SCABIES

Scabies is caused by arthropod mite (sarcoptesscabiei). It is transmitted by close personal contact after an incubation period of 3-4 weeks

Clinical features:

•        Nocturnal itching

•        Excoriated papules, papulovesicles, burrows on inter digital clefts of hands, wrist, axillary folds, breasts, periumblical region, medial side of thigh and genitals.

•        Face, palms, soles and scalp involved in infants

Diagnosis

•        Clinical

•        Inspection of mites from scabetic burrows. Nonpharmacological treatment

•        Maintenance of personal hygiene.

•        Disinfection of bedding and clothing.

•        All family members should be treated simultaneously.

Pharmacological treatment

•        Gamma benzene hexachloride (GBHC) lotion 1%. Single overnight application below neck on entire body surface after a thorough scrub bath, to be washed off next morning.

•        Permethrin 5% to be applied generously, after bath, at bed time, covering entire surface of the body below neck (except face).

•        25% Benzyl Benzoate emulsion overnight application for three consecutive days.

•        Tab.ivermectin 200mcg/kg as asingle stat dose to be repeated after 2weeks.

•        Antihistamines like Tab.cetirizine10mg daily. For children 0.3mg/kg/day.

PEDICULOSIS

It is commonly known as lice infestation. Transmission occurs by personal contact, sharing of combs, infected clothing and poor personal hygiene while transmission of pubic lice is by sexual-contact.

Types

1.   Pediculosis capitis - by Head louse

2.   Pediculosis corporis - by Body louse

3.   Phthiriasis pubis - by Crab louse

Causative organism

•        Pediculosis humanus var. capitis (head louse)

•        Pediculosis capitis var. corporis (body louse)

•        Phthirus pubis (pubic louse)

Clinical features

Presence of nits and louse associated with itching of the affected part. Excoriated papules and scratch marks may be seen.

Diagnosis

•        Finding lice in occipital region in P.capitis, inseams of clothes in P.corporis and in pubic region in phthiriasis pubis.

Non-pharmacological treatment

•        Maintenance of personal hygiene.

•        Disinfection of bedding and clothing.

•        All the family member should be treated simultaneously.

Pharmacological treatment

•        Pediculosis capitis: Permethrin l% to be applied topically. Hair should be washed and towel dried followed by application of drug over entire scalp, hair and retro-auricular areas for 10-15 minutes and then should be rinsed with warm water.

•        Pediculosis Corporis: Patient needs only to have a scrub bath and change of clothes. Laundering of clothes, especially underclothes, and bedding at high temperature and use of a hot iron with special attention to the seams of clothing.

•        Phthiriasis pubis: Gamma-benzene hexachloride l% (lotion/cream/shampoo) should be applied to the entire body below the neck for 8-12 hours and then washed off.

•        Tab Ivermectin: 200 mcg/kg single oral dose on an empty stomach.

LEPROSY

It is a chronic granulomatous disease caused by Mycobacterium leprae, principally affecting peripheral nerves and skin.

Clinical features (cardinal signs)

•        Hypopigmented or erythematous skin lesion with or without loss/impairment of sensation, sweating and hair.

•        Thickening of peripheral nerves with or without loss/impairment of function.

•        Slit skin smear shows acid fast bacilli.

Classification of Leprosy

1.   Ridley- Jopling classification: This classification is based on combination of clinical features, bacteriological index, immune response and histopathological features. Accordingly, it has been classified into 5 types: TT(TubercuIoid), BT (Borderline tuberculoid), BB(Borderline), BL (Borderline lepromatous), LL(Lepromotous).

2.   NLEP classification (for treatment purpose):

Diagnosis

Presence of at least 2 of the 3 cardinal signs

Investigations

Skin Smear for Acid Fast Bacilli, skin biopsy and rarely nerve biopsy is required in pure neural type of leprosy

Pharmacological treatment

Nonpharmacological treatment

•        Care of insensitive hands and feet- emollient application, avoidance of trauma and burns, daily inspection and rest.

•        Care of eyes – protective glasses.

•        In case of deformity- use correct splints, micro-cellular rubber (MCR) shoes.

ECZEMA AND DERMATITIS

The word eczema and dermatitis are often used interchangeably. All eczemas are dermatitis but all dermatitis are not eczemas. They refer to a pattern of infIammatory response of the skin characterized by itching, redness, oedema, clustered papulo-vesicles, oozing during the acute stage, crusting and scaling in the sub-acute stage and lichenification during the chronic stage.

General Classification

1.   Exogenous Eczema

Irritant Dermatitis, Allergic contact dermatitis, Photo allergic dermatitis

2.   Endogenous Eczema

Atopic Dermatitis, Seborrheic Dermatitis, Asteatotic eczema, Pompholyx, Stasis eczema.

CONTACT DERMATITIS

Causes

Inflammatory response to an exogenous substance, immunologically or non- immunologically mediated. Common allergens are cement, metals, epoxy resins, rubber, plastics, drugs, plants, fertilizers insecticides etc.

Clinical features

•        Sharp, well-defined erythema/ vesicIes, erosions associated with itching and oozing.

•        Lesions may or may not be confined to the site of contact.

Diagnosis & Investigations

•        Mainly clinical based on thorough history taking.

•        Patch testing and allergen specific IgE testing.

Treatment

Topical therapy:

•        Compresses using saline, potassium permanganate, 0.25% silver nitrate solution.

•        Topical corticosteroids - Mometasone furoate, 0.1%, Betamethasone dipropionate 0.05%, Betamethasone valerate 0.01%, Clobetasol 0.05%.

Systemic therapy:

•        Antihistaminics - Hydroxyzine hydrochloride l0-25mg, tab cetirizine 10mg HS (0.3mg/kg/day in children)

•        Tab prednisolone upto 1 mg/kg/day, tapered as soon as possible.

ATOPIC DERMATITIS

The word 'atopy' means “out of place' or 'strange“ to signify the hereditary tendency to develop allergies to food, inhalant substances. Atopic Dermatitis applies to cutaneous manifestation of atopic diathesis.

Types

•        Infantile Atopic dermatitis (2 months - 2 years)

•        Childhood Atopic dermatitis (2 years - 12 years)

•        Adult

Cause

Hereditary, environmentaI factors and infective causes.

Clinical features

•        Pruritus.

•        Flexural lichenification in adults. Facial and extensor involvement in infancy.

•        Chronic relapsing dermatitis.

•        Personal or family history of other atopic diseases as asthma, allergic rhinitis.

Treatment

•        Emollients and humectants e.g. coconut oil, glycerine, etc.

•        Topicul coritcosteroids of mild to moderate potency e.g.hydrocortisone valerate 1%, desonide 0.05%, fluticasone propionate 0.05%, betamethasone

dipropionate 0.05%.

•        Tacrolimus 0.03% and 0.1% in children above 2 years of age.

•        Anti-histamines to relieve itching.

SEBORRHEIC DERMATITIS

Cause

Exact cause is unknown. Association with P Ovale /MaIassezia furfur, seborrhea

Clinical features

•        Sites: Sites rich in sebaceous glands - scalp, face, upper trunk, axilla, groin.

•          Erythematous patches with greasy scales.

•        Mild form on the scalp is called dandruff.

Treatment

Topical therapy: in mild cases.

•        Selenium sulphide shampoo 1%

•        Coal tar shampoo 1%

•        Topical mild steroid cream or lotions e.g. desonide 0.05%

•        Anti-fungal preparations: ketoconazole 2% cream and lotion, ciclopirox olamine 1% cream and shampoo etc.

Systemic therapy: in moderate to severe cases.

•        Oral anti-fungal: Ketoconazole 200 mg/day x 7 days or Terbinafine 250 mg/ day x 4 weeks or Itraconazole200mg/day x 7 days.

POMPHOLYX

It is a type of eczema affecting the palm/soles and is a nonspecific type of reaction to various provoking factors.

Causes

Direct contact with chemicals, metals and drugs, dermatophytid reaction, cigarette smoking and hyperhidrosis.

Clinical features

Deep seated itchy vesicles which looks like sago grains, appear in crops on palms and sides of fingers.

Treatment

•        Potassium permanganate-(I :8000) compresses for 15 minutes 4 times/day.

•        Burrows solution - aluminium acetote 1% compresses.

•        Topical corticosteroids - Mometasone 0.1%, Betamethasone dipropionate 0.05%, Betamethasone valerate 0.01%, Clobetasol 0.05%.

•        Topical tacrolimus 0.1%

•        Antihistaminics - cetirizine 1 0 mg OD.

PITYRIASIS ALBA

It is a type of nonspecific dermatitis of unknown cause. Commonly seen in atopic individuals.

Clinical features

•        Age: Predominantly in children.

•        Presents as dry, scaly, irregular, rounded or oval, hypo-pigmented macules over face.

Treatment

•        An emollient (coconut oil/olive oil/paraffin) to reduce scaling.

•        If active signs of inflammation are present - mild topical steroid like hydrocortisone 1%, Desonide 0.05%.

•        Tacrolimus ointment 0.1 % and pimecrolimus 1% cream.

ACNE VULGARIS

It is a chronic inflammatory disease of pilo-sebaceous glands of the face, neck and upper trunk. It usually affects adolescents and young adults. Occurs due to obstruction of pilo-seboceous ducts, increased sebum production, alteration in lipid composition, secondary infection with Propionibacterium acnes, and hormonal imbalance.

Clinical features

•        Characterised by comedones (Blockheads (open) /white heads(closed)), papules, pustules, nodules, cysts and often scars depending upon the severity of disease.

•        Sites: Predominantly face, neck, upper trunk

Assessment of severity

Grade 1 (mild)                        –          Comedones, occasional papules

Grade 2 (moderate)           –          Comedones, many papules, few pustules Grade 3 (severe)    –                                    Predominantly pustules, nodules and abscesses Grade 4 (cystic)       –           Mainly cysts, abscesses, widespread scarring

Non- Pharmacological Treatment

•        Avoid diet rich in sugar and milk products

•        Avoid use of drugs causing acne like steroid, androgens, halogens

•        Avoid use of oils, pomades and cosmetics

•        Patient education about premenstrual flares and stress

•        Washing face to keep skin clean and non-greasy

•        Shampooing to keep scalp non-greasy

Pharmacological Treatment

Grade 1: Benzoyl peroxide gel or cream (2.5 - 5 %) or Azelaic acid 10- 20% to be applied at night.

Grade 2: Any of the following may be given:

•        Topical retinoids - Tretinoin (0.025%, 0.05%) creams and gels, Adaplene (0.1 %) gel. Use only at night.

•        Benzoyl peroxide gel or cream (2.5% - 10%) to be applied at night.

•        Topical antibacterials like clindamycin 1%, clarithromycin 1%, Erythromycin 4%, Nadifloxocin 1% cream/ gel. To be applied twice daily.

Grade 3: Prolonged course of oral antibiotics should be added. Various antibiotic options are:

•        Azithromycin 500 mg once daily for 3 days/week for 12 weeks.

•        Roxithromycin 150 mg twice daily.

•        Minocycline 100 mg once daily.

•        Doxycycline 100 mg once daily.

•        E rythromycin 500 mg twice daily.

•        Isotretinoin and hormonal therapy in resistant cases.

Grade 4

•        Isotretinoin therapy in nodulo-cystic acne.

URTICARIA

It is a vascular reaction of skin resulting in localized oedema of dermis and sometimes sub-cutis. Histamine is the most important mediator.

Causes

It occurs due to allergy to food such as shellfish, chocolate, peanut, meat etc. Natural food additives like yeast, citric acid, eggs or synthetic additives like azo dyes. Drugs like penicillin, NSAIDs and sulphonamides. Sometimes idiopathic.

Clinical features

Evanescent, erythematous wheals and plaques associated with itching.

Types

•        Acute – less than 6 weeks

•        Chronic – more than 6 weeks

Investigations

•        Thoroughly investigate the patient for the cause

•        Complete haemogram, AEC, Fasting Blood Sugar, urine examination, ESR, Liver Function Tests, Renal Function Tests, stool examination, urine culture/sensitivity, blood culture/sensitivity, thyroid profile, Antinucleor Antibody.

Non- pharmacological Treatment

•        Avoid triggering factors

•        Cold water sponging and soothing applications

Pharmacological Treatment

•        Tab cetirizine 10mg at night or tab chlorpheniramine maleate 4mg twice a day

•        Corticosteroids may be added if not controlled with antihistamines alone.

•        Inj Epinephrine 0.5 to 1ml SC and Inj Hydrocortisone 100mg IV stat in case of laryngopharyngeal oedema.

•        Cyclosporine, Azathioprine or Methotrexate may be added in resistant cases.

PSORIASIS

It is a chronic, recurrent, inflammatory, hyperproliferative disorder of skin characterized by circumscribed erythematous, scaly plaques.

Causes

Genetically mediated, association with HLA- DR3/4, drugs, alcohol, smoking, metabolic diseases. Driven by complex cascade of infIammatory mediators.

Clinical Features

•        Erythematous papules and plaques with silvery white scales.

•        Sites - elbows, knees, scalp, lower back, palms and soles, in a bilaterally symmetrical manner. Nails and joints may also be involved.

•        Mild pruritus is present.

•        Winter aggravation.

•        Auspitz sign (bleeding points on removal of scales) is positive.

Types

1.   Guttate Psoriasis: sudden onset of crops of erythematous scaly papules and plaques.

2.   Inverse Psoriasis: involves folds, recesses of flexor surfaces e.g. axilloe, groin.

3.   Nail Psoriasis: discoloration, nail pitting, subungual hyperkeratosis, 'oil drop' appearance of nail plate.

4.   Psoriatic arthritis: asymmetrical oligoarthritis.

Diagnosis

Clinical and skin biopsy

Investigations

To be done in moderate to severe cases (when contemplating to start systemic drugs). Complete haemogram, liver profile, renal profile, viral markers, fasting blood sugar, urine examination, serum lipid profile, chest X- ray, skin biopsy.

Non-pharmacological treatment

•        Identify and avoid triggering factors.

•        Avoid stress, alcohol and smoking.

•        Avoid beta-blockers and chloroquine.

Pharmacological Treatment

a)  For mild cases, topical therapy is sufficient. These include

•        Emollients (like coconut oil, liquid paraffin and white soft paraffin)

•        Topical Corticosteroids (like mometasone furoate 0.1% cream, clobetasol propionate 0.05% cream).

•        Keratolyics (like salicylic acid 3-6%, dithranol, tar preparations).

•        Vitamin D analogues: Calcipotriol and calcitriol etc.

b)  Moderate to severe cases :

•        Tab Methotrexate 5-7.5 mg/wwek

•        Tab Cyclosporine 50-100mg/day

•        Cap Acitretin 25mg/day