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Remember to check allergy status

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Adult Treatment - Skin & Soft Tissue Infections

Note: Refer to RCGP Skin Infections online training.[1D] For MRSA, discuss therapy with microbiologist.[1D]

Cold sores

Most cold sores resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12-18hrs 1,2,3B+,4
If frequent, severe, and predictable triggers: consider oral prophylaxis

Medicine Calendar

If frequent, severe, and predictable triggers: aciclovir

400mg BD

5-7 days

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 permethrin allergy: malathion 3 C

0.5% aqueous liquid

2 applications 1 week apart1 C

Impetigo

Sources: NICE-CKS

Topical antibiotics for very localised lesions to reduce the risk of resistance 1,5 C,4 B+.
Reserve mupirocin for MRSA 1 C.

For extensive, severe, or bullous impetigo, use oral antibiotics 1 C.

Medicine Calendar

Topical fusidic acid 2%

Apply thinly TDS

5 days

MRSA: topical mupirocin 2% ointment

Apply TDS

5 days

Flucloxacillin (oral)

250-500mg QDS

7 days

If penicillin allergic:
clarithromycin (oral)2 C

250-500mg BD

7 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 0.1 - 1% with oral antifungals 2,A+
If Candida spp or non-dermatophyte infection confirmed, use oral itraconazole
Topical lacquer is not as effective.
To prevent recurrence, apply weekly 1% topical antifungal cream to entire toe area.
For children, seek specialist advice

Medicine Calendar

First line Terbinafine6A+

250mg OD

Fingers 6 weeks; toes 12 weeks. Stop treatment when continual, new, healthy, proximal nail growth

Second line Itraconazole6A+

200mg BD

Fingers 7 days monthly 2 courses; toes 3 courses. Stop treatment when continual, new, healthy, proximal nail growth

Leg ulcer

SIGN-QRG
NICE-CKS
PHE

Ulcers are always colonized. Antibiotics do not improve healing unless active infection (purulent exudate/odour; increased pain; cellulitis; pyrexia)
Non-healing: antimicrobial reactive oxygen gel may reduce bacterial load.

Medicine Calendar

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

Varicella zoster/chicken pox/Herpes zoster/shingles

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

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

Chickenpox: consider aciclovir[2A+,3A+,4D] if: onset of rash <24 hours,[3A+] and one of the following: >14 years of age;[4D] severe pain;[4D] dense/oral rash;[4D,5B+] taking steroids;[4D] smoker

Shingles : treat if >50 years 5 A+(PHN rare if <50years 7 B-);and within 72 hrs of rash 6 B+ or if one of the following: active ophthalmic8 B+; Ramsey Hunt 9 C; eczema or non-truncal involvement; moderate or severe pain; moderate or severe rash.

Treatment not within 72 hours: consider starting antiviral drug up to one week after rash onset,[11B+] if high risk of severe shingles[11B+] or complications11B+.[7D,11B+]

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, valaciclovir ,10 B+ or famciclovir ,11 B+

1 g TDS valaciclovir;
500 mg TDS OR famciclovir 250-500mg TDS OR famciclovir 750mg BD

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

PVL - SA

PHE

Panton-Valentine Leukocidin (PVL) is a toxin produced by 20.8 - 46% of S. aureus from boils/abscesses.PVC strains are rare in healthy people, but severe.1 C.
Suppression therapy should only be started after primary infection has resolved, as ineffective if lesions are still leaking.
Risk factors for PVL: recurrent skin infections;invasive infections; if there is more than one case in a home or close community (school children; millitary personel; nursing home residents; household contacts).

See PHE PVL-SA guidance

Medicine Calendar

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Acne

For mild (open and closed comedones)[1D] or moderate (inflammatory lesions):[1D]

  • First-line: self-care1D.[1D]
  • Second-line: topical retinoid or benzoyl peroxide.[2D]
  • Third-line: add topical antibiotic,[1D,3A+] or consider addition of oral antibiotic.[1D]

For severe (nodules and cysts):[1D] add oral antibiotic (for 3 months max)[1D,3A+] and refer.[1D,2D]

Medicine Calendar

First line: self-care

Second line: topical retinoid OR benzoyl peroxide

Apply topical retinoid thinly OD OR benzoyl peroxide 5% cream OD-BD

6-8 weeks

Third line: ADD topical clindamycin 1% cream

apply thinly BD

12 weeks

OR If treatment failure/severe: ADD oral tetracycline OR oral doxycycline

tetracycline 500mg BD or doxycyline 100mg OD

6-12 weeks

Dermatophyte infection-skin

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

Most cases: use terbinafine as it is fungicidal 1, so treatment time shorter than with fungistatic imidazoles
If candida possible, use imidazole1
If intractable or scalp: send skin scrapings2C

If infection confirmed, use oral terbinafine/itraconazole3B+,5C
Scalp: oral therapy and discuss with specialist.

Medicine Calendar

Topical terbinafine 1% 4A+,5C

apply thinly OD-BD

1-4 weeks 4A+

OR topical imidazole 1%4A+

apply thinly OD-BD

4-6 weeks 4A+

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

OD-BD

4-6 weeks 4A+

Bites (human, cat or dog)

Sources: NICE-CKS

Thorough irrigation is important.
Assess risk of tetanus, rabies, HIV, hepatitis B&C1C

Human and cat: Give antibiotic prophylaxis 2B-

Dog: Give antibiotic prophylaxis if 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 (animal): metronidazole PLUS doxycycline 6 C

400mg TDS metronidazole + 100mg BD doxycycline4 C

7 days. Review at 24 & 48hrs as not all pathogens are covered3,4,5 C

OR metronidazole + clarithromycin (human bite)

400mg TDS metronidazole + 250-500mg BD clarithromycin 6 C

7 days. Review at 24 & 48hrs as not all pathogens are covered3,4,5 C

Cellulitis and erysipelas

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.

Erysipelas: often facial and unilateral. Use flucloxacillin for non-facial erysipelas

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

300mg QDS

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

If facial (non-dental): co-amoxiclav 4 C

500/125mg TDS

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

If penicillin allergy and on statins: doxycycline

200mg on day 1 then 100mg once daily

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

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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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).