INFECTIONS IN

DERMATOLOGY
D R K WA N Z H E N L I
D I V I S I O N O F D E R M A T O L O G Y, D E P T O F M E D I C I N E
OUTLINE → 10 COMMON CASES

• Bacterial infections
• Fungal infections
• Viral infections
• Parasitic infestations
CASE 1

• 3-year-old boy attending kindergarten

• Painful sores around mouth and nose for past 5 days
• Associated with fever and lethargy
• Yellow crusted erosions around perioral and perinasal regions
IMPETIGO

• Staphylococcus aureus, group A beta-haemolytic streptococcus

• Portals of entry
– Adjacent to sites of S. aureus colonisation e.g. nares
– Secondary infection
• Minor breaks in epidermis
• Preexisting dermatoses
• Other infections e.g. eczema herpeticum
• Wounds
IMPETIGO

• Superficial: asymptomatic
• Ecthyma: painful, tender
• Erosions with crusts, 1-3 cm, central healing in weeks
– Scattered/discrete
– Confluent
– Satellite lesion
• Bullous impetigo (intertriginous)
• Ecthyma: ulceration with thick, adherent crust; indurated
BULLOUS IMPETIGO
ECTHYMA
TREATMENT

• Prevention: Reduced colonisation

• Topical antibiotics: Mupirocin, retapamulin
• Systemic antibiotics: sensitivity of isolated organisms
CASE 2

• 63-year-old Malay lady

• Presented with one week history of worsening redness and
swelling over the right leg
• Developed blisters 2 days ago
• Associated with fever, chills and rigors
• Taken oral antibiotics from GP but no improvement
CELLULITIS

• Acute, spreading infection

• Dermal and subcutaneous tissues
• Red, hot, tender area of skin
CELLULITIS
• Aetiology
– Adults: S. aureus, GAS
– Beta-haemolytic streptococcus: group B, C or G, Erysipelothrix
rhusiopathiae, P. aeruginosa, Pasteurella multocida, Vibrio vulnificus,
Mycobacterium fortuitum complex
– Children: pneumococci, Neiserria meningitidis group B (periorbital),
Haemophilus influenzae type B (less common)
– Chronic STI: Nocardia brasiliensis, Sporothrix schenckii, Madurella
species, Scedosporium species, NTM
– Dog/cat saliva and bites: P. multocida and other Pasteurella species,
Capnocytophaga canimorsus
CELLULITIS
• Portal of infection
– Break in skin/mucosa
– Tinea pedis, leg and foot ulcers
– Cutaneous seeding: bacteraemia/sepsis
• Risk factors
– Host defense defects
– Diabetes mellitus
– Drug and alcohol abuse
– Cancer and chemotherapy
– Chronic lymphoedema: post mastectomy, previous cellulitis/erysipelas
CELLULITIS

• Entry
• Infection spreads to tissue spaces and cleavage planes
– Hyaluronidases break down polysaccharide ground substances
– Fibrinolysis digest fibrin barriers
– Lecithinases destroy cell membranes
• Local tissue devitalisation → anaerobic infection
• Reaction to cytokines and bacterial superantigens
CELLULITIS
CELLULITIS
• Clinical manifestations
– Fever, chills
– Local pain and tenderness
– Necrotizing infections: more local pain & systemic symptoms
– Red, hot, oedematous, shiny plaque (at portal of entry)
– Borders: sharply defined, irregular, slightly elevated
– Vesicles/bullae/erosions/abscesses/haemorrhage/necrosis
– Lymphangitis
– Tender, enlarged regional lymph npdes
CELLULITIS

• Distribution in adults
– Lower leg most common
– Arm
• Young male: IVDU
• Female: postmastectomy
– Trunk: operative wound site
– Face:
• Rhinitis, conjunctivitis, pharyngitis
• Colonisation of nares (S. aureus) and pharynx (GAS)
CELLULITIS

• Treatment: systemic high dose antibiotics

– Type and sensitivity
UMMC ONLINE ANTIBIOTIC
GUIDELINE
• http://farmasi.ummc.edu.my/antibioticguideline/4/4-10
NECROTISING FASCIITIS
ERYSIPELAS
OTHER MORE SERIOUS CONDITIONS…
STAPHYLOCOCCAL SCALDED SKIN
SYNDROME
STAPHYLOCOCCAL SCALDED SKIN
SYNDROME
• Exfoliative toxin → cleave desmoglein-1
• Neonates and young children
• Localized form
• Generalized form
– Macular scarlatiniform rash
– Diffuse, ill-defined erythema and fine, stippled sandpaper appearance
– 24h: erythema deepens, skin tender
– Periorificial on face, neck, axillae, groins → more widespread in 24-48 hours
– Nikolsky sign
– Flaccid bullae → erosions with red, moist base → desquamation
 SCARLET FEVER
• Aetiology
– Group A beta-haemolytic streptococcus (S. pyogenes), erythrogenic
toxin-producing strains
– Exfoliative toxin (ET)-producing S.aureus
• Infection
– Pharyngitis
– Tonsillitis
– Infected wound
– Infected dermatoses
SCARLET FEVER
• Toxin syndrome (scarlet fever)
– High fever
– Fatigue
– Sore throat
– Headache
– Nausea
– Vomiting
– Tachycardia
– Anterior cervical lymphadenitis associated with
pharyngitis/tonsillitis
SCALRET FEVER

• Exanthem
– Face flushed with perioral pallor
– Fine punctate erythema
• First: upper part of trunk
• Accentuated in skin folds
• Linear petechiae (Pastia sign) in body folds
• Palms/soles spared
– Confluent: scarlatiniform
– Fades within 4-5 days
– Desquamation and sheetlike exfoliation on palms/fingers/soles/toes
SCARLET FEVER
• Enanthem
– Pharynx beefy red
– Forchheimer spots: red macules on hard/soft
palate, uvula
– Punctate erythema and petechiae on palate
– White strawberry tongue (white with scattered
red, swollen papillae) → red strawberry tongue
(4th/5th day: hyperkeratotic membrane sloughed,
lingular mucosa bright red)
SCARLET FEVER
• Nonsuppurative sequelae
– Acute rheumatic fever
– Acute glomerulonephritis
– Guttate psoriasis
– Erythema nodosum
• Diagnosis
– Rapid direct antigen tests
– Isolate GAS on culture (throat/wound)
SCARLET FEVER

• Systemic antibiotics
– Penicillin
– Alternative: erythromycin, azathioprine, clarithromycin,
cephalosporins
CASE 3

• 32-year-old female
• Itchy, red plaques with peeling skin; annular (ring-like)
• Armpits, groins, buttocks, thighs
• 2 months
• No other comorbidities
CLUES

• Well-demarcated
• Annular
• Central clearing
• Location
TINEA CORPORIS & CRURIS: SKIN
SCRAPING FOR KOH
TREATMENT

• Topical:
– Imidazoles: clotrimazole, miconazole, ketoconazole, econazole, oxiconazole,
sulconazole, sertaconazole
– Allylamine: terbinafine

• Systemic (caution: CCF, liver, drug interactions):

– Itraconazole 200 mg OD x 1 week
– Terbinafine 250 mg OD x 2 weeks
– Fluconazole 150 mg/week x 2-4 weeks
– Griseofulvin 500 mg OD (micro-size) x 4-6 weeks
APPLICATION OF TOPICAL
ANTIFUNGALS

2 cm
FUNGAL INFECTION
DERMATOPHYTOSIS
• Aetiology
– Trichophyton
– Microsporum
– Epidermophyton
• Transmission
– Anthropophilic (Person): fomites, direct skin-to-skin contact
– Zoophilic (Animals)
– Geophilic (Environmental e.g. soil)
DERMATOPHYTOSIS

• Epidermal dermatophytosis: tinea faciei, tinea corporis,

tinea cruris, tinea manuum, tinea pedis
• Dermatophytoses of nail apparatus: tinea unguium (toenails
fingernails), onychomycosis (includes dermatophytes,
yeasts, molds)
• Dermatophytoses of hair and hair follicle: dermatophytic
folliculitis, Majocchi granuloma, tinea capitis, tinea barbae
TINEA FACIEI/FACIALIS
TINEA CAPITIS
KERION
TINEA BARBAE WITH KERION, TINEA
FACIEI
TINEA MANUUM, TINEA PEDIS,
ONYCHOMYCOSIS
“ONE-HAND, TWO-FEET”
DISTRIBUTION
 Interdigital type
- Dry scaling
Moccasin type
- Maceration/scaling/
fissuring

Tinea pedis

Inflammatory/bullous type Ulcerative type

TINEA UNGUIUM: DISTAL LATERAL
SUBUNGUAL ONYCHOMYCOSIS (DLSO)
TINEA UNGUIUM: SUPERFICIAL WHITE
ONYCHOMYCOSIS (SWO)
TINEA UNGUIUM: PROXIMAL
SUBUNGUAL ONYCHOMYCOSIS (PSO)
CANDIDA ONYCHOMYCOSIS: TOTAL
NAIL DYSTROPHY
TREATMENT OF ONYCHOMYCOSIS
DERMATOPHYTOSIS

• Pathogenesis
– Keratinases digest keratin and sustain existence of fungi in
keratinised structures
– Cell-mediated immunity and antimicrobial activity of
polymorphonuclear leukocytes restrict pathogenicity
DERMATOPHYTOSIS

Host factors Local factors

Atopy Sweating
Topical and systemic Occlusion
glucocorticoids Occupational exposure
Ichthyosis Geographic location
Collagen vascular disease High humidity
(tropical/semitropical)
DIAGNOSIS

• Tinea corporis and cruris

• Differential diagnosis:
– Candidiasis
– Flexural psoriasis
– Erythrasma
CUTANEOUS CANDIDIASIS:
INTERTRIGO – SATELLITE LESIONS
INTERDIGITAL INTERTRIGO
(CANDIDIASIS)
TINEA INCOGNITA
• Less raised margin
• Less scaly
• More pustular
• More extensive
• More irritable
• Secondary changes from long term use of
topical steroids
TINEA INCOGNITA
• Cease topical steroids
• Treat with topical and/or systemic antifungals
CASE 4

• 14-year-old boy
• Active in sports
• Whitish spots
especially on back x
3 months
CELLOPHANE TAPE METHOD FOR KOH
MOUNT
PITYRIASIS VERSICOLOR

• Superficial overgrowth of
Malassezia furfur
• Well-demarcated scaling
patches
• Variable pigmentation
• Direct microscopic
examination of scales
prepared with KOH
(cellophane tape method)
 PITYRIASIS VERSICOLOR
• Treatment:
– Topical
• Selenium sulfide 2.5% lotion or shampoo
• Ketoconazole shampoo
• Azole creams: ketoconazole, econazole, miconazole, clotrimazole
• Terbinafine 1% solution
– Systemic
• Ketoconazole 400 mg stat (1 hour before exercise)
• Fluconazole 400 mg stat
• Itraconazole 400 mg stat
PITYRIASIS VERSICOLOR
– Secondary prophylaxis
• Topical agents weekly
• Systemic agents monthly
CASE 5

• 70-year-old lady
• History of cat
scratch
• Nodular lesions
on upper limb;
linear
arrangement
HISTOPATHOLOGY
SPOROTRICHOSIS

• Granulomatous fungal infection

• Sporothrix schenckii
• Innoculated into skin or mucous membranes due to trauma
– Thorns/splinters
– Insect bites
– Animal bites/scratches
• Systemic: lung can be portal of entry
SPOROTRICHOSIS
• Types
– Fixed cutaneous
– Lymphocutaneous
– Systemic (extracutaneous)
• Osteoarticular
• Pulmonary
• Meningeal
• Disseminated
ROSE GARDENER’S DISEASE
TREATMENT

• Cutaneous/lymphocutaneous/osteoarticular
– Oral itraconazole 200 mg daily (2-4 weeks after lesions
resolve)
– Oral terbinafine 250 mg daily
– Potassium iodide (unpalatable)
• Pulmonary/meningeal/disseminated
– IV Amphotericin B
CASE 6

• 20-year-old college student

• Unwell for past 5 days with low-grade fever, lethargy and
headache
• Developed small blisters on face, body and limbs on third
day of illness
• Complained of pruritus and discomfort
DEWDROP ON ROSE PETAL
VARICELLA ZOSTER VIRUS
• Herpes virus
• Transmission: airborne droplets, direct contact
– Infectious: contagious several days before exanthem appears and until last crop of
vesicles
• Pathogenesis
– Enters through mucosa of upper respiratory tract and oropharynx
– Local replication
– Primary viraemia
– Replication in cells of reticuloendothelial system
– Secondary viraemia
– Dissemination to skin and mucous membrane
– Passes from skin lesions to sensory nerves → sensory ganglia → latent infection
VARICELLA ZOSTER VIRUS
• Laboratory
–VZV antigen detection DFA (smear of vesicle fluid,
scraping from ulcer base/margin)
–Tzanck smear
–Serology
CHICKEN POX
• Varicella
• Vesicular lesions
– Crops
– Single, discrete (more numerous in adults)
– Papules/wheals → vesicles (superficial, thin-walled,
surrounding erythema → pustules and crusted erosions (over
8-12 hour period)
– Polymorphic: all stages simultaneously
CHICKEN POX
• Crusted erosions
– Heal in 1-3 weeks
– Pink, depressed base
• Punched-out permanent scars
• Distribution
– Face & scalp → trunk & limbs
– More on trunk and face
– Palms and soles usually spared
CHICKEN POX
• Mucous membranes
– Vesicles → shallow erosions
– Palate
• General examination
– VZV pneumonitis: adolescents, adults
– CNS: cereballar ataxia, encephalitis
CHICKEN POX
• “Malignant” varicella (immunocompromised)
–Pneumonitis
–Hepatitis
–Encephalitis
–Disseminated intravascular coagulation
–Purpura fulminans
CHICKEN POX
• Diagnosis
– Clinical
– Serology
• Complications
– Secondary bacterial infection (<5 yo)
– Varicella encephalitis, Reye syndrome (5-11 yo)
– Fetal varicella syndrome
• Limb hypoplasia
• Eye and brain damage
• Skin lesions
CHICKEN POX

• Complications (continued)
–Immunocompromised
• Hepatitis
• Encephalitis
• Haemorrhagic complications
CHICKEN POX
• Treatment
– Immunisation
– Symptomatic: antihistamnes lotions
– Antivirals: decrease severity if given within 24 hours
• Acyclovir
• Valacyclovir
• Famciclovir
• Foscarnet (if acyclovir resistant)
ZOSTER
ZOSTER
ZOSTER
• Treatment
– Prevention: live attenuated vaccine
– Antivirals: oral famciclovir/valaciclovir/acyclovir
– Immunocompromised: IV acyclovir
– Acyclovir resistant: IV foscarnet
– Supportive: bed rest, sedation, analgesia, moist dressings
– Postherpetic neuralgia: gabapentin, pregabalin, tricyclic
antidepressants, topical capsaicin cream, nerve block
CASE 7
• 32-year-old lady
• Painful grouped vesicles over upper lip for 2 days
• Noted yellowish discharge when ruptured
ETIOLOGY AND EPIDEMIOLOGY
• Pathogenesis
–Primary infection
• Close contact with person shedding virus (peripheral site,
mucosal surface, secretion)
• Innoculation onto susceptible mucosal surface or break in skin
• Virus replicates in epithelial cells
– Lysis of infected cells
– Vesicle formation
– Local inflammation
ETIOLOGY AND EPIDEMIOLOGY
– Latency
• After symptomatic and asymptomatic primary infection
– Reactivation and recurrence
• Virus particles travel along sensory neurons to skin and mucosal sites
• Recurrent mucocutaneous shedding
– +/- lesions i.e. asymptomatic shedding
– Can be transmitted to new host
• Usually vicinity of primary infection
• Symptomatic/asymptomatic
ETIOLOGY AND EPIDEMIOLOGY

• Transmission
– Mostly when shed virus but lack symptoms/lesions
– Skin-skin (e.g. herpes gladiatorum)
– Skin-mucosa
– Mucosa-skin
– Most commonly young adults, range infancy to senescence
ETIOLOGY AND EPIDEMIOLOGY

• Etiology: HSV-1 and 2

– Labialis: HSV-1 (80-90%), HSV-2 (10-20%)
– Urogenital: HSV-2 (70-90%), HSV-1 (10-30%)
– Herpetic whitlow: <20 years of age usually HSV-1; >20 years of
age usually HSV-2
– Neonatal: HSV-2 (70%), HSV-1 (30%)
HERPETIC WHITLOW
GENITAL HERPES
GENITAL HERPES
LABORATORY EXAMINATIONS
• Tzanck smear
– Fluid from intact vesicle smeared onto slide
– Dried
– Stained with either Wright or Giemsa stain
– Acantholytic keratinocytes or multinucleated giant acantholytic keratinocytes
• Antigen Detection Direct Fluorescent Antibody (DFA)
– Specific for HSV-1 and 2 antigens
• Viral culture
• Serology
TREATMENT
Non-genital
Oral antiviral
Acyclovir 400 mg TDS or 200mg
5x/day for 7-10 days
Valacyclovir 1g BD for 7-10 days
Famciclovir 250mg TDS for 5-10
days
Continuous oral maintenance
(valaciclovir 500mg/day): severe
recurrent disease
Genital
Abstain from sexual activity while lesions present
Use condoms
First episode
Oral acyclovir 400mg 5x/day x 10 days or until lesions resolve
Recurrences
Oral acyclovir 400 mg 5x/day for 5 days or 800mg BD for 5 days
Valacyclovir 500 mg BD for 3 days or 1 mg BD for 3 days
Famciclovir 125 mg BD for 5 days or 1 g OD for 5 days
Maintenance
Daily suppressive therapy
Acyclovir 400 mg BD
Valcyclovir 500-1000 mg OD
Famciclovir 250 mg OD
Severely immunocompromised
IV acyclovir 5mg/kg every 8 hours for 5-7 days or oral acyclovir
400mg 5x/day for 7-14 days
Acyclovir resistant
IV foscarnet 40mg/kg every 8h for 14-21 days
ECZEMA HERPETICUM
CASE 8

• 25-year-old man
• Painful small lumps on soles for 6 months
• After going barefoot at swimming pool
HUMAN PAPILLOMAVIRUS

• Cutaneous warts
– Discrete benign epithelial hyperplasia
– Varying degrees of surface hyperkeratosis
– Minute papules to large plaques
– Confluent → mosaic
• Transmission: skin-to-skin contact
• Increased incidence and widespread: host defence defects
PLANE WARTS
FILIFORM AND FLAT WARTS
TREATMENT

Patient-initiated Clinician-initiated
• Small: 10-20% salicylic acid and • Cryosurgery
lactic acid in collodion • Electrosurgery
• Large: 40% salicylic acid plaster • CO2 laser surgery
for 1 week then apply salicylic
acid-lactic acid in collodion
• Imiquimod cream 3x/week
CASE 9

• 52-year-old man with HIV

• 2-month history of small painless lumps on face
• Not pruritic
• O/E: Multiple umbilicated papules on face
DIFFERENTIAL DIAGNOSES

• Opportunistic infections
– Penicilliosis
– Histoplasmosis
– Cryptococcosis
– Molluscum contagiosum
• Pruritic papular eruption of HIV
MOLLUSCUM CONTAGIOSUM

• Pox virus with 4 discrete subtypes (I, II, III, IV)

• Colonises epidermis and infundibulum of hair follicle
• Transmission: skin-to-skin contact
• Demography:
– Children, sexually active adults
– Males > females
– HIV: hundreds/giant
MOLLUSCUM CONTAGIOSUM

• Treatment
– Curettage
– Cryosurgery
– Electrodessication
– Topical: podophyllotoxin (men), iodine, salicylic acid, KOH, tretinoin,
cantharidin, imiquimod (adults)
– HIV: intralesional interferon
CASE 10
• 85-year-old gentleman
• History of stroke and ischaemic heart disease
• Lives in nursing home
• Itchy rashes over fingers and groins for past 3 weeks, spread to face,
neck and trunk
• Examination
– Thick, crusted plaques over fingers, hands, around nails
– Erythematous scaly plaques on face, neck, scalp, trunk
SCABIES
• Superficial epidermal infestation by mite Sarcoptes scabiei var
hominis
• Transmission: Skin-to-skin contact, fomites
LIFE CYCLE
SYMPTOMS
• Pruritus: intense, widespread, usually spares head and neck,
may be absent in hyperinfestation
• Rash: no rash → erythroderma, eczematous dermatitis esp in
atopic diathesis
• Tenderness: secondary bacterial infection
CUTANEOUS FINDINGS
• Types
– Lesions at sites of mite infestation
– Cutaneous manifestations of hypersensitivity to mites
– Lesions secondary to chronic rubbing and scratching
– Secondary infection
– Hyperinfestation
CUTANEOUS FINDINGS
• Variants in special host:
– Atopic diathesis
– Nodular scabies
– Infants/small children
– Elderly
INTRAEPIDERMAL BURROWS
• Skin-coloured ridges
• 0.5-1 cm in length (up to 10 cm)
• Linear/serpiginous
• Minute vesicle/papule at end of tunnel
• 1 infesting female mite = 1 burrow
• Distribution: areas with few/no hair follicles
– Webs, wrists, shaft of penis, elbows, feet, buttocks, axillae
– Infants: head and neck
NODULES
• 5-20 mm diameter
• Red/pink/tan/brown
• Smooth
• +/- burrow on surface of early lesion
• Resolved with PIH
• Distribution: scrotum, penis, axillae, waist, buttocks, areolae
SCABIES WITH HYPERINFESTATION
(NORWEGIAN SCABIES)
• May begin as ordinary scabies
• Hyperkeratotic, crusted
• Warty dermatosis of hands/feet with nail bed hyperkeratosis
• Erythematous scaling eruption on face, neck, scalp, trunk
• Odour
• Generalised or localised
OTHER CLINICAL FINDINGS
• “Id” or autosensitisation: small urticarial oedematous papules
– anterior trunk, thighs, buttocks, forearms
• Secondary changes
– Excoriations
– Lichen simplex chronicus
– Prurigo nodularis
– Post-inflammatory hyper- and hypopigmentation
– Bullous scabies
– Secondary infection by S.aureus
DIAGNOSIS
• Clinical
• Microscopy: drop of mineral oil placed over burrow and
scrape with curette or no. 15 blade – placed on slide
– Mites
– Eggs
– Scybala: faecal pellets
• Ink test: rub around suspicious bumps with marker, wipe
away ink with alcohol → dark irregular line (ink remains), tiny
dot at end (mite)
MANAGEMENT
Newborn – 2 months: Crotamiton
Children (2 months - 2 years old)
• First line: Permethrin 5%
• Second line: Crotamiton, 6% Sulphur in calamine
Children (2-12 years old)
• First line: Permethrin 5%
• Second line: EBB 12.5%, 1% Lindane (GHB), Crotamiton
Adults
• First line: Permethrin 5%
• Second line: EBB 25%, 1% Lindane, Crotamiton
Pregnancy
• Permethrin 5%, 6% Sulphur in calamine
Crusted scabies: oral ivermectin
Sunderkotter C, Mayser P and Folster-Holst R et al. Scabies.
JDDG 2007;5:424-30
TREATMENT OF HOUSEHOLD/CLOSE
CONTACTS AND ENVIRONMENTAL
MEASURES
• Close contacts should be treated concurrently, even if
they do not have symptoms
• Decontaminate all linens, towels and clothing used in the
previous 4 days by hot water washing (60 deg C) and
heated drying
• Items that cannot be washed in hot water should be dry
cleaned or sealed in a plastic bag for 5 days
 TREATMENT OF SCABIES
GENERAL PRINCIPLES

●Treat secondary infection first, as most scabicidals are irritant

●Avoid body contact until completed treatment and follow-up
●Give detailed and clear explanation on treatment application:
● Take a bath/shower to remove scales
● Apply the lotion or cream thoroughly all over body, from neck to soles, with special
attention to intertriginous areas, umbilicus, groin, genitalia, buttock and under
fingernails and toenails
● Avoid head and face
● Allow cream/lotion to dry before putting on clothes
● Reapply to hands or feet if the drug is washed away, or to diaper areas of babies
during changes
● Medication should be thoroughly washed off after recommended time period
● Repeat the application if indicated
TREATMENT OF SCABIES
PERMETHRIN 5% CREAM

• Apply at bedtime after bath

• Apply to entire body from neck downwards
• Wash off after 8-12 hours
• A single application often curative
• Can repeat after one week
TREATMENT OF SCABIES
EMULSION BENZYL BENZOATE
• 12.5% for children (2-12 yrs)
• 25% for adults
• Apply and wash off after 24 hours
• Repeat application for 2-3 days
• Do not use in children below 2 years or in patient of any age
with excoriated or infected skin
• Causes irritant dermatitis, scrotal irritation, stinging and
conjunctival irritation when eye is touched
• Neurotoxicity – in raw and eczematised skin
TREATMENT OF SCABIES
GAMMA BENZENE HEX ACHLORIDE 1% (LINDANE)

• Do not take a bath 2 hours before application because wet skin enhances
absorption
• Apply at bedtime and bathe/shower the next morning (leave for 6-8 hours)
• One application
• Should not be used in
– children below 2 years of age
– pregnant or breastfeeding women
– scabies with secondary infection/crusting
– excoriated skin (increased absorbtion)
• CNS side effects due to increased percutaneous absorption in damaged
skin, misuse, overuse, or accidental ingestion:
– Seizures, tremors, anxiety, numbness of skin and restlessness
TREATMENT OF SCABIES
6% SULPHUR IN CALAMINE LOTION/PETROLATUM

• Safe alternative for very young infants, pregnant and lactating women

• Apply before bedtime and wash off the next morning

• Repeat for 5 days

• Not as effective as other treatments

TREATMENT OF SCABIES
10% CROTAMITON CREAM (EURAX)

• Safe in children and infants

• Apply daily for 3-5 days
• Limited scabicidal activity
• Efficacy questionable
• Irritation is common
THANK YOU