Skin Conditions

Inguinal Bubo

Enlargement of lymph node in groin area; common causative organisms are STD related – LGV, chancroid and non STD – tuberculosis and filariasis.

Treatment

If no genital ulcers, it should be treated as in LGV. Fluctuant bubo may be aspirated in a non-dependent manner with a wide bore needle. (Incision and drainage is not recommended).

Pharmacological (LGV)

Cap. Doxycycline 100 mg twice a day for 2 to 3 weeks
Or
Cap. Tetracycline 500 mg every 6 hours for 2 to 3 weeks
Or
Tab. Erythromycin 500 mg every 6 hours for 2 to 3 weeks
Or
Tab. Cotrimoxazole 480 mg 2 tabs twice a day for 2 to 3 weeks
Also examine and treat the partner as above.
Follow up after 7 days and if improvement is there complete the treatment.
If no response refer to a higher centre.

Patient education

• Counselling and explain importance of single partner and methods of safe sex and use of condoms.
• Contact tracing and treatment of the sexual partners is important.

References

1. The Umbilical, Perianal and Genital Regions. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London; pp 3163.
2. Lymphogranuloma venereum. In: Dermatology in General Medicine. Freedberg IM (eds), 5th Edition, McGraw Hill Company Inc., pp 2519.

Balanitis & Balanoposthitis

Inflammation of glans (balanitis) and prepuce (posthitis) caused by Candida albicans or bacteria.

Treatment (Candidiasis)

Tab. Fluconazole 150 mg single dose (Also treat partner with the same dose and frequency).
If prepuce is retractable and there are ulcers, in addition, treat as in genital ulcers. If urethral discharge is present, treat as for urethral discharge. However, if there are no ulcers or discharge treat for candidiasis.

References

1. The Umbilical, Perianal and Genital Regions. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London, pp 3163.
2. Diseases and Disorders of Anogenitalia of Males. In: Dermatology in General Medicine. Breedberg I Metall (eds), 5th Edition, McGraw Hill Company Inc., pp 1348.

Genital Ulcers

Genital ulcers can occur commonly in syphilis, chancroid and herpes progenitalis and rarely due to donovanosis and chlamydia.

Approach for treatment

If vesicular lesions are present or there is a history of preceding ulcer give treatment for Herpes progenitalis. If there are no lesions, perform dark field microscopy and serological tests for syphilis (STS). If STS are positive give treatment for syphilis. If STS are negative, treat as for chancroid. However, where facilities for serological tests and dark field microscopy are not available should institute empirical therapy for both syphilis and chancroid.

Treatment (Syphilis)

Inj. Benzathine Penicillin 2.4 M units IM stat (1.2 M units in each buttock after sensitivity testing).
Or
Inj. Procaine Penicillin 1.2 M units IM daily for 10 days (after sensitivity testing).
If no response after 10 days or repeat STS become positive after initial improvement, refer to a higher centre.

In case of penicillin hypersensitivity
Cap. Doxycycline 100 mg twice a day for 15 days.
Or
Cap. Tetracycline 500 mg every 6 hours for 15 days.

Treatment (Chancroid)

Inj. Ceftriaxone 250 mg IM as a single dose.
Or
Tab. Cefixime 400 mg as a single dose.
Or
Inj. Ceftazidime 500 mg IM as a single dose.
Or
Tab. Erythromycin 500 mg every 6 hours for 7 days.
Or
Tab. Cotrimoxazole 960 mg twice a day for 7 days.
If no response after 7 days, refer to a higher centre.

Treatment (Herpes progenitalis)

Tab. Acyclovir 200 mg 5 times daily for 7 days.
Or
Tab. Acyclovir 400 mg 3 times a day for 7 days.

References

1. The Umbilical, Perianal and Genital Regions. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London, pp 3163.
2. Chancroid. In: Dermatology in General Medicine. Freedberg IM et al (eds), 5th Edition, McGraw Hill Company Inc., pp 2587.

Sexually Transmitted Diseases

Urethral Discharge

Common causative organisms are Neisseria gonorrhoeae (gonococcal urethritis) and Chlamydia trachomatis (non-gonococcal urethritis-NGU).

Treatment

Nonpharmacological

Plenty of oral fluids.

Pharmacological (Gonococcal urethritis)

1. Inj. Ceftriaxone 250 mg IM as a single dose.
   Or
   Tab. Ciprofloxacin 500 mg as a single dose.
   Or
   Inj. Spectinomycin 2 g IM as a single dose.
2. Cap. Doxycycline 100 mg twice a day for 1 week.

Pharmacological (Non Gonococcal Urethritis – NGU)

1. Cap. Doxycycline 100 mg twice a day for 1 week.
   Or
   Cap. Tetracycline 500 mg every 6 hours for 1 week.
   Or
   Tab. Erythromycin 500 mg every 6 hours for 1 week.

Patient education

• Tracing and treatment of sexual partners, health education and counselling.

References

1. The Umbilical, Perianal and Genital Regions. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London.
2. Gonorrhoea. In: Dermatology in General Medicine. Freedberg IM et al (eds), 5th Edition, McGraw Hill Company Inc., pp 2600.

Albinism

Albinism is an autosomal recessive inherited disorder. Patients are at risk of skin damage from sunlight and usually develop cutaneous malignancies at an early stage.

Treatment

There is no effective therapy other than total avoidance of direct sunlight from early childhood.

References

Drugs used in skin diseases, WHO Model Presecribing Information WHO, Geneva, 1997.

Melasma

Melasma often appears during pregnancy in women living in dry, sunny climates, but is most frequently seen in those taking oral contraceptives.

Melasma of pregnancy usually resolves in few months after delivery but, otherwise, spontaneous remission is rare.

Treatment

Sunscreens containing either p-aminobenzoic acid or benzophenones a sun protection factor (SPF) rating of at least 15,
Or
Topical preparations containing Calamine, Zinc oxide, Titanium dioxide or other constituents which reflect incident light (physical sunblock) can also provide useful protection when they are applied carefully.

Vitiligo

Vitiligo is a pigmentation disorder in which melanocytes in the skin, mucous membranes, and the retina of the eyes are destroyed. The cause of vitiligo is not known. It is more common in people with certain autoimmune diseases including hyperthyroidism, adrenocortical insufficiency, alopecia areata and pernicious anaemia. Vitiligo may also be hereditary.

Treatment (To be treated at a tertiary care center) Pharmacological

Therapy for vitiligo takes a long time – it usually must be continued for 6 to 18 months. The choice of therapy depends on the number of white patches and how widespread they are and on the patient’s preference for treatment. Each patient responds differently to therapy, and a particular treatment may not work for everyone.

1. Topical Group 4 steroid for 4 to 6 months (for details see Table 1 in a section on eczema and dermatitis pp 267).
   Or
   Topical psoralen photochemotherapy.
   Or
   Cap. Methoxsalen (10 mg) 0.3-0.4 mg/kg administered 2 hours before exposure to ultraviolet radiation. Between 12-24 sessions are usually necessary. The sessions should be given 2 or 3 times weekly (at least 48 hours apart).
2. Depigmentation of the unaffected area if greater than 90% area is already affected to get uniformity in colour.
3. Surgical Therapies

• Autologous skin grafts, skin grafts using blisters, micropigmentation (tattooing), Autologous melanocyte transplants.
• Cosmetics that cover the white patches improve their appearance and help patients to feel better about themselves.

Patient education

• Counselling and reassurance as it can cause a lot of emotional stress.
• Talking with other people who have vitiligo may also help a person to cope up.
• The National Vitiligo Foundation can provide information about vitiligo and refer people to local chapters that have support groups of patients, families, and physicians. Family and friends are another source of support.

Psoriasis

Psoriasis is a common, genetically determined, inflammatory and proliferative disease of the skin characterized by chronic, red scaly plaques, particularly on the extensor prominences and on the scalp.

Treatment

Investigate for baseline parameters and counselling about chronicity of the disease.

Nonpharmacological

Identify and avoid triggering factors.

Pharmacological

Patient suffering from less than 10% body involvement may only be treated at a primary care level. Patient having greater than 10% body involvement should be referred to a tertiary care level for initiation of therapy, management thereafter may be continued under primary care physician.
Avoid systemic corticosteroids.
1. Tar (6% in white vaseline) – applied topically at bed time except face and flexures followed by sun exposure next morning.
Or
Group 4 potent topical corticosteroids applied once daily, with or without occlusion till improvement occurs.
2. Salicylic acid (3%) in white vaseline, a thin layer is applied daily which the lesions have resolved.
3. Tab. Erythromycin 500 mg 4 times a day for 1 week.
4. Cap. Vitamin A 50,000 units to 1 lac units daily 6-8 weeks.
5. Tab. Pheniramine maleate 25 mg 2 times a day.
Refer to a tertiary care centre if patient shows no improvement in 6-8 weeks or develops pustular psoriasis, psoriatic
arthropathy or erythroderma.

Patient education

· It is a chronic disease characterized by remissions and relapses and prognosis is variable.
· Trauma infection, streptococcal throat infection, pregnancy, hypocalcemia, winter, emotional stress, alcohol, AIDS and drugs like beta blockers, NSAIDs, lithium, chloroquine and rapid withdrawal of corticosteroid therapy can exacerbate psoriasis.

References

1. Psoriasis. In: Textbook of Dermatology. Champion RH et al (Eds.) 15899, 6th Edition. Blackwell Science Ltd., London.
2. Psoriasis. In: Dermatology in General Medicine. Irwin M. Freedberg et al (eds), 5th Edition, McGraw Hill Company Inc., pp 495.

Lichen Planus

Viral Warts

Human papilloma virus (HPV) causes viral warts. Transmission occurs by inoculation of infected material in breaches in skin or mucous membranes. Incubation period varies from 1 to 4 months.

Treatment

1. Paring and debridement of the lesion so as to remove dead tissue.
2. Application of chemical cauterizing agent like 25-50% Trichloroacetic acid (TCA).

For genital warts:
Podophyllin 20-25% in Tr. Benzoic Co. applied locally (after covering the surrounding normal skin with vaseline) weekly for 6-12 sittings.
Or
Electrocautery (single sitting).

Patient education

• Avoid contact with the infected patients. Transmission occurs via contact with breach in the skin and mucous membrane.
• Education on safe sex in case of genital warts.

References

1. Warts. In: Dermatology in General Medicine. Fitzpatrick TB et al (eds), 5th Edition, McGraw Hill Company Inc., New York, pp 2484.
2. Viral Infections. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London, pp 1005.

Molluscum Contagiosum

A common pox virus infection of early childhood, transmitted by contact. In adults, infection is transmitted sexually. Incubation period varies from 14 days to 6 months.

Treatment

Nonpharmacological

Do not share towels/clothing.

Pharmacological

For extensive lesions
Extirpate molluscum body and touch the central core with Trichloroacetic acid (TCA) 10% to 20%.
Or
Tretinoin cream (0.05%) to be applied topically daily till lesions heal.
If possible, patient should be seen at least twice, about 3-4 weeks apart, in order to treat the incubating lesions that are too small to see initially.

Patient education

• Avoid any kind of direct contact with the infected persons. Pregnant women should avoid sexual contact with a partner who has molluscum, (especially late in the pregnancy). The use of condoms is recommended for those who do not abstain.
• Avoid swimming pools, communal baths and contact sports.
• Partner education for prevention of this disease.

References

1. Viral Infections. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London, pp 1005.
2. Molluscum Contagiosum. In: Dermatology in General Medicine. Fitzpatrick TB et al (eds), 5th Edition, McGraw Hill Company Inc., New York, pp 2478.

Herpes Simplex

Herpes simplex is the commonest infection caused by DNA virus, Herpes virus hominis (HSC). Type 1 classically associated with facial infections and type 2 is typically genital. Following primary infection, virus remains latent in sensory nerve ganglia and its reactivation under various circumstances is responsible for recurrent episodes. Transmission occurs by direct contact or droplets from infected secretions. Incubation period is 4-5 days. Diagnosis is confirmed by Tzanck smear made from a vesicle, on Giemsa staining it shows multinucleated giant cells and ballooning degeneration of keratinocytes.

Treatment

Supportive therapy in herpes labialis

A. Mild case is self limiting (5-7 days) and no specific therapy is required.

B. Moderate to severe case. Tab. Acyclovir 200 mg 5 times a day for 5 days.

Prophylaxis (Recurrent episodes more than 6 per year, Refer to a specialist)
Tab. Acyclovir 400 mg 2 times a day Or 200 mg 3 times a day for 6 months to 1 year and, in addition, continue supportive therapy.

Patient education

• It is an infectious condition transmitted by direct contact/droplet infection. Therefore, the patient should avoid contact until all the lesions get crusted.
• Herpes simplex 2 is transmitted via sexual route, so patient should take proper precautions.

References

1. Viral Infections. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd, London, pp 1008.
2. Herpes Simplex. In: Dermatology in General Medicine. Fitzpatrick TB et al (eds), 5th Edition, Mc Graw Hill Company Inc., New York, pp 2414.

Herpes simplex is the commonest infection caused by DNA virus, Herpes virus hominis (HSC). Type 1 classically associated with facial infections and type 2 is typically genital. Following primary infection, virus remains latent in sensory nerve ganglia and its reactivation under various circumstances is responsible for recurrent episodes. Transmission occurs by direct contact or droplets from infected secretions. Incubation period is 4-5 days. Diagnosis is confirmed by Tzanck smear made from a vesicle, on Giemsa staining it shows multinucleated giant cells and ballooning degeneration of keratinocytes.

Treatment

Supportive therapy in herpes labialis

A. Mild case is self limiting (5-7 days) and no specific therapy is required.

B. Moderate to severe case. Tab. Acyclovir 200 mg 5 times a day for 5 days.

Prophylaxis (Recurrent episodes more than 6 per year, Refer to a specialist)
Tab. Acyclovir 400 mg 2 times a day Or 200 mg 3 times a day for 6 months to 1 year and, in addition, continue supportive therapy.

Patient education

• It is an infectious condition transmitted by direct contact/droplet infection. Therefore, the patient should avoid contact until all the lesions get crusted.
• Herpes simplex 2 is transmitted via sexual route, so patient should take proper precautions.

References

1. Viral Infections. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd, London, pp 1008.
2. Herpes Simplex. In: Dermatology in General Medicine. Fitzpatrick TB et al (eds), 5th Edition, Mc Graw Hill Company Inc., New York, pp 2414.

Herpes Zoster (Shingles)

Herpes Zoster occurs due to reactivation of VZV which lies dormant in sensory nerve root ganglion following primary infection as chickenpox.

Treatment

Nonpharmacological

Rest and isolation alone in case of mild disease in an otherwise healthy person.

Pharmacological

Supportive therapy

1. Tab. Ibuprofen 400 mg 3 times a day till resolution of symptoms
   In children 10 mg/kg/day.
   Or
   Tab. Nimesulide 100 mg 2 times a day till resolution of symptoms
   In children 5 mg/kg/day in 2 divided doses.
2. Tab. Pheniramine 25 mg 2 times a day till resolution of symptoms
   In children 0.5 mg/kg/day every 8 hours.
3. Calamine lotion topically till resolution of symptoms.

Definitive therapy
When patient reports within 24-72 hours and has disseminated lesions Tab. Acyclovir 800 mg 5 times a day for 5-7 days.
In children 80 mg/kg/day in divided doses.
Refer immediately to a tertiary care hospital in case of immuno-compromised patient (HIV/AIDS and patients with chronic debilitated disease), involvement of ophthalmic division, and non-responders.
Inj. Acyclovir 10 mg/kg IV 8 hourly for 5-7 days.

Viral infections- Chicken Pox or Varicella

Varicella is the primary infection caused by VZV. It is highly infectious and is transmitted by droplet infection. The incubation period is about 14 days. Reactivation disease results in Herpes zoster or Shingles.

Cutaneous Reactions To Drugs

Drug eruptions may follow the use of topically or systemically administered drugs. A drug reaction should be suspected whenever there is a sudden worsening of a dermatitis at a time when the patient should be improving.

Treatment

Stop the suspect drug, particularly if the drug eruption is severe. In some mild drug reactions, it may be possible to continue the drug if it is medically necessary. Treatment is symptomatic in a mild case. However, in severe drug eruptions such as exfoliative dermatitis and generalized bullous reactions, systemic corticosteroids with following may be required:
Tab. Prednisolone 1 mg/kg (maximum 60 mg/day).

Acute Urticaria

Urticaria (hives) is a nonspecific vascular response to a wide variety of stimuli. Acute urticaria presents with erythematous wheels, which may be associated with swelling of loose connective tissue (angioedema) affecting lips, face, scrotum, larynx and trachea.

Treatment

Nonpharmacological

Soothing applications – cold water sponging and clearance of airway in case of laryngeal oedema.

Pharmacological

Tab. Pheniramine maleate 25 mg 2 times a day for 1-2 weeks.
In children 0.15 mg/kg daily in 3 or 4 divided doses. The dosage should be adjusted according to response and tolerance.
Or
Tab. Hydroxyzine 10-25 mg 4 times a day.
In children 15-25 mg 4 times a day.
Or
Tab. Cetrizine 10 mg once daily.
In children 5 mg once daily.
In severe cases, antihistaminics can be started intravenously and once controlled, patient is maintained on oral preparations as above.

Angioedema of the larynx is a medical emergency.

Inj. Epinephrine (as hydrogen treatment) in 0.5-1.0 ml of 1:1000 IM injection. Patients with severe airway obstruction may have to be intubated immediately (for details see section on anaphylaxis).

Patient education

Identify and avoid precipitating factors.

Pityriasis Alba (Patchy Hypochromia)

1. The topical preparations (emollients) should be applied at night and washed off in the morning. The treatment is maintained for 4-6 weeks.
2. Hydrocortisone -17 butyrate ointment or cream 0.1% apply thin layer of cream on the affected skin twice daily until symptoms resolve.
   Or
   Crude coal tar sol 5-10 %/ ointment, apply a thin layer of ointment to
   the affected areas once daily until lesions resolve.
3. Tab. Mebendazole 100 mg 2 times a day for 3 days.
4. Zinc and vitamin supplementation if signs of deficiency are present.

Pityrosporum Infections Of The Skin

1. Topical 2.5% Selenium sulfide lotion.
   Or
   Topical Ketoconazole 2% lotion, apply once for 15 minutes before taking bath below neck upto the waist.
   In facial lesions,
   Topical Miconazole 2% cream apply twice daily for several weeks.
   Or
   Topical Clotrimazole 1% cream.
2. Tab. Fluconazole 400 mg as a single dose (can be combined with topical therapy for faster relief).

Alopecia Areata

Drugs used in Skin Diseases, WHO Model prescribing information WHO, Geneva, 1997.

Acne Vulgaris

1. Topical therapy as above.
2. Cap. Tetracycline 250 mg daily 4 times for 4-8 weeks. The dosage can be reduced in accordance with the clinical response and discontinued.
   Or
   Cap. Minocycline 50-100 mg daily.
   Or
   Tab. Erythromycin (as stearate or ethyl succinate) 250 mg 4 times daily for 6-8 weeks, then 2 times daily until improvement occurs.

   Treatment may need to be continued for up to 6 months. Severe and unresponsive cases should be referred to a tertiary care hospital.

• Redness and scaling with retinoic acid indicates a therapeutic response. Gels are less irritating. Lasting benefit only after long duration use of comedolytic agents usually for more than 6 months.
• Avoid oil application on the scalp and should wash scalp on alternate day.
• Not to use occlusive applications: oils, creams, pomades, foundation makeup, occlusive topical medications, if at all required, use preferably a gel or lotion.

1. Disorders of the Sebaceous Glands. In: Textbook of Dermatology, Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London, pp 1940.
2. Disease of the Sebaceous Glands. In: Dermatology in General Medicine. Fitzpatrick TB et al (eds), 5th Edition, McGraw Hill Company Inc., New York, pp 769.