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Adult Treatment - Skin & Soft Tissue Infections

For MRSA infection see PHE Quick Reference Guide

Scabies

NICE-CKS

Treat whole body from ear/chin downwards and under nails. If under 2/elderly, also face/scalp 2
Treat all home & sexual contacts within 24h 1 C.

Medicine Calendar

First line permethrin 3 A+

5% cream

2 applications 1 week apart1 C

If allergic: malathion 3 C

0.5% aqueous liquid

2 applications 1 week apart1 C

Impetigo

Sources: NICE-CKS

For extensive, severe, or bullous impetigo, use oral antibiotics 1 C.
Reserve topical antibiotics for very localised lesions to reduce the risk of resistance 1,5 C,4 B+.
Reserve mupirocin for MRSA 1 C.

Medicine Calendar

oral flucloxacillin 2 C

500mg QDS

7 days

If penicillin allergic: oral clarithromycin 2 C

250-500mg BD

7 days

topical fusidic acid 3 B+

TDS

5 days

mupirocin (MRSA only) 3 A+

TDS

5 days

Dermatophyte infection-nail

NICE-CKS

Take nail clippings: start therapy only if infection is confirmed by laboratory 1C
Oral Terbinafine is more effective than oral azoles6A
Liver reactions rare with oral antifungals 2,A+
If Candida spp or non-dermatophyte infection confirmed, use oral itraconazole 3B+,4C

For children, seek specialist advice 3C

Medicine Calendar

First line Terbinafine6A+

250mg OD

Fingers 6-12 weeks; toes 3-6 months

Second line Itraconazole6A+

200mg BD

Fingers 7 days monthly 2 courses; toes 3 courses

Third line for very superficial only as limited evidence of effectiveness amorolfine 5% nail lacquer 5B-

1-2x/weekly fingers
toes

Fingers 6 months; toes 12 months

Leg ulcer

SIGN-QRG
NICE-CKS
PHE

Ulcers are always colonized. Antibiotics do not improve healing unless active infection 1 A+.
Active infection: if cellulitis/increased pain/pyrexia/purulent exudate/odour 2 C. If active infection, send pre-treatment swab 3 C. Review antibiotics after culture results.

Medicine Calendar

If active infection: flucloxacillin

500mg QDS

7 days. If slow response continue for a further 7 days

or: clarithromycin

500mg BD

7 days. If slow response continue for a further 7 days

Bites (human, cat or dog)

Sources: NICE-CKS

Thorough irrigation is important.
Assess risk of tetanus, rabies, HIV, hepatitis B&C1C
Antibiotic prophylaxis is advised 2B-

Give prophylaxis if cat bite/puncture wound2; bite to hand, foot, face, joint, tendon, ligament; immunocompromised/diabetic/asplenic/cirrhotic/presence of prosthetic valve or prosthetic joint.

Medicine Calendar

Prophylaxis or treatment:
co-amoxiclav 6 C</s

375-625mg TDS 3 C

7 days 3,4,5 C

If penicillin allergic: metronidazole PLUS doxycycline (for cat/dog/man) AND review at 24 & 48hrs 6 C

400mg TDS metronidazole + 100mg BD doxycycline4 C

7 days 3,4,5 C

OR metronidazole + clarithromycin (human bite) AND review at 24 & 48hrs 6 C

200-400mg TDS metronidazole + 250-500mg BD clarithromycin 6 C Review in 24 & 48hrs

7 days 3,4,5 C

Varicella zoster/chicken pox/Herpes zoster/shingles

NICE-CKS-Varicella zoster
NICE-CKS- Herpes zoster

Pregnant/immunocompromised/neonate: seek urgent specialist advice 1B+

Chicken pox: IF onset of rash <24hrs & >14years or severe pain or dense/oral rash or secondary household case or steroids or smoker consider aciclovir 2-4

Shingles : treat if >50 years 5 A+and within 72 hrs of rash 6 B+ (PHN rare if <50years 7 B-); or if active ophthalmic8 B+ or Ramsey Hunt 9 C or eczema.

Medicine Calendar

If indicated: aciclovir 3B+,5A+

800 mg five times a day

7 days ,3 B+

Second line for shingles if compliance a problem, as ten times cost valaciclovir ,10 B+ or famciclovir ,11 B+

1 g TDS valaciclovir;
500 mg TDS OR 750mg BD famciclovir

7 days ,10 B+
7 days ,11B+

Cellulitis

Sources: NICE-CKS

Class I: If patient afebrile and healthy other than cellulitis, use oral flucloxacillin alone 1,2,5 C
Class II: If febrile and ill, or comorbidity, admit for IV treatment or use OPAT (if available)
Class III: If toxic appearance - admit.1 If river or sea water exposure, discuss with specialist.

Medicine Calendar

flucloxacillin 1,2,3,5 C

500mg QDS

7 days. If slow response continue for a further 7 days1 C

If penicillin allergic: clarithromycin 1,2,3 C, 5 C

500mg BD

7 days. If slow response continue for a further 7 days1 C

If unresolving: clindamycin1,2, C

300-450mg QDS

7 days. If slow response continue for a further 7 days1 C

If facial: co-amoxiclav 4 C

500/125mg TDS

7 days. If slow response continue for a further 7 days1 C

If on statins: doxycycline

200mg on day 1 then 100mg once daily

7 days. If slow response continue for a further 7 days1 C

PVL

PHE

Panton-Valentine Leukocidin (PVL) is a toxin produced by 4.9% of S. aureus from boils/abscesses.This bacteria can rarely cause severe invasive infections in healthy people; if found suppression therapy should be given1 C.

Send swabs if recurrent boils/abscesses.
At risk: close contact in communities or sport; poor hygiene 1 C

Medicine Calendar

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Eczema

Sources: NICE-CKS

If no visible signs of infection, use of antibiotics (alone or with steroids) encourages resistance and does not improve healing 1 B. In eczema with visible signs of infection, use treatment as in impetigo 2 C

Medicine Calendar

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Cold sores

Cold sores resolve after 7–10d without treatment. Topical antivirals applied prodromally reduce duration by 12-24hrs 1,2,3B+,4

Medicine Calendar

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Dermatophyte infection-skin

NICE-CKS-body & groin
NICE-CKS-foot
NICE-CKS-scalp

Terbinafine is fungicidal 1, so treatment time shorter than with fungistatic imidazoles
If candida possible, use imidazole1
If intractable: send skin scrapings2C and if infection confirmed, use oral terbinafine/itraconazole3B+,5C
Scalp: discuss with specialist.

Medicine Calendar

Topical terbinafine 4A+,5C

BD

1-2 weeks 4A+

OR topical imidazole 4A+

BD

for 1-2 wks after healing (i.e. 4-6wks) 4A+

or (athlete’s foot only): topical undecanoates (Mycota®) 4B+

BD

for 1-2 wks after healing (i.e. 4-6wks) 4A+

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).