PDP SELF-TEST QUESTIONNAIRE SKIN INFECTION AND INFESTATION

Transcription

1 Number 3 CORE TUTORIALS IN DERMATOLOGY FOR PRIMARY CARE PDP SELF-TEST QUESTIONNAIRE AERIAL VIEW OF CORAL SKIN INFECTION AND INFESTATION REEF IN THE MALDIVES UPDATED PDP SELF-TEST QUESTIONNAIRE SEPTEMBER 2011 Active edge border of lesion raised or increased scaling with relative clearing in centre (characteristic of ringworm)

2 CORE TUTORIALS IN DERMATOLOGY FOR PRIMARY CARE AUTHOR: DR BRIAN MALCOLM, BSc, MBChB, MA, DRCOG, DPD, DCH, Dip Derm (Glasg), FRCGP. GENERAL PRACTITIONER AND GPwSI, LITCHDON MEDICAL CENTRE, BARNSTAPLE. ASSOCIATE SPECIALIST, NORTH DEVON HEALTHCARE TRUST. PDP SELF-TEST QUESTIONNAIRE INTRODUCTION This self-test questionnaire has been written by Dr Brian Malcolm, based on the recently updated (2011) Chapter 3 Skin Infection and Infestation of the Core Tutorials in Dermatology for Primary Care. This revised Chapter has been sent out to healthcare professionals with the compliments of Dermal Laboratories. If you have not received a copy of this updated Chapter, you can order a copy from Dermal at the address below. Alternatively, the Chapter is available to download from the Dermal website within the Healthcare Professionals Resources section. RESOURCES FOR MANAGING SKIN INFECTION AVAILABLE FROM DERMAL PROFESSIONAL TRIAL PACKS Antibiotics are becoming increasingly prone to resistant bacterial strains, e.g. MRSA and FRSA, particularly when applied topically. Antiseptics, on the other hand, may be considered equally effective against both strains, whether sensitive or resistant to antibiotics like methicillin or fusidic acid. The Dermol antimicrobial emollient range provides antiseptic activity combined with emollients to rehydrate dry, irritated skin. There are five product choices to suit the different needs of patients: On dry skin Dermol Lotion On very dry skin Dermol Cream As a wash Dermol Wash Under the shower Dermol Shower In the bath water Dermol Bath To assist with patient compliance, trial packs are available to health professionals. INFECTION CONTROL Regular handwashing is one of the most important infection control measures. However, repeated exposure to soaps, detergents and alcohol rubs can be very drying to the hands. Dermol Lotion and Dermol Wash are formulated to be effective and well tolerated when used for hand washing to control bacterial contamination. Further information is available on the use of Dermol Lotion and Dermol Wash for routine, frequent hand washing by healthcare professionals on the Dermal website To request professional trial packs or further information, please contact Dermal at the address below. SPONSORED BY DERMAL LABORATORIES, TATMORE PLACE, GOSMORE, HITCHIN, HERTS, SG4 7QR, UK. TEL: (01462)

3 QUESTIONS 1. What is invariably the causal organism in the bullous form of impetigo? 2. What is the commonest implicated organism in the causation of cellulitis? 3. In what percentage of the population is tinea unguium clinically diagnosable? 4. Why has little bacterial resistance emerged to topical mupirocin (Bactroban ) and how can this be maintained? 5. What 2 common infections is Corynebacterium responsible for?

4 QUESTIONS 6. How can you reliably differentiate between granuloma anulare and fungal ringworm? 7. What percentage of warts self resolve within 2 years? 8. What produces the depigmentary colour changes in infection with pityriasis versicolor? 9. Is cryotherapy more effective in treating warts than topical applications? 10. What is the fundamental difference between the pharmacological actions of azoles e.g. itraconazole and allylamines e.g. terbinafine?

5 REFLECTIVE LEARNING 11. What did I find useful about the learning module on Skin Infection and Infestation? 12. Having reflected on this module, how might my practice change in managing Skin Infection and Infestation?

6 ANSWERS (PLEASE TURN UPSIDE DOWN) QUESTION 7. Answer: 67% Ref page 9 67% will self resolve within 2 years and plantar warts demonstrate 30 50% regression within 6 months. Persuasive arguments to treat include painful, symptomatic warts, usually verrucae on pressure points of the foot, and significant cosmetic morbidity e.g. prominent hand warts in young adults or filiform facial warts in children where ridicule at school can be a factor. QUESTION 8. Answer: Azelaic acid produced by the Pityrosporum yeast. Ref page 8 this common fungal infection literally translated means scaly and of various colours. This typically affects young adults especially if there is a history of foreign travel in hot and humid climes. The normal commensal organism, P. orbiculare undergoes a change to a more aggressive variation, Malassezia furfur. This yeast produces azelaic acid which temporarily damages the melanocyte resulting in a fine, scaly, moth-eaten pigmentary disturbance, characteristically affecting the trunk and limbs. QUESTION 9. Answer: No the efficacy is largely similar. Ref page10 The next most popular treatment is cryotherapy. There are a number of misconceptions regarding this modality; one is that it is a more potent treatment than topicals, but parallel treatment studies show no statistically significant outcome measures between these two. QUESTION 10. Answer: Azoles are fungistatic but have extended activity against yeasts as well as dermatophytes; allylamines are fungicidal but are only active against dermatophytes. Ref page 6 Only itraconazole is available in liquid preparation; it again is fungistatic rather than its main competitor, terbinafine, which has a more effective fungicidal action. Ref page 7 The management of these infections has been revolutionised by the advent of the synthetic antifungal agents, available both topically and systemically, which augmented the limited pre-existing options of topical imidazole creams and systemic griseofulvin. The classification of antifungal drugs available is as follows Allylamines e.g. terbinafine Azole group including imidazoles e.g. ketoconazole and tioconazole and triazoles e.g. fluconazole and itraconazole The triazoles are fungistatic but are active against yeast infections as well.

7 ANSWERS QUESTION 1. Answer: Staphylococcus Ref page 1 The implicated organisms are Staphylococcus or, less commonly, Group A haemolytic Streptococcus (10% of cases). The bullous variation is staphylococcal mediated. Infestation/eczema are commonly secondarily impetiginised. QUESTION 2. Answer: Streptococcus pyogenes Ref page 2 This is another common presentation manifesting as a rapidly progressive infection through the deeper subcutaneous planes, usually due to the ingress of bacteria, most commonly Strep. pyogenes but sometimes Staphylococcus aureus. There is usually some pre-existing minor breach in the epidermis. QUESTION 3. Answer: 2% Ref page 5 The appearances of chronic tinea unguium are often put down to ageing tinea unguium, which is in evidence in over 2% of the population Tinea unguium rarely causes complications. QUESTION 4. Answer: Mupirocin (Bactroban) has a unique bactericidal action via RNA inhibition. To avoid resistance emerging, prolonged use should be avoided. Ref page 1 The other topical antibiotic in common usage is mupirocin (Bactroban) with its unique bactericidal action via RNA inhibition. It is active against both Staphylococcus, including MRSA, and Streptococcus. Resistance is presently very low but long term usage can induce irreversible Staph. aureus resistance and is therefore to be discouraged. QUESTION 5. Answer: Erythrasma and pitted keratolysis Ref pages 2 and 3 There are two common but poorly recognised infections caused by the humble Corynebacterium minutissimum. The first is erythrasma, often masquerading as fungal infection with a predilection for the toe webs, axillae and genitocrural region. Clinically, there is often a subtle confluent, slow spreading, well demarcated scaly erythema which fluoresces coral pink under Wood s light (filtered long wave UVL) as a consequence of porphyrin production as a metabolic byproduct. The second is pitted keratolysis which is a consequence of Corynebacterium overgrowth in the soles of feet of hyperhidrotic individuals, giving a very characteristic punctate appearance in association with macerated and malodorous skin on the plantar aspects. QUESTION 6. Answer: The former is primarily dermal with an infiltrate but no scale. The latter involves the epidermis and there will be scale present. Ref page 6 TINEA CORPORIS this manifests as the classical ringworm, a slow, radially enlarging dermatosis, single or multiple, and often relatively asymptomatic with an inflammatory scaly edge and central clearing. Three common genera of dermatophyte are implicated: Microsporum, Epidermophyton and Trichophyton. The incubation period is 1-3 weeks. The diagnosis can be confused with discoid eczema and can often be very difficult to distinguish initially, although discoid eczema is often intensely itchy and settles into a symmetrical distribution. Less forgivable is confusion with the other commonly occurring annular lesion, granuloma annulare, which is a dermal inflammatory process with no epidermal involvement i.e. an absence of scale.

8 Dermol knocks out Staph... and soothes itchy eczema Dermol A family of antimicrobial emollients WASH SHOWER LOTION CREAM BATH The Dermol family of antimicrobial emollients for patients of all ages who suffer from dry and itchy skin conditions such as atopic eczema/dermatitis. Specially formulated to be effective and acceptable on sensitive eczema skin Significant antimicrobial activity against MRSA and FRSA (fusidic acid-resistant Staphylococcus aureus) 1 Over 10 million packs used by satisfied patients 2 Dermol Wash, Dermol 200 Shower Emollient and Dermol 500 Lotion Benzalkonium chloride 0.1%, chlorhexidine dihydrochloride 0.1%, liquid paraffin 2.5%, isopropyl myristate 2.5%. Dermol Cream Benzalkonium chloride 0.1%, chlorhexidine dihydrochloride 0.1%, liquid paraffin 10%, isopropyl myristate 10%. Uses: Antimicrobial emollients for the management of dry and pruritic skin conditions, especially eczema and dermatitis, and for use as soap substitutes. Directions: Adults, children and the elderly: Apply direct to the skin or use as soap substitutes. Dermol 600 Bath Emollient Benzalkonium chloride 0.5%, liquid paraffin 25%, isopropyl myristate 25%. Uses: Antimicrobial bath emollient for the management of dry, scaly and/or pruritic skin conditions, especially eczema and dermatitis. Directions: Adults, children and the elderly: Add to a bath of warm water. Soak and pat dry. Contra-indications, warnings, side-effects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. In the unlikely event of a reaction stop treatment. Keep away from the eyes. Take care not to slip in the bath or shower. Package quantities, NHS prices and MA numbers: Dermol Wash: 200ml pump dispenser 3.55, PL00173/0407. Dermol 200 Shower Emollient: 200ml shower pack 3.55, PL00173/0156. Dermol 500 Lotion: 500ml pump dispenser 6.04, PL00173/0051. Dermol Cream: 100g tube 2.86, 500g pump dispenser 6.63, PL00173/0171. Dermol 600 Bath Emollient: 600ml bottle 7.55, PL00173/0155. Legal category: P MA holder: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR. Date of preparation: June Dermol is a registered trademark. Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Dermal. References: 1. Gallagher J. Rosher P. Temple S. Dixon A. Routine infection control using a proprietary range of combined antiseptic emollients and soap substitutes their effectiveness against MRSA and FRSA. Presented as a poster at the 18th Congress of the EADV in October 2009, Berlin. 2. Dermol Range Total Unit Sales since launch. Dermal Laboratories Ltd. Data on file DEM363/SEP11