Skin Infections

This new dermatologist podcast is sponsored by La Roche Posse in Cerevi. La Roche Posse has been evaluated in over 700 clinical studies and 124 publications, contributing to dermatology research and innovation in common skin concerns. La Roche Posse, a better life for sensitive skin. Cerevi has a unique slow release technology with three naturally-occurring ceramides that are essential in supporting the skin barrier. Cerevi, developed with dermatologist Worldwide. Available from selected retailers, pharmacies and online. Hello and welcome to the new dermatologist podcast. We are a group of consultant dermatologists who are friends as well as colleagues. We have a collaborative approach to medical practice and have worked with GP colleagues to bring you this podcast on the management of common skin conditions in primary care. I am Vicki Atcrass, a consultant dermatologist working in St. George's Hospital in London. I have a special interest in skin cancer and connective tissue disease. It gives me great pleasure today to be joined again by Dr Monica Sahar. She is a consultant dermatologist from Lewisham and Grenet NHS Trust and an old friend. Hello Monica, welcome back. Thanks Vicki, nice to be back. And we are also very lucky to have Dr. Nebula Bari. She is a GP from Tower Hamlets and she has a special interest in respiratory medicine. So welcome Nebula. Hello. So today we are going to discuss infections that commonly affect the skin and the conditions that can mimic them. We will not discuss warts and maloscum as that has been dealt with in a previous podcast on common pediatric skin conditions. As always, the information in this podcast is based on available evidence and the experience of the clinicians involved. It is intended to be a useful guide for clinicians and the advice given in the podcast must take into account an individual patient's background and be adapted accordingly. So without further ado, a hand over to you, Nebula. Okay, so Monica, in general practice we see a lot of impatigo, most commonly managed using flu coxicillin. Do you have any specific guidance on which antibiotics to use and for how long? Thanks Nebula, yeah. So impatigo is a superficial skin infection and you mostly see in children but it can occur in any age and is primarily caused by staphylococcus or reus but can be caused by streptococcus pyrogens and it is highly contagious. There are two main forms. There's the bullis impatigo, one where you have blisters with clear fluid or pus and this tends to affect young children or infants. And then you have the non-bullis form which might start as a sort of a pink patch and then you may see vesicles and pastules and then the characteristic honey coloured crust on the air at the thematic space, sometimes with some satellite lesions. And typically in the non-bullis form the patient is well, they don't have fevers compared to the bullis form where you may, they may be unwell and have a fever. And interestingly, impatigo can result spontaneously in about 20% of patients in a few weeks but we often find ourselves treating it for symptomatic reasons or to prevent spread or to avoid complications such as staphylococcus, gold and skin syndrome or post-streptococcus, glomerio, nephritis. But one key thing I would advise to do is always take a swab as soon as you see patients with query impatigo because this may help treatment later on. So regarding treatment, evidence has shown that using topical treatment should be enough. If it's non-bullis impatigo though and I would usually use feucidin cream or feucidic acid or mupericin ointment and these are equally efficacious and you use these four times a day for seven to 14 days. I would sometimes consider an oral antibiotic especially if they're cases of bullis impatigo or non-bullis impatigo with systemic symptoms or if you have more than five impatigo lesions or in patients who fail on topical treatments. So if swabs show MRSA, then I would use clindermycin or doxycycline. What do you recommend for patients who seem to get recurrent impatigo monococcus? That's sometimes a problem we see, isn't it? Yeah, I see it especially in children vicki actually and this is because sometimes staff may reside in the nostrils and it's important to consider whether nasal staff carriage could be fueling recurrent impatigo on the face or even the body. And if you feel this is happening, I would recommend a swab from the anterior naries and if positive treat with an aseptin which is a mixture of clalhexidine and neomycin and you do this four times a day for ten days or mupericin ointment four times a day for five days to decolonize and obviously treat the impatigo as well. Just beware, naseptin does contain peanut or also don't use in peanut allergic individuals. Thanks Monica, really helpful. Sennelitis is another common infection that we see in general practice. Could you give us some useful tips on management? So cellulitis is different, it's a deeper infection of the skin and it involves a subcutaneous fat and it's usually caused by beta hemolytic streptococcus or staphococcus aureus or other bacteria and it's important to treat early with oral antibiotics and usually your local CCG or trust will have guidelines regarding treatment protocols. Locally we use flu-cloxicillin, 500 milligrams to 1000 milligrams QDS or if you're a penicillin allergic clarithromicin, 500 milligrams BD for 7 to 14 days. Some protocols use a keflosporin such as oral kefilexin or intravenous kef triaxone or sometimes you can see protocols using doxycycline for penicillin allergic patients. I would probably refer in for an IV antibiotics if the patient is systemically unwell or there is no improvement or if there is progression of the cellulitis. And I probably would refer to A&E or AMU rather than metology as they are set up to give IV antibiotics in ambulatory care. I've often been referred patients with ininverted commas bilateral cellulitis on the wards and in A&E. So can you elaborate on this a little bit for us Monica? Yes, beware of bilateral cellulitis. I think basically doesn't exist. You might be actually looking at varicosexmer or lipodermatosclerosis or lymphodema. The difference here is that patients with cellulitis will generally feel unwell. They might have a fever and raise inflammatory markers and they don't generally have bilateral signs. Whereas in venousxmer you might see scaling, dryness, erythema and you want to look for underlying venous disease such as varicose veins. Also the patient will be well and they won't have a fever and have normal inflammatory markers. Lipodermatosclerosis is inflammation of the subcutaneous fat and that's due to venous insufficiency and legs can often look swollen and they feel hard and ingerated. And in the acute form this can be red and can mimic cellulitis. So treatment is based on treating the underlying varicosexmer with amoliance and topical steroids and managing the underlying venous congestion. Vicki, I know you have a great lymphodema service at St. George's that I'm very jealous of. Can you tell us what you do? Yeah, sure. I asked Dr. Gordon who runs a lymphodema service about this actually and mainly because I mean in the community now there's less and less access to people doing compression bandaging etc. It's really important that patients with this condition have any underlying issues treated so venous congestion and that usually means elevating the legs and compression bandaging. And basically, Dr. Gordon often advises GPs looking after patients with venous insufficiency to prescribe class 2 compression rosary or Velcro compression. And apparently the garment companies are really keen to support community nurses and they'll send out their reps to help with measuring patients for these garments. There's no longer a need to check ABPI's before prescribing compression and community nurses can now assess vascular status clinically and there is a toolkit published by the British Lymphology Society to help with that. Okay, thanks Vicki, very helpful. So Monica, a staff that feels like the most common skin organism and we always refer, you know, we think it's staff straightaway but can you actually tell us about what other organisms commonly cause skin infections? Obviously there are other bacterial infections but in the skin, sometimes we see pseudomonas and this can look green and there's an offensive smell and we often treat empirically with sipprofloxicin. And I've certainly seen this many times in infected leg ulcers, so just beware of that one. It has that characteristic green colour and always take a swab. Another tip is to think about non-bacterial causes, such as co-existent viral disease. So sometimes we can see herpes simplex virus infection in infected eczema, so that's eczema hepaticum and they have this classic appearance with monomorphous papules and vesicles with this kind of cluster formation. So just remember, if you see a cluster formation in the skin, just think could this be viral in etiology and also think about fungal and rarely parasite infections, especially in atypical presentations? Can you tell us a bit more about PVL staff or is monococcus? There was quite a lot in the dermatology literature about that a few years ago. Yeah, so PVL is panton valentine leukosidin and it's a toxin produced by some strains of staphylococcusorias and it can cause cancer. i'n acrocydd i'n lucosau i'n lucosau'n lysus. Mae'n acrocyddio, mae'n acrocyddio i'n lucosau. Mae'n acrocyddio i'n lucosau i'n lucosau i'n lucosau i'n lucosau i'n lucosau i'n lucosau. Mae'n acrocyddio i'n lucosau i'n lucosau i'n lucosau i'n lucosau i'n lucosau. Mae'n acrocyddio i'n lucosau i'n lucosau i'n lucosau. i'n prynvenciŵn, but it's really important if you are querying PVL staff, do write on the microform that you are querying this as they may not necessarily check for it and do ask for antibiotic sensitivities. And if there is an abscess it may need draining or if the infection is severe they may need IV antibiotics. So the health protection agency has published guidelines on treatment of PVL infections and essentially involves treatment with either flu clocks or sillin or clinder mice in for a week. And if it is MRSA a combination of refampusin and doxycycline can be used. So after the initial infection is treated the body must be cleared of PVL staff. So at diagnosis do take swabs from the nose and exili and treat the body with an antibacterial wash such as chlorhexidine and naseptin for the nose and not dissimilar to the MRSA protocols and also think about decolonizing close family contacts at the same time. Thanks Monica, that's very interesting. So moving on then I've heard that cellulitis is often caused by athlete's foot. This isn't something we commonly look for in general practice. Should we be co-treating cellulitis with Tabinaphenodactocort as well as antibiotics? Yes it can be a common cause especially for broken skin and so it may be a portal of entry for bacteria that's causing cellulitis but you should also look for other routes of entry like lacerations, injection sites, boils and insect bites. So it's good to look for all of these and yes it is a very good idea to treat athletes to prevent further infections. Thank you. So sometimes it's actually difficult in general practice to distinguish between a fungal infection and a bacterial skin infection. Do you have any top tips for us? Yeah so I think one thing to remember is that most infections are asymmetrical and now fungal infections can have quite a variable presentation so you can get your classic annular ring lesion with erythema and scale that you may see in a child but in athletes' foot you see sort of scaling erythema and maceration in between the toes whereas in fungal toenail infections you might see yellowish discoloration and dystrophy but the main thing is scaling is a key feature of a fungus infection so for example in tiniacapetus which is a fungal infection of the scalp one can see scale first but if you leave this untreated it can lead to something called a carry-on which is a deeper fungal abscess which looks like an inflamed bogey area with pus-filled lumps on the scalp. You may think clinically that this is bacterial but patients need oral antifungals and we usually use oral tabinaphein or grizzio-fulvin or itchriconazole and we use this for four to eight weeks depending on which one you give and then sometimes you can get these deep seated fungal infections that can look like large boils and it can and they can be mistaken for skin cancers such as squamous cell cancers so mycology is important. If you do get an odd skin infection which is progressing and not responding to treatment do you think about uncommon causes like a typical micro bacterium infections and consider referral into dermatology so always delve into the history and look for possible entry routes have they been on holiday recently what do they do for a job do they work with animals and fish do they have any odd hobbies it can give you a clue. Thank you Monica okay so a simple question but something that we're faced with daily in general practice what's superior in treating a fungal infection. Dacta cortal dectarine. So decta cort is a combination of an antifungal dectarine which is maconazole and hydrocortazone which is a steroid whereas dectarine is an antifungal only and you have to be careful here so something like seborate eczema which is a combination of eczema associated with malasai zai furfer which is a type of yeast this responds very well to decta cort but if you just have a fungal infection so for example a child with an isolator scaliania ring I would just use an antifungal only because sometimes if you use steroid creams it can artificially suppress fungus and then when you stop this can lead to worsening rebound fungal infection so just beware of that sometimes that they can present with tinia and cognito. Okay thank you so moving on to fungal nail infections then that how long should we be treating these for and do we always need to send off nail clippings before starting treatment. So yeah I mean fungal infections are really common especially of the toenails roughly one in four people have this at any given time but you know some patients may not want any trees treatment especially if it's only one nail and it's not bothering them but it's important to let them know that it won't get better on its own but if it affects multiple nails and there's an issue with cosmesis or if they're very symptomatic or they're painful then treatment is indicated and it's also important to think about psoriasis as a differential where you can get multiple thick and yellow nails and in children also think about 20 nail dystrophy which may be a sign of skin disease later in life and regarding my collogy for nail clippings yes please it's very important to do that and but the false negative rate of this test is very high so I can sometimes repeat the test up to three times and when you do take a sample it's really important to take a nice big nail sample from the affected area plus get some of the chalky material under the nail you're more likely to get a valid positive result so fingernails are easier to treat but toenails need a longer course of an anti-fungal and I usually use an oral treatment like tabinifin 250 milligrams once a day for six weeks for fingernails and three to four months for toenails which is obviously a much longer compared to how we treat fungal skin infection which is usually two weeks oral itchriconazol is also another option and it can be given in a it can be given in a pulsed manner so 200 milligrams twice a day for one week every month for three months and do you check liver function tests with this monocle with any of your anti oral anti-fungal regimes I think if I'm giving a long course for example to finifine you do need to check baseline for blood count and LFTs and nice do recommend rechecking at four to six weeks after onset and then I usually recheck every two months thereafter and also if you do decide to treat a patient do warn them that it can take many months before you see improvement it can take up to 12 to 18 months before your toenails look normal do you ever give advice on topical treatments do they work because a lot of patients kind of bulk when you tell them that you need to give them an oral anti-fungal for several months but they can work and there is a bit more of a rigmarole to this because you have to use it for many months but topic of options include lossaryl nail lacquer or cyclo pyrox or canispro but for patients who don't want to use normal option it is definitely an option and the BAD recommend using lossaryl once or twice a week for 12 months and cyclo pyrox daily for 48 weeks but you've just got to warn them that cure rates are very low and it can range between 10 to 30% whereas if you use a combination of an oral to finifine and lossaryl topically it can improve the cure rate thank you that's great thanks Monica so often in general practice particularly in the summer months we see insect bites that have spreading erythema around them and we commonly start antibiotics what do you think about that so that spreading erythema may suggest a secondary infection or possibly an exaggerated response by the host to the insect bite I might consider antibiotics but if there's only one or two lesions I'm all likely to give a mixture of a topical antibiotic and steroids such as fusiblecreme wants to twice a day for one to two weeks and obviously take a swab first and you do sometimes see this sort of exaggerated insect bite eruptions where they may present with blistering or popular ticaria which can be difficult to treat and can be persistent and it can be mistaken for an infection okay so another thing in general practice it feels like we don't see or I haven't seen much scabies in general practice and I often worry that I'm missing it could you just go over the classical signs and treatment for scabies yeah so this reminds me of something my old professor said when I was a junior and he said to me scabies is one of the top three itchy skin conditions in dermatology and I'm going to throw this question back to you two what do you think the other two are allergy exomebulous pemphagoid so lycan planus oh and pre-bulous pemphagoid those are your top three for itchy conditions. Obviously they are more. But I always remember that. So intense itch is obviously a very important sign for scabies along with a rash and it's important to ask in the history if there are other contacts who are affected or if they are in a nursing home or others and if other patients are itchy too. And Nabilit clinically you might see a mixture of tiny little red spots sometimes in lines or burrows and scratch marks and key areas to look for are in between the fingers in the web spaces or toes, wrists, ankles and particularly genitals and men where you can find scrotal nodules. And it seems to spare the face which is interesting and so generally you won't be able to see the might as they're tiny they're about 0.4 millimeters. But if you do have a damatoscope it can be quite useful and you get this characteristic jet stream sign although I don't think I've ever seen one of a key of you. Yeah I often use my dramatic scope to look for scabies and what you're meant to see is this little brown triangle at the end of a sort of path of scale and it's really useful for checking for a residual disease after patients have had treatment for example. So yeah I think it's a really useful way without having to pick up people's skin with a needle and get your microscope out which is what we used to do in the old days. Okay I'll keep hunting. I don't know Nabilit, do you have access to a damatoscope? No I don't. Some GPs do but they're a few and far between. Just a very mind with scabies it can present also like a wide spread x-mer or a postular eruption or even a heavily crusted itchy eruption that we sometimes see in Norwegian scabies. So treatment it is an application of permethrin 5% cream from the chin and ear downwards paying special attention between the fingers and toes and under the fingernails. An alternative treatment is malathion 8.5% if permethrin is contraindicated for example in patients who are allergic to chrysanthemum and what you do is leave it on for 12 hours for permethrin and 24 hours for malathion and then you repeat the treatment a week later. It's also very important to treat close contacts even if they're asymptomatic and also tell the patient to wash clothes, their clothes and bedding at a high temperature more than 60 degrees or you can put the clothes in a bag and the mites do die after three days. I sometimes use oral either mectin in severe or recurrent cases and I use 200 micrograms per kilogram, sometimes with permethrin and this is particularly useful for bed bound elderly patients but just bear in mind either mectin is not licensed in the UK for treatment of scabies but worldwide it is used much more readily and dermatologists do use this off-license. I have a question for you Monica often patients can have prolonged itching even after they've been treated and we know that this is normal for two weeks after treatment but what if it persists what do you do then? So I sometimes use topical steroids if I'm convinced that the scabies has gone and but I will hunt for the scabies might. I don't know Vicki what do you do? Yeah I think I kind of do the same because permethrin is irritant it's amazing how many patients come after having treatment with permethrin and say I'm still itching you know I still have scabies and I guess the thing to check is you know have they got residual disease have they used it correctly twice one week apart have their contacts been treated and then do they have a predisposition to eczema that's kind of been triggered by the permethrin and you know if I think it is eczema then I'll just treat them with you know something like eloconointment once a day for a couple of weeks and you know see if that knocks things on the head. Thanks Vicki so monica hydra-admitis operative is something that we see rarely in general practice we might see it it sometimes in a mild form but very very rarely more severe disease could you just go through some classic signs and symptoms please on this disease and is this more common in any particular subgroup? So yeah a hydra-admitis operative is it's a chronic painful disease and you see recurrent boils in areas of the skin that contain apocrine glands so you can find this in the xilly breasts and groin and there is often a degree of follicular blockage so clinically you will see boils pass and scarring it seems to be more common in women in effects about 1% of the population and can start in puberty and it can take a while for the penny to drop and for patients to be diagnosed they're often labelled as having infective boils but this condition is primarily inflammatory rather than infective. Okay that's that's interesting quite a high incidence what should be the first line management of this in general practice and what simple advice can we give our patients and when should we be referring? So this can be a very difficult disease to control and it cannot be cured but there are different treatment options and you can definitely start treatment in the community so if it's mild you can prescribe 1% clindermycin solution twice a day to affected areas after that then I use an antibiotic such as doxycycline 100 milligrams once a day or lymasyclin 408 milligrams once a day and I usually use this initially for three months but I can extend it to six months and rarely longer and I use this along with an antibacterial wash such as hibiscrub or dermal 500 but if you can try and have antibiotic breaks that is useful because antibiotic resistance can occur and also think about the lesions themselves and sometimes using special non adherent dressings such as gelinette or mepital or mepilex border are quite useful because the patients are going to have to look after these wounds and during acute flare pain can be a big problem so also think about pain relief and other things you can do in the community is counsel patients regarding smoking which can be a risk factor for HS but also HS can be associated with cardiovascular disease so stopping smoking is important if the patient is obese reducing weight can reduce disease severity and depression is also more common in patients with HS and something GP's can look out for and manage I think if the disease is severe and not improving on any of these treatments I would definitely advise referral to dermatology and we may consider options such as a combination of clindermycin and refampicin or maybe a retinoid or dapsone or an immunosuppressant we also sometimes use this biological agent called Adeluma Mab which we use for psoriasis as well and this is can be useful for resistant cases sometimes we refer for surgery and this is usually last line and it's better for recurrence severely affected areas but recurrence rates are high with this about 30% that's great thank you Monica I know that Nabila's finished her questions so I'm going to ask you do you have any anecdotes of memorable patients or other pearls of wisdom and I do actually have three patients I'd like to share with you and the first one is this elderly lady who was an impatient and she had this wide spread a very itchy postular eruption and I was convinced this was a toxic postular derma secondary to a new drug and even joked with the Uncle Consultant that I would eat my handbag if this was gave these and we did do a biopsy and guess what it was gave these and and you know I can't look at that consultant again without being embarrassed so yeah just the take home message really for that is remember scabies is intensely itchy and it can present with postures and then this other case someone I saw as a junior and this was a middle-aged lady who had this abscess on her right cheek and she'd had it for many weeks and it didn't respond to antibiotics all her initial swabs were negative and and then when we dealt further into the history she alluded to having a facelift and finally a swab became positive with mica bacteria and coloni so this was an atypical mica bacterial infection and we think they got they got this through the facelift so the tip here is to think about a typical infections and especially in cases that don't seem to respond to antibiotics and I've got one more that one of the first patients I wrote up was a junior actually and he was a young man with psoriasis and he was on methotrexate for this and he he had just one ulcerating infective plaque of psoriasis all so we thought I mean generally psoriasis doesn't get infected so that was on odd in itself but then when we when we we delved into his travel history he had been to South America and then the biopsies showed a parasite infection called leach maniasis so again just remember to do sort of an in-depth travel history for odd infections very very interesting and cautious retails. Before we finish, can I ask you Monica to point us to some more resources, particularly for patients who have hydrodynamic supertiva, as this is a chronic condition with a significant effect on quality of life? Yes, there are some very good patient information leaflets on the BAD website and the BAD have also published guidelines for management of HS, which you might find useful since skin infections and onachomychosis. One of my favourite websites, they're very good for pictures and advice if you need that during clinic. And regarding HS, there is the HS Trust, which is an excellent patient support group. That's great, thank you. So thank you Nabila and Monica for a great session on infections and hydrodynamic supertiva. Monica, you've given us some excellent tips for treatment and Nabila, you've asked some very pertinent questions, so thank you both and I hope our listeners have found this useful. Join us again soon for more podcasts from the new dermatologist group. 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