6% benzoic acid in lanolin base) on alternate days.

Comments and Duration of Therapy

Send skin scraping from multiple sites for microscopy to confirm diagnosis. This will usually be positive in crusted scabies due to the high mite burden.

Test for HIV.

Duration:

Apply scabicide every second day for the first week, then apply twice weekly until cured.

Mild: Give ivermectin on days 1 and 8

Moderate: Give ivermectin on days 1, 2 and 8

Severe: Give ivermectin on days 1, 2, 8, 9 and 15

Cutaneous Larva Migrans

Caused by animal hookworm. Presents with erythematous intensely pruritic, serpiginous tracks due to migrating larvae. Progress a few centimeters per day. Commonly involves feet, legs, and buttocks.

Antimicrobial

Albendazole 400mg (child 10 kg or less: 200 mg) PO OD

Alternative:

Ivermectin 200mcg/kg PO OD (not in children <15kg or pregnant women)

Comments and Duration of Therapy

Diagnosis is based on clinical history and examination. Patients typically have a history of exposure to contaminated sand or soil.

Duration:

Albendazole: Treat for 3 days

Ivermectin: Treat for 1-2 days

Yaws

Yaws is a skin infection caused by Treponemal pallidum subspecies pertenue which is transmitted by skin to skin contact. Mostly causes self-limiting primary infection with papules that enlarge into wart-like lesionswith superficial erosion that heal spontaneously within 6 months. Weeks to months later a generalised eruption of similar skin lesions occurs via haematogenous or lymphatic spread, and multiple relapses occur in the first 5 years. Typically lesions are painless, raised, and reddish brown with a yellow crust.

Antimicrobial

Benzathine penicillin 1.2 million (900mg) (child <20kg 0.6 million IU (450mg)) IM single dose

Alternative:

Azithromycin 30mg/kg (maximum dose 2g) PO single dose

Comments and Duration of Therapy

Syphilis serology can be used to assist in the diagnosis of yaws. These tests cannot distinguish between infection with the organisms which cause syphilis or yaws. See Syphilis in Chapter 8: Genital Infections for serology interpretation.

Repeat nontreponemal tests at 6 and 12 months following therapy. A fourfold decrease in titre should occur within 12 months of successful treatment.

Yaws can be complicated by periostitis or paranasal maxillary erosions. Yaws is not known to cause congenital infection.

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