DEPLOYMENT DERMATOLOGY
1. TERMINOLOGY
2. THE DERMATOLOGIC EXAMINATION
3.
ACNE AND RELATED DISORDERS
A.
Acne
B.
Rosacea
C.
Pseudofolliculitis barbae
D.
Acne keloidalis nuchae
4.
ECZEMAS AND DERMATITIS
A. Atopic
Dermatitis
B. Acute
Contact Dermatitis
C. Seborrheic
Dermatitis
5.
PAPULOSQUAMOUS DISORDERS
A. Psoriasis
6.
FUNGAL INFECTIONS
A. True
tineas (dermatophytosis)
B. Tinea
Versicolor
7.
VIRAL INFECTIONS
A.
Warts (common, plantar, flat, genital)
B.
Molluscum Contagiosum
C. Herpes
Simplex
D. Herpes
Zoster
8.
BACTERIAL INFECTIONS
9.
SUN DAMAGE AND SKIN CANCER
A. Actinic
Keratosis
B. Squamous
Cell Carcinomas
C. Basal
Cell Carcinomas
D. Melanoma
10. MISCELLANEOUS
A. Scabies
and other arthropod reactions
B. Keloids
C. Melasma
D. Alopecia
Areata
E. Skin Tags
(acrochordons)
F.
Seborrheic Keratosis
11.
FORMULARY
12.
REFERRAL: WHEN AND HOW
TERMINOLOGY
Macules: flat lesion which differs from surrounding skin because of its color (eg purpura, ecchymoses, lentigenes), < 1 cm in
diameter
Patch: large macules (some use patch to mean a lesion flat with its surroundings but with different texture, eg
tinea versicolor), > 1 cm in diameter
Papules: smaller than 1 cm in diameter, major portion of a papule projects above the plane of surrounding skin.
-Acuminate (pointed)
-Surmounted by scale or keratin
-Dome-shaped
-Flat-topped
-Vegetative (multiple, small, closely packed projections, eg some warts))
-Keratotic
-Maculopapular: an eruption with both macules and papules (eg many viral exanthems); (some consider
“maculopapular” an oxymoron because a single lesion cannot be both a macule and a papule)
Plaques: mesa-like elevation that occupies a relatively large surface area in comparison with its height
above the skin.
Nodules: palpable, solid, round or ellipsoidal lesion larger than a papule.
Wheals: rounded or flat-topped edematous elevated lesion that characteristically disappears within hours.
-Urticaria, dermatographism
Vesicles: circumscribed, elevated lesion that contains fluid, walls are thin (translucent), < 0.5 cm.
Bullae: same as vesicle except size is > 0.5 cm.
Pustules: circumscribed, raised lesion that contains pus.
Erosions: moist, circumscribed, usually depressed lesion that results from loss of epidermis.
Ulcer: lesion which there has been destruction of the epidermis and a least the upper dermis.
Cysts: a sac that contains liquid or semisolid material. Epidermal inclusion cyst (EIC)
Atrophy: diminution in the size of a cell, tissue, organ, or part of the body (dermal or epidermal).
Scars: wherever ulceration has taken place and reflects the pattern of healing in these areas.
Lichenification: thickened plaques with accentuated skin markings from incessant scratching
Sclerotic: circumscribed or diffuse hardening or induration of the skin.
Scale: abnormal shedding or accumulation of stratum corneum in perceptible flakes.
Crusts: results when serum, blood or purulent exudate dries on the skin surface.
Necrotic: dead tissue, usually sharply demarcated, black
Excoriations: superficial excavations of the epidermis resulting in linear or punctate abrasions/ulcerations.
Fissures: linear cleavages or cracks in the skin that are deep and usually painful.
THE DERMATOLOGIC EXAMINATION
History
Complaint
Onset - when and where
Evolution - individual lesions,
spread
Duration
Symptoms - pruritus, pain,
paresthesia
Aggravate/alleviate - seasonality,
menses, temperature, sunlight
Treatment
Prior history
Allergies
ROS
Meds - Rx, OTC, topical, oral
Family - hereditary conditions,
atopy
Exposures - occupational, hobbies,
soaps, travel
Examination
Patient’s general appearance and
temperature
Number of lesions (e.g. single, few,
abundant, innumerable)
Distribution - single, local,
regional, generalized, universal
Primary lesions: macule, papule-plaque, patch, nodule,
vesicle-bulla, wheal,
pustule, telangiectasia,
purpura, cyst
Secondary lesions: crust, weeping,
scale, pustule, erosion, fissure, atrophy, excoriation,
ulcer, lichenified, scarred, sclerosis
Shape - annular, polygonal, round,
oval, arciform, linear, iris/targetoid, umbilicated, reticulate
Arrangement - isolated, scattered, grouped
(herpetiform, zosteriform, arciform, annular, reticulated,
polycyclic)
Borders - serpiginous, discrete,
confluent, demarcated
Color - uniform, variable,
circumscribed, blanching
Pattern- symmetric or not, random (scattered) or
focal (e.g. sites of pressure or exposure, intertriginous, extensor surfaces, follicular, acral, palms
and soles, truncal, extremities)
Palpation - consistency,
temperature, mobility, tenderness, depth
Comment when appropriate on mucosa,
hair, nails, teeth, eyes, joints, lymph nodes, sensation, ability to sweat
Laboratory
examinations
Microbiology - Wood’s lamp, KOH,
Tzanck, gram stain, culture, darkfield, scabies scraping
Blood - RPR, CBC with differential,
immune serologies, chemistries, TFTs
Patch testing
Biopsy
Other - radiographic, stool,
urinalysis
3. ACNE AND RELATED DISORDERS
A. Acne therapy is based largely on what type of primary lesions are present. Acne treatments require weeks to months work.
The complexions of most patients are not affected by diet.
l. Mild acne (mostly comedones – blackheads or whiteheads – and few pustules)
a. Benzoyl peroxide (BP) products qd or bid
b. Topical antibiotics:
(1) Erythromycin 2% solution qd to bid (least expensive) or
(2) Cleocin T solution qd or bid (expensive) or
(3) Sulfacet-R lotion qd to bid.
c. Retin A cream (0.025% gray; 0.05% blue; 0.1% red) or gel (0.01% green - 0.025% red) qhs to qohs.
d. Retin-A and benzoyl peroxide products inactivate each other. Use BP in the AM and Retin-A at night.
Some patients will find it too drying to use both Retin-A and BP.
2. Moderate acne (mostly papules and pustules with few comedones or cysts)
a. Topical regimen as listed above.
b. Oral antibiotics (just one of the following):
(1) Tetracycline 250-500mg PO bid (photosensitivity; may decrease OCP effects; not in kids, pregnancy) or
(2) Erythromycin 250-500mg PO bid (safe in pregnancy; drug interactions; nausea; take with food) or
(3) Doxycycline 100mg PO qd (photosensitivity; nausea; may take with food of) or
(4) Minocin l00mg PO qd (very expensive; may take with food; vertigo; pigmentation) or
(5) Septra DS qd (if nothing else works; many side-effect including rashes and fatalities)
3. Severe (cystic or scarring) acne
a. start with the regimen for moderate acne
b. isotretinoin/Accutane is the treatment of choice but is expensive, has many side effects (birth defects to dryness), and
requires monthly clinical and lab monitoring; usually a 20-week course; needs derm evaluation
4. Acne during pregnancy - can safely use erythromycin (oral or topical) or topical benzoyl peroxide preparations. Tetracyclines and Accutane are contraindicated. Retin-A has not been proven safe in pregnancy.
5. Other points about acne therapy
a. When using Retin-A, tell patients that some people become easily sunburned. Light-skinned patients should use sunscreen daily.
b. Retin-A users need to apply moisturizers as often as necessary for facial dryness. Use simple, inexpensive moisturizers.
c. The patient should not apply Retin-A until the face is dry (20-30 minutes after washing). Use only a pea sized amount of what may to cover the face and forehead. Some redness, trying, and peeling may be expected in the first few weeks of use.
d. Retin-A can be used every other night or stopped for a few days to lessen redness or dryness. Creams are less drying than gels. In arid climates, start with 0.025% cream.
e. Benzoyl peroxide products can bleach clothing and sometimes are not tolerated in people with overly dry or sensitive skin.
f. Advise your patient to be compliant with the medication to get acne under control. It may take up to 3 months before there is significant improvement. During the first few weeks of Retin-A therapy, acne often seems to worsen
g. Use mild soaps (Dove) along with moisturizers to reduce the drying effects of the acne medications.
h. Avoid scrubbing face with harsh cleansers (eg abrasive granules or Buff-Puff)
B Rosacea. Three types: telangiectatic erythema; papulopustular; hyperglandular. First two types often co-exist.
a. Topical metronidazole 0.75% (gel or cream) bid, or Tetracycline 250mg qd to bid or Sulfacet-R daily.
b. Erythema may clear with electodesiccation or newer lasers. Try green-based makeups.
c. Mixed reports on triggering substances (eg alcohol, spicy foods, coffee)
d. In the field, TCN may be the easiest and most effective treatment. (photosensitivity; may decrease OCP effects; not in kids or pregnancy)
C. Pseudofolliculitis barbae
The treatment for PFB in the field is to avoid shaving. Keep the beard trimmed closely (1/4”) with scissors per regulations.
There is some disagreement whether or not a person with PFB fails to get a complete seal when wearing a protective (gas) mask. Sometimes people with PFB are excluded from assignments (e.g. Johnston Atoll) where protective masks are worn regularly.
The approach to PFB in the non-operational setting includes:
1. Let existing bumps clear by not shaving for one month
2. Use a clean needle or tweezers to lift and free (but do not pluck) the ingrowing, buried hairs.
3. Apply a gentle cortisone to relieve inflammation. Try desonide/Tridesilon or HCT 1%.
4. After the old bumps have cleared, try an electric razor especially designed fro black men. This may avoid causing formation of new bumps.
5. If using a blade razor, follow these rules
a. Do not pass over the same area repeatedly
b. Shave in direction of beard growth (with the grain)
c. Clean your skin before and after shaving
d. Never pull the skin tight while shaving
e. Use a Buffpuff or a heavy terrycloth to gently scrub the skin between shaves to free ingrowing hairs
f. Apply HCT 1% after shaving
6. Some men have had success with depilatories, such as Magic Shave, that work by dissolving hair. These must be used when the face is completely dry, not right after washing. Depilatories may be used once every 2-3 days. The directions for use must be followed carefully. Incorrect use of a depilatory can cause painful, irritated skin.
7. Multiple shaving profiles without interruption are permissible. In many individuals, there is no benefit in expecting the service member to repeatedly try to shave to see if the PFB has resolved spontanteously – it doesn’t.
D. Acne keloidalis nuchae (AKN) is a form of scarring alopecia most
common in young black men. It consists of firm folliculocentric keloidal
papules on the occipital-nuchal region. The papules may coalesce into giant
scarring plaques. Etiology is unclear; intuitively one may consider AKN as a
scarring nuchal-located variant of PFB (but demographic and histologic analyses
don’t support this assumption). Most military dermatologists believe AKN is an
inflammatory response to mildly traumatic close haircuts.
Therapy:
1. avoid close haircuts (high-and-tights) on the
nuchal/occipital region. Remind your gung-ho soldiers that 1/4 -
1/2” hair
is perfectly within regulations. Further remind them that the creation of a
permanently disfigured
scalp is
not worth the military glamour of a high-and-tight.
2. oral antibiotics (see 3A2) should be given for
1-2 months for new onset or actively inflamed AKN. Also add
a topical
steroid (Temovate or Synalar scalp solution qd or bid).
3. Hair growth cannot be restored to scarred papules
and plaques. Consider intralesional Kenalog 10-40 mg/cc
IL q 4-6
weeks to soften and reduce these scarred areas.
4. Refer patients to dermatology or plastic surgery
for possible resection of large plaques.
5. Uncommonly a patient is prevented from wearing a
Kevlar helmet because of pain associated with pressure
on the
AKN. This occasionally leads to a medical retention board.
4. ECZEMAS AND DERMATITIS
Eczema = dermatitis. Four components: red, scaly, itchy, vesicles. Vesicles may be clinically obvious (as in poison ivy), or oozing (as in dyshidrotic eczema), or microscopic spongiotic intra-epidermal vesicles (as in nummular dermatitis.
A. Atopic Dermatitis - common, chronic, dry, scaly, itchy eruption on the scalp, face, flexor areas of the extremities, that can also be generalized. This condition is usually worsened by overbathing with drying soaps, or exposure to allergens, chemicals, or wool; and possibly stress.
1. Topical management
a. Limit bathing to brief bath or shower (less than 5 minutes with cool water) once daily or every other day. Explain that the more water that one is exposed to - or the hotter the water - the worse the skin will become.
b. Use a mild soap (Dove, Tone, Basis, Cetaphil). If someone is prone to recurrent impetiginization (superficial bacterial infection) of their skin, an antibacterial soap (e.g., Lever 2000) can be used.
c. Lubricate the skin often. Apply ointments such as Vaseline, Aquaphor, Eucerin, or even Crisco shortening. Creams and ointments are more effective than lotions. The simpler - and often cheaper - the moisturizer, the better (as the addition of fragrances, colorizers, preservatives may irritate the skin)
d. For oozing lesions, first dry out the eruption by using aluminum acetate astringents (Domeboro's soaks) tid. Use two tablets in a quart of warm water and apply with a clean washcloth. Be sure to rinse the skin with plain water afterward to avoid overdrying. Stop using the soaks when the oozing stops. Steroid creams can be applied to oozing areas and ointments may be resumed once the oozing stops
2. Facial eczema
a. 1% hydrocortisone (2.5% HCT or desonide/Tridesilon if eczema is severe) cream bid. Avoid eye contact. The principle is to use mild, non-fluorinated creams.
b. For sensitive facial skin, you can try 1% or 2.5% pramasone lotion (doesn’t contain some of the potentially irritating substances usually found in creams and lotions).
3. Body eczema (avoid intertriginous areas).
a. Westcort or triamcinolone 0.1% cream or ointment (low-mid potency steroid) qd - bid
b. Lidex or Topicort cream or ointment mid-high potency steroid) qd to bid
c. Other topical steroids can also be tried depending on severity and extent of the condition.
d. Systemic steroids - 14 days of tapering prednisone or IM steroids (Celestone and triamcinolone/Kenalog) may help to bring severe eczema under control
4. Antihistamine therapy
a. Sedating. Tell patients about sedative side effects. Some patients find the medications effective even if used only at bedtime.
(1) hydroxyzine/Atarax 10-25mg (higher if necessary) P0 q6 hours PRN or qhs
(2) diphenhydramine/Benedryl 25-50mg PO q6 hours PRN or hs.
(3) chlorpheniramine 4mg PO q6 hours PRN or hs
b. Nonsedating forms: Claritin or Zyrtec (cetirizine; 10mg po qhs).
5. Antibiotics:
a. Systemic - dicloxacillin (Dynapen), cloxicillin, cephradine (Velocef) for staph and strep coverage.
b. mupirocin (Bactroban) ointment tid.
6. Other topical antipruritic preparations one can use prn:
a. camphor/menthol preparations (e.g.Sarna, Sarnol); pramoxine (pramosone, Prax)
b. Vick’s Vaporub or other camphor/menthol products.
c. avoid Caladryl because topical Benedryl portion may cause allergic sensitization.
d. Avoid topical benzocaine because this also induces frequent allergic contact dermatitis
7. Pediatric
Eczema
a. 1% - 2.5% hydrocortisone cream up to desonide/Tridesilon .05% cream to affected areas. May use short courses of higher strength topical steroid but do not use on the face, groin, or armpits for more than one week.
b. Frequent moisturizing is essential.
c. Antihistamine therapy: diphenhydramine or hydroxyzine
d. Oral antibiotics and/or topical Bactroban if secondarily infected.
e. For severe eczema 10-14 days of systemic steroids (prednisolone or prednisone) may bring the patient under control.
8. Many patients use medications properly but don't improve due to excessive bathing with hot water and strong soaps that irritate and dry the partly-healed rash. Skin may worsen because of patients overbathe faster than the medicines can help. Have your patients shower once daily with lukewarm water, using no scrubber or washcloth, use mild cleansers or soaps briefly, pat (rather than rub) dry the skin with a soft towel, and apply the medicine or moisturizer right away to seal moisture into the damp skin.
9. In treating eczema/atopic dermatitis, a realistic goal is to obtain reasonable control, not cure. The patients need to realize that this condition cannot be cured. They must take responsibility for their treatment (i.e. as long as they continue to vigorously scratch and if they do not use their medications as often as they should, their condition will not improve). Stress and anxiety may have significant roles in the persistence and exacerbation of eczema. Patients and physicians often rely on creams and oral antihistamines alone to bring the eczema under control.
This form of contact dermatitis is extremely itchy and often appears in linear streaks. Common causes includes plants, such as poison ivy; rubber and elastic products; nickel and metals with nickel alloys; topical preparations such as fragrances, sunscreens, neomycin/Neosporin products. Begin the treatment by identifying the offending agent, if possible, and removing it. Treatment:
1. Mild - erythema without vesicles
a. Triamcinolone cream 0.1% BID for 7-14 days.
2. Moderate - erythema, vesicles, exudate.
a. Cool tap water or Domeboro compresses tid
b. Apply moderate-to-potent steroid.
3. Severe - widespread with marked edema and bullae:
a. Topical therapy as above.
b. Oral prednisone (lmg/kg/day) tapered over 14-21 days or IM Kenalog (up to 1mg/kg x 1 dose).
c. This can debilitate a soldier for days. Consider admitting severely affected soldiers to your field hospital and dress them in loose clothing (eg a loincloth made of towels or chux).
C. Seborrheic Dermatitis - very common, chronic, dry, scaly eruption on oily areas of the scalp, hairline, ears, forehead, sides of the nose, cheeks, midchest, and midback areas. Commonly confused with lupus erythematosus and rosacea.
1. Topical steroids:
a. Liquid cortisone preparations such as fluocinonide/Synalar bid for 7 days then qohs for scalp involvement.
b. Hydrocortisone 1%-2.5% cream or ointment bid for mild face and body involvement. Moderate strength steroids may be used for two weeks.
2. Shampoos. With all medicated shampoos, keep shampoo on the hair for 15 minutes before rinsing. Shampoos should be used daily for best results. Shampoos can be rotated every 2-3 months if needed to prevent tolerance from developing
a. OTC shampoos
(1) Tar containing - T-Gel, T-Sal, Ionil-T, Pentrax Gold, Polytar, etc
(2) Zinc containing - DHS zinc, Head and Shoulders
(3) Sulfur and salicylate shampoos (or salicylic acid - Ionil Plus)
(4) Selenium sulfide 1% (Selsun Blue, Head and Shoulders (blue bottle)
b. Prescription shampoos - use only if the OTC shampoos fail.
(1) Selenium sulfide 2.5%
(2) ketoconazole/Nizoral shampoo (expensive)
3. Topical antifungals (eg clotrimazole not Nystatin) may be helpful to control Pityrosporum (an organism which may exacerbate seborrheic dermatitis in some individuals)
5. PAPULOSQUAMOUS DISORDERS
Psoriasis is a common, chronic, often pruritic, scaly, erythematous eruption on the scalp, ears, palms, soles, and extensor surfaces of the extremities. Such lesions are caused by rapid growth of epidermis, especially in areas of trauma. This condition varies considerably in its extent (surface area involved and thickness of the lesions), and may be exacerbated by some medications (lithium, beta blockers, antimalarials, and systemic steroids). When uncertain about the diagnosis, check the scalp, behind the ears, fingernails (pitting, yellow spots, nail separating, and subungual debris).
1. Topical steroids
a. Face - 1%-2% hydrocortisone cream or desonide/Tridesilon bid.
b. Scalp - same as for seborrheic dermatitis
c. Trunk, feet, and hands - triamcinolone 0.1% cream bid (mild involvement) to diprosone .05% oint (moderate)
d. Intralesional Kenalog (5-l0mg/ml) can be effective for small plaques.
e. For those patients who do not respond to topical steroids, try applying any mid-potency topical steroid to the trunk or extremity lesions (preferably when they are moist following a shower), then cover it with clear plastic wrap. This occlusive therapy potentiates the topical medicine and if used overnight for up to two weeks, it may help to improve or clear a problem area.
f. DO NOT USE SYSTEMIC STEROIDS.
2. Tar products
a. Scalp - see seborrheic dermatitis. For thicker plaques on the scalp, Baker’s P&S solution may loosen scale.
b. Trunk and extremities - T-Derm, Fototar qhs (warn patients that tars can cause photosensitivity and can stain
cloth)
3. Emollients/Lubricants - use bid to decrease scale on plaques. (Remember: ointments are more effective than creams and creams are more effective than lotions). LacHydrin can help clear silvery scale.
4. For thick plaques, salicylate gel (Keralyt) qd may be helpful.
5. Alternative therapies -- refer to Dermatology to consider Dovonex, anthralin, PUVA, UVB, methotrexate, etc.
This benign but often very itchy eruption is commonly seen in young adults. This typically produces a slightly red or reddish-brown scaly 2-6 cm diameter herald patch followed 2-15 days later by an eruption widespread on the trunk and proximal extremities. Patients with PR remain afebrile and are otherwise healthy. Many variants occur – such as papular PR and intertriginous PR and these may be difficult to diagnose. PR usually occurs in outbreaks – you may see several young people with it in the same week. Because the condition is harmless and its mode of transmission is not clear, we recommend that no precautions are needed.
Treat with topical antipruritic preparations, emollients, or topical steroids. Brief sunlight exposure (but without getting sunburned) is often helpful.
Differentiation from secondary syphilis is important – the
two eruptions can resemble each other. Syphilitics often feel poorly, have
malaise, and low grade fevers. Also
check for presence (or recent history) of genital lesions or other STDs.
Examine for diffuse adenopathy, pharyngitis, palmoplantar lesions, or
oral/genital lesions. Also remember that travel/deployment is a risk factor for
syphilis. Don’t hesitate to order an RPR.
6. FUNGAL INFECTIONS
Fungal infections are frequent problems in deployed soldiers, especially in hot humid climates and when daily hygiene is curtailed.
A. Tinea corporis and tinea cruris are common, chronic, pruritic and scaly fungal infections. Localized, uncomplicated
infections are best treated with twice daily application of a topical antifungal cream (start with miconazole or clotrimazole). Treat affected areas for 2 weeks beyond the point of clinical resolution to prevent relapse. If widespread or very inflammatory, the patient may need griseofulvin 10-l5mg/kg/day (250-750 mg PO for adults) qd with food or milk for 4-6 weeks. Failures occur when fungus is resistant to the medicine, if the fungus has penetrated deep into the hair follicles, or if areas of rash are missed when applying the medicine. If the diagnosis is in doubt, perform KOH scraping at the first visit. Fungus loves to live in areas that are moist so keep the groin and intergluteal areas as clean and dry as possible. Use of a mild steroid like 1% hydrocortisone cream bid for ONE WEEK ONLY may help control the itching while the infection is clearing with the topical antifungal. OTC antifungal powders can help to keep the wetness under control (decrease the frequency of application or discontinue use of this powder once the area has become dry).
B. Tinea unguium is best left untreated in the field environment. Topical preparations will not cure nail infections. You can try 4-12 months of oral griseofulvin (with appropriate follow-ups and lab tests); this will clear fingernail infection about 50% of the time. Itraconazole (Sporanox) and terbenifine (Lamisil) are the most effective oral agents. Itraconazole may be used as follows: itraconazole 200 mg bid for the first 7 days of each month for 3-4 months. The cure rate with this medication is >90% for fingernails and ~75% for toenails. Itraconazole should not be used with the oral antihistamines, Seldane and Hismanal. Also it is best absorbed on an acid stomach so patients should take it with food. Ulcer medications such as Zantac and Tagamet will decrease absorption. The affected nails should be trimmed and filed regularly. Itraconazole and Lamisil cost several hundred dollars pre regimen so one’s P&T Committee may wish to adopt guidelines for their use.
C. Tinea capitis has two common forms. “Black-dot ringworm” is a scaly plaque with alopecia and shows abundant hairs broken off at skin level, creating “black dots.” A kerion is a boggy inflamed, potentially-scarring plaque usually in kids. Treat both with griseofulvin (taken with meals) for approximately 6-8 weeks. Topicals will not work. Separate comb and face towel from those of other family members. Boggy kerions may require short course of prednisone to decrease inflammation and reduce risk of scarring alopecia. Antibacterial antibiotics are not needed. Monitor for relapses. Consider referring children with kerions to Dermatology.
D. Tinea Versicolor appears as light to dark brown, fine powdery scaly discrete and coalescent macules on the back, neck, chest, shoulders, and upper arms. This condition is due to a type of fungus that is a part of the normal skin flora and can recur in hot, humid conditions. It is harmless and probably does not require treatment, nevertheless, TV is perhaps the major complaint of healthy patients. Have patient apply Selsun-type shampoo from the neck down to the waist and also to the arms 15-20 minutes prior to daily showering for one week then repeat weekly for the next month. Clotrimazole bid for 3 weeks. Oral ketoconazole 200mg PO qd for one week is very effective (caution: interaction with some oral antihistamines). Remind patient that, even if treated perfectly, TV will leave abnormal pigmentation for another month beyond cure. Relapses are inevitable so I treat this condition reluctantly when on MEDRETEs.
E. Macerated tinea pedis is a painful inflammatory disorder, usually caused by a polymicrobial (dermatophyte and mixed bacterial) infection. It appears as white, gooey cakes in the webspaces of toes.
1. First clear the macerated inflamed tissue and then treat the underlying fungal infection. For 1-2 weeks, use an anti-infective astringent (such as colorless Castellani’s paint or gentian violet) tid. Other drying solutions include teabag soaks (two teabags steeped in 6 oz of water and liquid allowed to cool), dilute vinegar, or Domboro’s (aluminum acetate) soaks. When using Domeboro, rinse surface with plain water afterwards. After the astringnet has dried, followed by Vioform HC (a cream that combines HCT 1% and a mild antibiotic). On the subsequent visit, start the directed antifungal therapy.
2. Prevention: allow feet to dry completely when the situation permits. Put on dry socks at mid-day and change shoes or boots daily. Wear sandals (eg Teva) if conditions (tactical, insect, vegetation) permit. Consider antifungal foot powders.
7. VIRAL INFECTIONS
Warts
A. Common warts
Usually respond to multiple freezings with liquid nitrogen (but can be very resistant to treatment if located on the palms, soles, and in periungual and subungual locations). Freeze time (amount of time white frost remains on the warts following application of liquid nitrogen) may need to be 15-30 seconds and two separate freeze-thaw cycles may need to be done per session. Patients should be informed of possible blister formation (even blood blisters) following the treatments and care of the treatment site (keeping it clean, applying antibiotic ointment if needed, and sterile puncturing the blister if necessary). Topical acid preparations include salicylate and lactic acid preparations (Occlusol HP, Duofilm, Transversal, and Mediplast). As with all topical acid preparations, the patients/parents must be very patient and conscientious about applying the medication daily. Podophyllin 25% and cantharone preparation are also effective. Occasionally you may choose to pare down a wart with a scalpel blade (particularly painful, hyperkeratotic plantar warts) but avoid surgery and electrocautery of warts as this is painful, rarely effective, and may lead to scars that are worse than the warts.
B. Flat Warts- Common in children and young adults. Lesions appear as small, flat-topped, skin-colored papules and are often found on the face, hands, arms and legs. Forms of treatment include liquid nitrogen, Retin-A 0.1% cream qhs. In children Retin-A can work quite well and leave little scarring, however, it is slow.
C. Plantar warts
1. Similar approach as for common warts. Avoid long freezes as this may impede walking and running.
D. Venereal Warts
1. Podophyllin - most effective on moist, mucosal lesions. Apply podophyllin 25%-40% (usually mixed in tincture of Benzoin) directly to condyloma with a cotton-tipped applicator. Instruct patient to wash off well in 8 hours. Patient should follow routine hygiene afterwards, refrain from intercourse for several days, and use condoms to diminish risk of spreading the wart
2. Liquid nitrogen is another treatment
3. Soldiers who are deploying or who are unable to return for regular follow-up may use Condylox (podofilox), a purified dispensable version of podophyllin. Apply per directions.
4. Ask the patient to inform the partner(s) so that they may seek care. Gynecologists are better able than dermatologists to provide care for genital warts in women Remind the patient that genital warts take a number of treatments before clearing and still, many patients have genital warts for a lifetime.
5. Consider a history, examination, and testing for other STDs.
6. Advise the use of condoms
E. Molluscum Contagiosum - Common viral infection in children and in immunocompromised individuals. Any procedure that gently removes/expresses core of the lesions can be effective. Such treatments include light liquid nitrogen application, topical agents such as Keralyt gel (salicylate gel), Duofilm (lactic acid/salicylic acid), podophyllin. In some areas, such as the eyelids in small children, observation only may be prudent since lesions may be self-limited. Cantharidin (in Cantharone or Cantharone Plus) can be very carefully placed on individual lesions, allowed to dry, then covered with tape for 12 to 24 hours. The treated sites will blister, so discuss blister care with the parents (keeping the treated sites clean, apply antibiotic ointment twice a day, etc). Most of the time, only one treatment is necessary. Most children experience little or no pain from the treatment but may be annoyed by the abundant small blisters. Do not place this medication on areas of normal skin (apply only to the lesions) and NEVER dispense the medication for home use.
F. Herpes simplex
G. Herpes zoster.
8. BACTERIAL SKIN INFECTIONS
Bacterial infections of the skin can spread rapidly on an infected individual and can spread rapidly to other previously-uninfected individuals.
1. Impetigo is a bacterial infection confined to the epidermis. It is usually caused by Strep, Staph, or both organisms. Lesions can be dried with Burow’s soaks, vinegar soaks, Castellani’s paint, or gentian violet. Antibacterial treatment can be topical (e.g., Bactroban/mupirocin tid for one week) or with oral anti-Staph antibiotics. This rapidly spreading contagious condition should be treated. Complications: progressions to ecthyma (scarring bacterial infection of the skin); post-streptococcal glomerulonephritis
2.
Ecthyma occurs when the
infection goes below the epidermis and into the dermal collagen where scarring
may occur. Impetigo may lead to Ecthyma. Treatment is with oral antibiotics or,
if mild, mupirocin.
3. Furuncles and carbuncles are types of boils. Furuncles are single lesions and carbuncles are several boils that have coalesced through dermal communications. They are usually red, warm, and tender. If lesions are mature (firm and globose), treatment is incision and drainage. The site is left open (unsutured) and is often packed with sterile gauze (e.g., Iodoform gauze packing) that is replaced daily for several days.
4.
Erysipelas
5.
Cellulitis
6.
Paronychia
7.
Necrotizing fasciitis is a
surgical emergency.
9. SCABIES
1. Sarcoptes scabiei is a minute mite that infects only humans. It is transmitted by close contact amongst children, period may be
4-6 weeks before itching begins. In adults, there may be co-existing STDs.
2. Scabies lesions are polymorphous and can have papules, vesicles, crusts, excoriations, and secondary pyodermas in addition to the classic burrows. The distribution is a symmetric eruption of pruritic lesions, most often on finger webspaces and volar wrists. Penis, nipples, and axillae are commonly involved. It generally spares the face and scalp in adults but may in infants.
3. Nodular scabies occurs on male genitalia and appears as an itchy indurated 4-6mm diam papule without an obvious burrow. This lesion, in combination with the hand lesions, is virtually diagnostic of scabies. Crusted scabies is a generalized psoriasiform dermatosis caused by scabies that occurs most commonly in immunocompromised or mentally-debilitated persons.
4. The diagnosis is from classic presentation or with a positive scraping that shows a mite or egg.
5. Treatment consists of Permethrin cream 5% (Elemite) applied to all areas of the body from neck down and washed off after 8-14 hours.
6. Alternative regimens include lindane 1% (Kwell) (1 oz of lotion or 30 gm of cream) applied thinly to all areas of body from neck down and washed off thoroughly after 8 hours. One may also use crotamiton 10% (Eurax) applied to entire body from the neck down, nightly for 2 consecutive nights, and washed off 24 hours after the second application.
7. Apply medication to all surfaces, not just affected areas. Rub it under fingernails, too.
8. Permethrin is now the drug of choice because it is virtually free of side effects and because there is resistance to the other two medication. Permethrin and crotamiton are safe in children and pregnant women. Lindane may be neurotoxic in children and fetuses and may cause aplastic anemia.
9. Bedding and clothing should be washed and dried on a hot-cycle or removed from body contact for at least 72 hours.
10. Retreatment is probably not necessary when using permethrin. Nevertheless, I usually recommend retreatment after one-week. It may be overkill but it gives patients peace-of-mind.
11. Pruritus will persist for about 2-3 weeks because the dead mites remain in the stratum corneum for that long and continue to elicit an itch response. Consider adding Sarna or a topical corticosteroid, such as desonide, to help control itching.
12. Treat secondary bacterial infections with dicloxacillin or a similar anti-Staph/Strep antibiotic.
13. Notify sexual partners, close household contacts, and daycare centers as appropriate.
10. SUN DAMAGE, SKIN CANCER, AND SUNSCREENS
A. Actinic keratoses are very common in older Caucasians. Chronic, small, indistinct, scaly or raspy, pink to red-brown, easily irritated patches of papules (which can bleed when traumatized located on sun exposed areas (most notably on the bald scalp, ears, face, chest, shoulders, back, arms, and dorsal hands. These lesions are often treated at the primary care level. Liquid nitrogen applied for approximately 3 to 10 seconds or longer can be effective (longer application times are used for the thicker lesions).
The treated sites usual heal in about 2-3 weeks. Some lesions may require `several treatments (especially if the patient has a habit of constantly picking at the lesions).
B. Squamous cell carcinomas are indurated papules, plaques, and with thick keratotic scale and are often crusted, eroded, or ulcerated and are more apt to bleed. SCCs occur most commonly on ears, lips, and dorsal hands. They don't respond well to liquid nitrogen. These require biopsy and surgical excision.
C. Basal cell carcinomas are the most common skin cancers. The most common appearance is pink to reddish, pearly, somewhat translucent appearing papules and nodules, with rolled borders and fine telangiectasias and frequently ulcerate and bleed.
D. Melanoma
1. Use the ABCDs to recognize suspicious lesions. These guidelines are good but not perfect. The diagnosis suspected on a clinical basis but made on histopathology. A biopsy is necessary to establish the diagnosis.
2. Presence or absence of melanoma characteristics:
a. Asymmetry
b. Border irregularity
c. Color variety
d. Diameter (greater than 6mm)
3. When normal moles mature (grow and change) they can undergo some changes that are not signs of malignancy.
Congenital moles are often much larger than 6mm.
E. Sunscreens
Until recently, sunscreens blocked only UVB, the wavelength associated with most skin cancers. UVB levels peak at mid-day. Newer sunscreens also block UVA that causes skin aging and photodermatitis. UVA levels are high all day. I recommend that Caucasians use a UVA/UVB sunscreen that is PABA-free. Most sunscreen agents can cause some allergic reactions but PABA causes the most. Titanium dioxide is free of side effects and may be the best one to use on the face but it is fairly expensive.
11. MISCELLANEOUS
Seborrheic keratosis and skin tags (acrochordons) are usually of cosmetic concern only. Treatment is often unnecessary although reassurance may be required. Skin tags (which are very common benign small tabs of skin usually found on the neck, axillae, and groin) can be effectively removed with liquid nitrogen, a pair of scissors (followed by application of Drysol/aluminum chloride or Monsel's/ferric chloride solution to stop the bleeding), or via light electrodesiccation. These procedures are very simple. Seborrheic keratoses are common, harmless, brown, verrucous to velvety surfaced, "stuck-on" appearing papules located most commonly on the sun exposed areas and the trunk. These can be effectively treated with liquid nitrogen or light curettage.
Keloids are firm scars that extend beyond the margins of the original trauma or incision. Try intralesional Kenalog 10 to 40 mg/cc to decrease itching, tenderness, and to soften the scars (usually every 4-6 weeks for 4-6 months). Can also try strong topical steroids. Monitor for skin atrophy. Excision is risky as subsequent scar may form even larger keloid. There have been attempts to use laser surgery or to apply silicone sheeting to the excisional wound to reduce the regrowth of keloids but the verdict is not in.
Melasma (or chloasma) is a symmetric, patchy, brownish, macular facial hyperpigmentation. It occurs most commonly in women with a medium skin coloration, such as women with an Asian or Hispanic background. Melasma often arises during pregnancy or from female hormone therapy (eg OCPs or supplemental estrogen). Can try OTC or prescription bleaching agents (Esoterica, Porcelana, Melanex, Eldopaque, Viquin Forte, or Solaquine) that contain hydroquinone 2%-4% qhs for 3 months or longer. Patients need to be very conscientious about daily sun protection. The Kligman formula combines hydroquinone, tretinoin cream and a cortisone. Try Eldopaque 4%, Retin-A 0.1% cream, and HCT 1% cream. Apply pea-sized tabs of all three to one’s palm, mix together, and apply to affected areas. It may take 3-4 months to see improvement. Not all patients are helped, especially if the pigment is incontinent (i.e. dropped below the epidemris into the dermis). WARNING: some people experience a paradoxical darkening (ochronosis) from the hydroquinone so advise (orally and on your notes) that the patient test the hydroquinone alone on the inner biceps qhs for two weeks as a test site before using it on the face.
Alopecia areata is a common circumscribed area of hair loss on the scalp or face. It is uninflamed and non-scarring. Occasionally linked with autoimmune conditions, especially thyroid disorders. Can be progressive. If the occiput is involved, this suggests a poor prognosis. Can use topical Lidex solution or gel bid or intralesional steroids (Kenalog 5mg/ml in small amounts injected every 4-6 weeks. If there is erythema, scale, folliculitis, bogginess, purulence, or scarring, refer the patient to dermatology. Patients may report that the area of alopecica is tender. (See handout.)
12. ULCERS IN YOUNG ADULTS
If ulcers occur on pressure sites (such as the sole), determine whether a peripheral neuropathy exists. Check sensation, muscle strength, and look for signs of muscle wasting. The two most common causes of neuropathy that lead to ulcers are Hansen's disease (leprosy) and diabetes.
Causes of genital ulcers include primary syphilis (chancre), chancroid, HSV. Causes of ulcers elsewhere include ecthyma (common pyoderma that goes into the dermis), leishmaniasis. Cutaneous inoculation anthrax and diphtheria, brown recluse spider bites, and rickettsially-infected tickbites can form ulcers with black or necrotic surfaces. Other causes of ulcers include an ectopic syphilitic chancre, myiasis, Buruli ulcer and tropical phagedynic ulcer, trauma, sickle cell disease, BCC, pyoderma gangrenosum, necrotizing erythema multiforme, emboli, and of course the more common vascular ulcers (arterial and venous stasis).
13. REFERRALS: WHEN AND HOW
PROMPT REFERRALS
Referrals should be made promptly for biopsy of suspected melanoma or for evaluation of widespread blistering disorders; petechiae or purpura with hypotension, fever, or renal failure; ulcers with fever; buboes.
On the consultation request form, please write legibly and include the following information:
1. Extent, duration, description (size, color, shape, etc.), and location of the lesion/ problem.
2. Your differential diagnosis.
3. Pertinent related history or physical findings.
4. Pertinent medications and diseases.
5. Current and previous therapeutic attempts (i.e. acne medications, topical steroids for eczema, Occlusol
solution for warts, etc
ROUTINE REFERRALS
Recalcitrant acne or Accutane evaluation
Children with kerions
14. SEXUALLY TRANSMITTED DISEASES
syphilis
gonorrhea
chlamydia
HSV
condyloma acuminata
chancroid
scabies
15. FORMULARY
1. Oozing lesions should be dried with an astringent such as Domeboro's soaks (aluminum acetate). Gentian violet and Castellani’s paint are excellent astringents and anti-infectives. Application of a dab of GV is the simplest way to treat masses of kids with infected insect bites on the legs. Inform the parent that GV can stain when it is wet (but once dry, it will be a memento of the kid’s visit to the doc).
2. Open sores, ulcers, and infected insect bites can be disinfected with Castellani’s paint, gentian violet, or potassium permanganate.
3. Use creams rather than gels or ointments on open oozing lesions, such as an acute contact dermatitis.
4. Neomycin is a good broad-spectrum antibiotic but it induces a contact allergy in 10% of patients so I recommend avoiding it.
5. Vaseline and Crisco shortening are the cheapest effective moisturizers.
6. Refer to Sanford’s antibiotic guide.
ANTIFUNGALS
1. Nystatin will treat only candida infections (but not dermatophyte or tinea versicolor).
2. Griseofulvin will treat only dermatophytes (such as tinea corporis but NOT tinea versicolor).
3. Azole creams will treat candida, dermatophytes, and tinea versicolor.
4. Griseofulvin can be taken in large doses taken once daily. It is best absorbed with fatty food (whole milk, cheese, or meat -- not necessarily fried chicken and potato chips). Ketoconazole (oral) is very expensive; rare cases of fatal drug-induced hepatitis; and interacts adversely with several medications. I recommend not using it for tinea versicolor and mild dermatophytoses.
5. Topical ketoconazoleis also expensive and should be the topical antifungal of last resort. Use clotrimazole or miconazole instead.
6. Topicals to avoid include topical Benedryl, Caladryl, and neomycin/Neosporin.
CORTICOSTEROID STRENGTHS
CLASS I
diflorasone diacetate 0.05% ointment Psorcon
clobetasol propionate 0.05% cream, ointment Temovate
betamethasone dipropinate 0.05% cream, ointment Diprolene
CLASS
2
amcinonide 0.1% cream, ointment Cyclocort
fluocinonide 0.05% gel Lidex
desoximetasone 0.25% cream, ointment Topicort
halcinonide 0.1% cream, ointment Halog
fluradrenolide tape Cordran
fluocinolone acetonide 0.2% cream Synalar HP
betamethasone dipropionate 0.05% ointment Diprosone
CLASS 3
triamcinolone 0.5 cream, ointment TAC, Kenalog, Aristocort
fluticasone propionate 0.005% ointment Cutivate
betamethasone dipropionate 0.05% cream Diprosone
CLASS
4
triamcinolone 0.25 cream, ointment TAC, Kenalog, Aristocort
hydrocortisone valerate oint Westcort
mometasone furoate 0.1% cream, ointment Elocon
CLASS 5
triamcinolone 0.1% cream, ointment TAC, Kenalog, Aristocort
hydrocortsone valerate cream Westcort
betamethasone valerate 0.1% cream, ointment Valisone
desoximetasone 0.05% cream Topicort
fluocinolone acetonide 0.05% cream Synalar
halcinonide 0.025% cream Halog
fluticasone propionate 0.005% cream Cutivate
CLASS
6
aclometasone 0.05% cream, ointment Aclovate
desonide 0.05% cream, ointment Tridesilon, Desowen
fluocinonide acetonide 0.01% cream Synalar
hydrocortisone 2.5% cream, lotion, ointment Hytone
CLASS 7
hydrocortisone 1% cream
other topicals with dexamethasone, flumethalone, methylprednisolone, and prednisolone
16. STATUS OF DERMATOLOGY IN THE DEVELOPING WORLD
The world's dermatologists are
distributed inequitably. More than 3 billion people in over 125 countries lack
access to basic dermatologic care. Not only are communities lacking the
expertise of dermatologists, but the shortage can be measured in entire
nations, or even in portions of continents.
Dermatology in developing
nations typically includes four subdisciplines: general dermatology, leprology,
venereology, and HIV-associated diseases. The term
"dermatovenereology," once applied to our entire specialty, is still
used in many nations. Sexually transmitted diseases (STDs) still compose a
large part of the dermatology practice in the developing world.Syphilis,
chancroid, and granuloma inguinale-- uncommon in most Western practices--are
hyperendemic in some regions. Dermatologists are often the primary doctors for
HIV-infected patients in the same manner that we once cared for patients with
syphilis, even though the major morbidity involved organs other than the skin.
Leprology comprises far more than simply making a diagnosis and initiating
therapy. Leprologists also manage reactional states, ensure compliance with
therapy, and devise rehabilitation programs. Some dermatoleprologists perform
complex procedures such as tendon transfers, management of ocular
complications, and debridement of infected bone.
HIV infection has had a
devastating effect on some nations. The high prevalence of infection has caused
catastrophic changes in demographics, economics, and social structure.
Individuals with the cutaneous
hallmarks of advanced HIV infection may seem ubiquitous
in some countries.
When patients refer themselves
to your clinic, the acuity and the complexity of the skin conditions diminish.
Several studies in rural tropical settings, as well as in unpublished data,
show that the leading reasons for self-referral are, in order: eczema,
infestations (especially scabies), tinea versicolor, pyodermas,
dermatophytosis, acne, and pigmentary disorders (such as
pityriasis alba, vitiligo, and melasma) (Table 2) .
Most of what you see might be described as primary care
dermatology. Teach your local colleagues who remain in country how to manage
these conditions.
In many countries, patients
with disorders of hypopigmentation, ranging from the trivial (pityriasis alba)
to the nearly untreatable (vitiligo), are seen in disproportionately high
numbers. In many tropical areas, light-colored spots confer the diagnosis and
stigma of leprosy. An important part of treating these patients (and their
parents) is to assure them that these hypopigmented conditions are not leprosy.
Decide before the trip how you
will manage innocuous and common concerns. For example, tinea versicolor is
nearly universal in humid tropical areas. Does it deserve to be treated? Should
you use limited supplies to treat a harmless and quickly recurring condition?
Will treatment of these conditions meaningfully improve the health of the local
population? If your organization's goal is to dispense goodwill, then you may
wish to treat the condition. If you must ration your goods and services, consider
not treating tinea versicolor with topical antifungals or mild acne with oral
antibiotics and the like.
Scabies for example is
hyperendemic in many societies. There have been several attempts to develop
community scabicidal programs with troughs of scabicides
such as benzyl benzoate or a lindane slurry into
which people would immerse themselves. These programs
have proven unsuccessful as customs of modesty and hygiene, as well as sex
restrictions, menstrual taboos, and class distinctions, make the sheep dip
approach to treating scabies unacceptable. Recent
scabies eradication programs that use a single oral dose of ivermectin appear
to be both more effective and more acceptable.
This table lists the most commonly seen skin diseases in
rural areas of tropical developing nations.
Urbanization, prosperity, and higher latitude will alter
the mix.
Eczema and
dermatitis
Often secondarily infected
Infestations Scabies and headlice; often
secondarily infected
Tinea (pityriasis)
versicolor Nearly universal in some populations
Pyoderma Primary infections or secondary infected sites
Dermatophytosis
Acne vulgaris
Pigmentary disorders Often pityriasis alba, melasma, and
vitiligo
You may need to become familiar
with medications that you may have never used before. Some are standard outside
the US (such as Whitfield's ointment for dermatophytoses); some are
underappreciated in the
US (such as oral rehydration salts); and some are nearly
forgotten in the US (such as chloramphenicol).
Bring along a pocket antibiotic guide (such as Sanford's
Guide) to refresh your memory on the spectra of
activity for various workhorse antibiotics.
WHO recommends that nations
establish lists of essential drugs "that satisfy the health needs of the
majority of the population; they should therefore be available at all times in
adequate amounts and in the appropriate dosage forms." More than 120
nations have created such essential drug lists (EDL). Countries without EDLs are
often developed nations whose pharmaceutical industries discourage such
economic parochialism. Therefore it is likely that any country that might need
humanitarian assistance already has an EDL. WHO recommends criteria for
selecting medications on the EDL and has created a model list but each country
is free to compile its own list. The dermatologic formulary in many developing
countries consists mostly of inexpensive medications that have long
shelf-lives. Many of these, such as gentian violet, are purchased in bulk and
are compounded locally. The topical agents found in the WHO's model EDL that
lists other items that are customarily used by dermatologists are as follows:
Whitfield's ointment or cream
miconazole cream *
sodium
thiosulfate
selenium sulfide
gentian violet *
neomycin/bacitracin *
silver sulfadiazine
betamethasone valerate cream *
hydrocortisone acetate cream *
calamine lotion *
ASTRINGENT DRUGS
aluminum diacetate
KERATOPLASTIC AND KERATOLYTIC DRUGS
benzoyl peroxide
coal tar
dithranol
fluourouricil
podophyllum resin *
salicylic acid solution
urea
SCABICIDES AND PEDICULICIDES
benzyl benzoate
permethrin
ULTRAVIOLET-BLOCKING AGENTS
benzophenones, SPF-15 *
zinc oxide *
* example of a therapeutic group
[Adapted from the World Health Organization: The Use of
Essential Drugs, ed 7. WHO Technical Report 867, Geneva, 1997.]
Do not expect to prescribe
medications as you would in a developed nation. Review therapies from the New
Emergency Health Kit (later in text), the model EDL, and similar guidelines
before your trip: gentian violet, potassium permanganate, crystal violet, and
chlorhexidine for impetigo and secondarily impetiginzed lesions; lindane (gamma
benzene hexachloride), benzyl benzoate, and sulfur preparations for scabies;
coal tar and salicylic acid preparations for psoriasis; Whitfield's ointment
for dermatophytosis; and sodium thiosulfate for tinea versicolor.
To overcome the chaos of
poorly coordinated drug supplies, the WHO developed the New Emergency Health
Kit (NEHK). This is a standardized list of medical supplies and pharmaceuticals
adopted by WHO and dozens of NGOs as a "reliable, standardized,
inexpensive, appropriate, and quickly available source of the essential drugs
and health equipment urgently needed in a disaster situation." The NEHK is designed to address the needs of
a disrupted or displaced population of 10,000 for 3 months after the acute
emergency phase of a natural or manmade disaster. These guidelines, of course,
will be influenced by the nature of the disaster, causes of morbidity and
mortality, demographics of population, climatic factors, and customary medical
standards.
The NEHKs basic unit includes only
a few items that are used to treat skin diseases. The NEHKs
supplementary unit contains an additional dozen or so
dermatologic medications. Treatment guidelines for skin conditions accompany
the NEHK and are found in the second table.
Quantity Basic unit Comments
Benzyl benzoate, lotion 25% 1-L bottle dilute if in a stronger concentration
Chlorhexidine 5% 1-L
bottle dilute if in a stronger
concentration
Gentian violet, powder four 25 g units needs
reconstitution
Sulfamethoxazole/trimethoprim 400/80
mg 2000
tabs
Tetracycline eye ointment 1% in 5 gm tubes 50 tubes
Mebendazole, aspirin, paracetamol
acetominophen
Antibiotics
Ampicillin,
250-mg tablets 2000
Ampicillin, 500-mg vials
200
Penicillin
benzathine, 2.4-mU vials 50
Penicillin
procaine, 3.4-mU vials 1000
Chloramphenicol,
250-mg capsules
2000
Chloramphenicol,
1-g vials
500
Nystatin,
100,000 IU tablet 2000
Tetracycline,
250-mg capsules 2000 for cholera and chlamydial infections
Corticosteroids
Dexamethasone (injectable)
Prednisolone
(oral)
Topicals and miscellaneous
Povidone
iodine 10% solution
four 500-mL
bottles not tincture of iodine
Zinc
oxide 10% ointment two 1-kg tubs
Benzoate
6%/salicyate 3% ointment one 1-kg tub known
as Whitfield's ointment
Lidocaine
Practice universal precautions
just as you would in your home country. Insist that your assistants adhere to
appropriate precautions. At your field site, establish a hazardous waste
disposal point and use a red
biohazard bag or identifying tape to mark the site. Discard sharps into suitable puncture-resistant, leakproof
containers. I try to bring sharps containers with me but
have used plastic jugs with biohazard warning labels attached. Dispose of the
used containers properly.
Nutritional deficiencies are
common in some parts of the world, particularly among displaced people and
refugees. Scurvy, hypovitaminosis A, and pellagra, have afflicted up to 20%,
7%, and 6% of displaced populations in Africa, respectively. The diagnosis of
many of these conditions can be made dermatologically but the morbidity and
mortality of these conditions is with co-existent infections such as measles,
diarrheal diseases, and malaria. If one
becomes involved in the care of refugees, realize that one-on-one care that is
customary in developed nations is by necessity subordinated to the collective
health needs of the community.
“Simple
guidance for the training of primary health care workers using the basic unit.”
[Adapted from
the World Health Organization: The New Emergency Health Kit. WHO/DAP/90.1.
Geneva, 1990.]
Wounds:
extensive, deep, or on face Refer
Wounds: limited and
superficial Clean
with clean water and soap or with diluted chlorhexidine solution. Apply gentian
violet daily
Burns:
extensive, severe, or on face Treat
as for mild burns and refer
Burns:
mild or moderate Immerse
immediately in cold water or use a cool compress.
Continue until pain eases
then treat the wounds.
Bacterial
infection: severe or febrile Refer
Bacterial infection: mild Clean with
clean water and soap or with diluted chlorhexidine solution. Apply gentian
violet twice daily. If not improved after 10 days, refer.
Fungal
infection Apply
gentian violet daily for 5 days.
Scabies,
non-infected Apply
benzyl benzoate
Scabies: infected Treat
mild bacterial infection as above. When infection is cured, apply benzyl
benzoate.