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Remember to check allergy status

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Paediatric Treatment - Skin & Soft Tissue Infections

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

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)2 C

See BNFc

7 days

If penicillin allergic:
clarithromycin (oral)2 C

See BNFc

7 days

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

see BNFc

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

OR clarithromycin

see BNFc

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

Varicella zoster/ chickenpox

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

Medicine Calendar

If indicated: aciclovir 3B+,5A+

see BNFc

7 days

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

see BNFc for tetracycline and doxycycline dosing

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

See BNFc

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

If penicillin allergic:
metronidazole PLUS clarithromycin added (human bite)

See BNFc for metronidazole and clarithroymcin dosing

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

If penicillin allergic (animal): metronidazole PLUS doxycycline 6 C

See BNFc for metronidazole and doxycycline

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

See BNFc

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

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

See BNFc

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

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

See BNFc

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

If unresolving: clindamycin1,2, C

See BNFc

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).