Skin Conditions

Miliaria

• Avoid causal factors like heat and occlusion due to oils, creams, cosmetics etc.
• Cool baths and aeration.

1. Emollients like anhydrous lanolin or Calamine lotion locally.
   Or
   Talc or any commercially available powders.
2. In case of secondary infection (see section on bacterial skin infections).
3. For relief of itching Tab. Pheniramine 25 mg 2 times a day.

• Frequent cool bath and aeration.
• No oil application over scalp and body.

Eczema And Dermatitis

• Endogenous (constitutional; atopic dermatitis, seborrhoeic dermatitis, lichen simplex chronicus (LSCh) and
• Exogenous (environmental; contact dermatitis (ABCD), primary irritant dermatitis, photosensitive eczema).

1. Hydrocortisone 0.1% locally thrice a day in cream base during acute and subacute stage and in ointment base during chronic stage for 2-3 weeks (see Table 1).
   Or
   Betamethasone valerate 0.1%/Triamcinolone acetonide 0.1% in cream base in acute and ointment base in chronic stage for appropriate duration in twice daily doses.

   Table 1. Preparations of local corticosteroids available in the market

   Group 1	(Hydrocortisone acetate 1%, Desonide 0.05%) Generally safe for chronic application. Safest amongst steroids for use on face, under occlusion/bandage, in neonates/infants. Not expected to cause local or systemic side effects in the course of normal use.
   Group 2	(Clobetasone butyrate 0.05%, Mometasone furoate 0.1%, Fluticasone propionate 0.01%, Betamethasone valerate 0.05-0.1%) May be used on chronic dermatoses on extremities. Used for limited periods only on face and/or intertriginous areas of adults and children, under close supervision and follow up. Potential for local side effects with prolonged use.
   Group 3	(Betamethasone dipropionate 0.05%, Halcinonide 0.025%-0.1%) To be used on recalcitrant chronic dermatoses of adult-elder children only. Can cause local or systemic side effects.
   Group 4	(Clobetasol propionate 0.05% combination preparation with Gentamicin sulphate (0.1%) with Miconazole 2% available). To be used for limited period of time (2 week at a time) as the risk of side effect is highest. Use only in extremities and thickened skin lesions. To be used only when follow up/supervision is good. Not to be used on face/flexures or in infants/neonates.

2. Systemic treatment
   Tab. Pheniramine maleate 25 mg 2 times a day till symptoms subside (about 7 days).
   In children 0.5 mg/kg/day in 3 divided doses.
   Or
   Tab. Cetrizine 10 mg at bed time till symptoms subside.
   In children Syp. Promethazine 1 mg/kg/day 3 times a day till symptoms subside (about 7 days) or Syp. Cetrizine 0.3 mg/kg/day once daily till symptoms subside.
3. Secondary bacterial infection should be treated in the acute stage with systemic antibiotics (see section on bacterial skin infections).

If there is no response or in case of extensive eczema (preferably under the supervision of a specialist) give, Tab. Prednisolone 1 mg/kg (maximum 60 mg) as a single oral dose given in the morning after breakfast for 7-10 days.

• Common skin allergens are: overexposure to water or dry air, soaps and detergents, solvents, cleaning agents, chemicals, rubber gloves, or ingredients in skin and personal care products.
• Following local side effects can occur due to misuse or over use of corticosteroids: thinning of skin, striae distensae, increased facial redness and telangiectasia, purpura, tinea incognito, acneform papules and increased hair growth.
• Systemic side effects can occur due to prolonged use of systemic corticosteroids or local applications on large surface area.

1. Eczema, Lichenification and Prurigo. In: Textbook of Dermatology. Champion RH et al (eds), 6th Edition, Blackwell Science Ltd., London ;pp 629.
2. Topical Glucocorticoids. In: Dermatology in General Medicine, Fitzpatrick TB et al (eds), 5th Edition, McGraw Hill Company Inc., New York.
3. Potical Therapy. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London; pp 3547.

Diaper Dermatitis

• Avoid impermeable disposable diapers.
• Keep the skin dry.

Tinea Capitis

• All siblings, children in contact should be screened and treated simultaneously if required.
• Fomites such as combs should be kept separate.

Mycology. In: Textbook of Dermatology. Champion RH et al (Eds), Blackwell Science, Oxford, pp 1277-1366.

Candidiasis

• Common locations for the infection include the genitourinal, subaxillary, gluteal, interdigital and submammary areas and between the folds of skin of the abdominal wall.
• Pruritus, erythematous macerated areas of skin with satellite vesicopustules.

• Redness, swelling and tenderness of the paronychial area with prominent retraction of cuticle toward the proximal nail bed. Occasionally pus can be expressed from beneath this area. The nails might also be infected.

Treatment

Nonpharmacological

To keep the affected area dry and clean.

Pharmacological

Cap. Fluconazole 3-6 mg/kg (maximum 150 mg) orally once a week depending upon the area affected for 4-6 weeks. In case nail plate is also involved treat as onychomycosis except griseofulvin.

Onychomycosis

Myiasis (Maggots)

• Explain the patient about personal hygiene and also explain about the proper care of the wound.

Diseases Caused by Arthropods and other Noxious Animals. In: Textbook of Dermatology. Champion RH et al (eds), 6th Edition. Blackwell Science Ltd., London.

Pediculosis (Lice Infestation)

1. Specific therapy
   Lotion GBHC 1% to be applied on scalp (in head louse infestation), whole body including pubic region, thighs, buttocks (in pubic and body lice infestation) for a period of 12 hours to be washed off later on.
   Or
   1% Permethrin rinse, single one hour application on the affected area.
   For scalp lice repeat after one week.
2. Supportive therapy
   If persistent itching,
   Tab. Cetrizine 10 mg once daily at night for 7 days.
   In Children (2-6 years) 5 mg; (>6 years) 10 mg once daily.
   Or
   Tab. Pheniramine maleate 25 mg 3 times a day for 7 days.
   In Children 0.5 mg/kg/day in 3 divided doses.
3. Treatment of the secondary infection (see section on bacterial skin infections).
   In pubic lice infestation, sex partner should be treated as well, and a search for other STD should be undertaken.

• Infested clothing and bedding should be washed properly in hot water and dried in sunlight.
• In case of pubic lice shave the area, if possible, and adequate personal hygiene.
• Daily bath with soap and water and change of clothing. To remove nits with the help of a fine toothcomb in head lice. Other family members and schoolmates, if infested have to be treated simultaneously.

1. Diseases Caused by Arthropods and other Noxious Animals. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London, pp 1423.
2. Scabies and Pediculosis. In: Dermatology in General Medicine. Fitzpatrick TB et al (eds) 5th Edition, McGraw Hill Company Inc., New York, pp 2680.

Scabies

A common skin infestation caused by anthropoid mite (Sarcoptes scabiei) and transmitted by close personal contact after an incubation period of 3-4 weeks.

Treatment

• Disinfestation of bedding and clothing by ordinary laundering is required.
• In lactating mothers-before feeding, areola should be washed thoroughly with soap and water. After the feed, permethrin cream should be reapplied on breasts and hands.
• Itching will persist for few days but usually resolves within 1-2 weeks. The overuse/repeated treatment with topical antiscabetic is not required.
• All family members and close physical contacts symptomatic or not should be treated simultaneously to prevent recurrences.
• Repeated topical application of GBHC or accidental ingestion may lead to adverse neurological effects such as seizures.

1. Disease Caused by Arthropods and other Noxious Animals. In: Textbook of Dermatology. Champion RH et al. (eds), 6th Edition, Blackwell Science Ltd., London, pp 1458.
2. Scabies and Pediculosis. In: Dermatology in General Medicine, Fitzpatrick TB et al (eds), 5th Edition, McGraw Hill Company Inc., New York, pp 2677.

Cutaneous Tuberculosis

• Skin tuberculosis is a milder type of tuberculosis infection, and is generally noncontagious.
• It shows excellent response to antitubercular therapy.

1. Antitubercular Therapy. Mycobacterial Infections. In: Textbook of Dermatology. Champion RH et al. (eds), 6th edition, Blackwell Science Ltd., London, pp 1189.
2. Tuberculosis and other Mycobacterial Infections. In: Dermatology in General Medicine – Fitzpatrick TB et al (eds), 5th edition New York, pp 2274.

Leprosy

• Treatment of leprosy with only one drug or incomplete treatment will result in drug resistance. Explain that the treatment for leprosy has to be carried out without default for many months to obtain complete cure. Also explain the dangers of inadequate or no treatment.
• Explain the side effects of dapsone which include dapsone syndrome, fixed drug eruptions, exfoliative dermatitis; Clofazimine can cause darkening and staining of the skin which is reversible on stopping treatment.
• All patients who were earlier treated with dapsone monotherapy (prior to implementation of MDT programme) should be retreated with appropriate regime of MDT irrespective of disease activity.
• All patients who have either received irregular or doubtful treatment should also be given an appropriate MDT regime.
• Reassurance that the disease is completely curable and do not need segregation.
• All the members of the family in contact with the leprosy patient should be examined.

1. Leprosy. In: Textbook of Dermatology. Champion RH et al. (Eds), 6th edition, Blackwell Science Ltd., London,pp 1215.
2. Leprosy In: Dermatology in General Medicine. Fitzpatrick TB et al (eds), 5th edition, McGraw Hill Company Inc., New York, pp 2306.

Pyomyositis

• Maintainance of local hygiene by cleaning with soap and water is important.
• Avoid use topical antiseptics as they produce contact dermatitis.

1. Bacterial Infections. In: Textbook of Dermatology. Champion RH et al (eds.), 6th Edition, Blackwell Science Ltd., London, pp 1097.
2. Pyoderma. In: Dermatology in General Medicine. Irulla M Freedberg et al (eds), 5th Edition, McGraw Hill Company Inc., pp 2183.

Cellulitis And Erysipelas

Treatment

If patient has systemic features i.e., high grade fever, and symptoms of endotoxic shock. Either regimen A or regimen B depending on sensitivity pattern of the patients to penicillin.

Regimen A
Inj. Procaine Benzylpenicillin 1.5 g (1 million IU) IM 24 hourly. In children 50 mg/kg (50,000 IU/kg) up to 1.5 g IM 24 hourly.
Or
Inj. Benzylpenicillin (sodium or potassium salt) 0.6-1.2 g (1-2 million IU).
IV or IM 6 hourly for 7-10 days.
In children 30-60 mg/kg up to 1.2 g IV or IM 6 hourly.
Once improved, followed by
Cap. Amoxicillin 500 mg orally 8 hourly.
In children 10 mg/kg up to 500 mg orally 8 hourly.

Regime B (For patients sensitive to Penicillin
Inj. Amoxycillin 250 mg plus Clavulanic acid 125 mg 3 times a day for 7-10 days.
In children Amoxycillin 6.7 mg/kg plus Clavulanic acid 1.7 mg/kg 3
times a day for 7-10 days.
Once improved followed by
Cap Cephalexin 500 mg orally 6 hourly.
In children 12.5-25 mg/kg up to 500 mg orally 6 hourly.

If localized cellulitis
Cap Amoxicillin 500 mg orally 8 hourly.
In children 10 mg/kg 8 hourly.
Or
Cap Cephalexin 500 mg orally 6 hourly.
In children 12.5-25 mg/kg up to 500 mg orally 6 hourly.

Bacterial Skin Infections

Treatment

Nonpharmacological

Look for immuno-compromising factors and rule out endocrine disease like diabetes mellitus. Advise for proper hygiene and nutrition. Advise on removal of dirt, crusts and necrotic debris by washing with non-medicated soap and water and drainage of pus.

Pharmacological (Furunculosis, folliculitis)

Majority of purulent lesions of skin structures do not need systemic antibiotic therapy. However, more extensive lesions with collection of pus require drainage and antibiotic. Cover lesions with clean dressing.

A. Mild and localized superficial infection
Give topical therapy with following and should be applied locally twice a day as a thin film after thoroughly washing the affected sites with soap and water for 7-10 days.
Cream Framycetin sulphate in base 1%
Or
Cream 2% Sodium fusidate base
Or
Cream 2% Mupirocin base

B. Multiple site superficial pyoderma, invasive varieties and secondary pyoderma
Cap. Cloxacillin 250-500 mg 6 hourly for 5-7 days.
In Children 12.5-25 mg/kg to 500 mg 6 hourly.
Or
Cap. Cephalexin 500 mg orally 6 hourly for 5-7 days.
In Children 12.5-25 mg/kg up to 500 mg 6 hourly for 5-7 days.
Or
Tab. Cotrimoxazole (960 mg) 12 hourly for 5-7 days.
In Children 6 mg/kg of Trimethoprim up to a maximum of 160 mg 12 hourly for 5-7 days.

C. Impetigo
Cloxacillin or Cephalexin in same doses as above.
Or
Tab. Erythromycin stearate 250-500 mg every 6 hours for 7 days.
In Children: Syp. Erythromycin 40 – 50 mg/kg/day in 4 divided doses for 7 days.
If no response to the above treatment within 48 to 96 hours refer to a tertiary care level.