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13.2 Infections of the skin

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

13.2.1 Bacterial Skin infections

 

 

Metronidazole

  • Gel, 0.75%    

 

Mupirocin

  • Bactroban® Ointment 2%      

Notes:

  • Mupirocin should only be used on recommendation of Infection Control or Microbiology. 
  • It should not be used for longer than 10 days.
  • Mupirocin should be kept in reserve to avoid resistance developing and is particularly useful in treating MRSA.
  • Mupirocin (Bactroban® nasal) is of value when the carriage of Staphlococcus aureus in the nose or ears has to be cleared.
  • Use as per: Five Day Treatment Protocol for MRSA 

 

Octenisan® (Amber 1)

  • Antimicrobial wash 500mL

Note:

 

 

Silver sulfadiazine

  • Cream 1%     20g, 50g, 250g, 500g

Notes:

  • Silver sulfadiazine is used in the treatment of infected burns.
  • 250g and 500g pots of silver sulfadiazine (Flamazine®) cream should be discarded 24 hours after opening. 

 

Fusidic acid (Amber 2) 

  • Cream / Ointment 2%         
  • Topical fusidic acid is included for 2nd line treatment of impetigo 

 

 

 

13.2.2 Fungal skin infections 

Imidazole antifungals  

Clotrimazole

  • Cream 1% 
  • Solution 1%           

 

Miconazole nitrate

  • Daktarin® Cream 2% (contains: butylated hydroxyanisole)      

 

 

Other antifungals

Amorolfine

  • 5% nail lacquer, 5mL

Notes:

  • Review every three months

 

Terbinafine

  • Cream 1%    
  • Tablets 250mg

Note:

  • Tinea infection of the nail should be treated orally once a positive culture from nail clippings has been observed.  

Mycota®

  • Cream 
  • Powder

 

 

13.2.3 Parasitic Skin Infections 

Parasiticides

Suitable quantities of Parasiticidal preparations 

  Skin creams   Lotions
 Cream rinses
Scalp (head lice)  -  50-100ml 50-100ml
Body (scabies) 30-60g 100ml -
Body (crab lice) 30-60g 100ml -

These amounts are an approximate guide. Large / tall individuals may require larger quantities.

It is important that all skin surfaces are covered and products should be re-applied after hand washing.

 

Scabies

Treatment:

Permethrin (Lyclear®) 

  • Dermal Cream, 5%
  • Creme rinse, 1%        

Notes: 

  • Alcoholic lotions are not recommended for head lice in severe eczema, asthma or in small children, or for scabies or crab lice. 


When scabies is diagnosed, close household contacts (bed partners and children) will also require treatment. Generally, it requires 5 minutes skin-to-skin contact to acquire the infection.       
The patient is contagious from a few days of acquiring the infection when no signs of the infection may be present. Itching, particularly at night, is the main symptom of scabies in otherwise healthy individuals. It is usually delayed one to two months after exposure except when the patient has been exposed before, in which case itching can start after one week. It is important to advise the patient that itching still occurs after treatment and this does not always imply treatment failure.
It is advised that patients apply treatment before going to bed and leave on overnight. If hands are washed, it is necessary to reapply. It is usually applied below the jaw line and including the soles of feet and genitalia, however, for elderly and the young, it is applied from the head to toes. When applying, work down from the jaw-line to the feet, then sit down and apply to the feet. All household members should be treated at the same time.
Crusted, or Norwegian scabies, affecting mainly immuno-suppressed patients and patients in nursing / residential homes, is more difficult to treat and requires more applications of treatment. 
If an outbreak is suspected in a nursing or residential home, it is important to inform Public Health to look at mass treatment of staff and residents. Unfortunately, sometimes patients receive a steroid preparation for the treatment of itchy skin / rash rather than being correctly diagnosed as scabies.

 

Head and crab lice

Lice eggs hatch within 7-10 days of being laid, then the empty egg cases (nits) move further along the hair shaft as the hair grows out. Lice take about 6-14 days to become fully-grown, after which they are capable of reproduction.
The policy of rotating insecticides on a district wide basis is now considered outmoded. To overcome the development of resistance, a mosaic strategy is required whereby, if a course of treatment fails to cure, a different insecticide is used for the next course.
Treatment should only be considered when live lice are observed on the scalp.


Treatment options:

  • wet combing with a nit comb every 3 days for 2 weeks
  • insecticide – 2 applications used 7 days apart to prevent lice re-emerging from any eggs that survive the first application. (Alternatively, wet combing can be used to check for immature lice before re-application at 3-5 and 10-12 days.)

 

 

Suggested Treatment:

Dimeticone

  • Lotion, dimeticone 4%

Notes: 

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase
  • Dose: Rub into dry hair and scalp, allow to dry naturally, shampoo after minimum 8 hours (or overnight); repeat application after 7 days

 

Malathion

  • Liquid, 0.5% malathion in aqueous basis

Notes: 

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use
  • Indications: Head lice, Crab lice, Scabies
  • Dose: Head lice, rub 0.5% preparation into dry hair and scalp, allow to dry naturally, remove by washing after 12 hours (see also notes above); repeat application after 7 days
  • Dose: Crab lice, apply 0.5% aqueous preparation over whole body, allow to dry naturally, wash off after 12 hours or overnight; repeat application after 7 days

 

Permethrin (Lyclear®) 

  • Dermal Cream, 5%
  • Creme rinse, 1%        

Notes: 

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use
  • Indications: Crab lice, Scabies
  • Dose: Crab lice, adult over 18 years, apply 5% cream over whole body, allow to dry naturally and wash off after 12 hours or after leaving on overnight; repeat application after 7 days
  • Permethrin is effective for scabies and crab lice. It is active against head lice but the formulation and licensed methods of application make them unsuitable for treatment.
  • Alcoholic lotions are not recommended for head lice in severe eczema, asthma or in small children, or for scabies or crab lice. 
  • Crab lice (or pubic lice) can exist in eyelashes, beard hair, axillary hair and the hair on the trunk and limbs, as well as pubic hair. 

 

 

  

13.2.4 Viral skin infections 

 

Aciclovir 

  • Cream 5%        

 Notes: 

  • Aciclovir cream is licensed for the treatment of initial and recurrent labial and genital herpes simplex infection. Systemic treatment is necessary for buccal or vaginal infections.
  • Treatment should begin when the patient is symptomatic (pro-dromal phase) i.e. tingling, but once there is any evidence of a lesion, evidence shows that aciclovir is only as effective as a base cream.
  • Should not be prescribed in Primary Care or at Discharge for herpes simplex virus infections of the lips.
  • Advise patient to purchase.

 

 

Traffic light status explained:

 

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

Return to Chapter: 13. Skin

Last updated by: Dupe Fagbenro on 13-03-2019 09:34