Macules and papules

DRUG REACTIONS

L27.0

Commonly associated with:

  • sulphur-containing agents,
  • penicillin,
  • anti-epileptics (e.g. carbamazepine, lamotrigine),
  • NSAIDs,
  • anti-tuberculosis drugs, and
  • non-nucleoside reverse transcriptase inhibitors.

A variety of rashes may occur, including:

  • erythema multiforme (see: Erythema Multiforme),
  • uriticarial eruptions,
  • measles-like maculopapular rash, or
  • fixed drug reactions, which are flat or slightly raised, symmetrical patches of < 0.5cm in size.

Lesions recur upon re-exposure to the causative agent and may present as blisters.

GENERAL AND SUPPORTIVE MEASURES

  • Stop causative agents.

MEDICINE TREATMENT

Antihistamines:

For children 2 years and older:

  • Cetirizine, oral, as a single dose.
    • Children 2 - 6 years: 5 mg.
    • Children 6 - 12 years: 10 mg.

LoEIII [4]

For children less than 2 years:

  • Chlorphenamine, oral, 0.1mg/kg/dose as a single dose at night. (Maximum 4mg).

Where the oral route cannot be used:

  • Promethazine, IV, 0.1 mg/kg/dose 8–12 hourly. (Maximum 25mg).

REFERRAL

  • Systemic involvement with organ dysfunction.

ACNE

L70

DESCRIPTION

An inflammatory condition of hair follicles leading to comedone formation that can cause scarring and post inflammation hyper-pigmentation.

DIAGNOSTIC CRITERIA

  • Black or white heads (comedones).

GENERAL AND SUPPORTIVE MEASURES

  • Avoid greasy and oily topical products.
  • Discourage excessive facial washing.

MEDICINE TREATMENT

  • Doxycycline, oral, 100 mg once daily for a maximum of three months.

If ineffective, after 3 months:
To limit skin irritation, introduce topical retinoids, gradually at night.
Topical retinoid, e.g.:

  • Tretinoin cream/gel 0.05%, topical, applied sparingly once daily at bedtime until substantial improvement.
    • Avoid contact with eyes and mucous membranes.
    • To prevent irritation, introduce tretinoin gradually - apply on alternate days for 1 - 2 weeks.
    • Limit exposure to sunlight, especially with concomitant use of doxycycline.

Tretinoin is teratogenic.
Do not use where pregnancy is a possibility.
If used, ensure adequate contraception.

Teratogenic risk also applies to males.

To avoid sun irritation:

  • Sunscreen, topical, applied daily.

REFERRAL

  • Recalcitrant and/or fulminant acne.
  • Psychologically disturbed or depressed patient.
  • Young females with premenstrual flare or with clinical signs of hyperandrogenism for consideration of oral contraceptives.

CELLULITIS AND ERYSIPELAS

L03.9/A46

DESCRIPTION

Infection of the skin and subcutaneous tissue usually caused by streptococci, staphylococci or H. influenzae . In cellulitis, the border of the lesion is indistinct.

Erysipelas

The affected area is:

  • well demarcated with clear borders,
  • very tender and warm,
  • bright red and swollen.

Erysipelas must be distinguished from necrotising fasciitis, where there is infection and inflammation by a gas-forming organism that spreads rapidly along the fascial tissue.
Complications include septicaemia.

DIAGNOSTIC CRITERIA

  • Acutely ill child with fever and malaise.
  • Affected area is swollen, indurated, erythematous and tender, with regional lymphadenopathy.

GENERAL AND SUPPORTIVE MEASURES

  • Ensure adequate nutrition and hydration.
  • Elevate the affected limb to reduce swelling.
  • Exclude eczema, immunocompromised state, diabetes and underlying osteomyelitis.

MEDICINE TREATMENT

Choice of intravenous or oral antibiotics depends on the severity of the condition.

Severe disease

  • Cloxacillin, IV, 50 mg/kg/dose 6 hourly for 5 days.

Non-severe disease

  • Flucloxacillin, oral, 25mg/kg/dose 6 hourly for 7 days

LoEIII [1]

  • OR (if flucloxacillin is unavailable)
  • Cephalexin, oral, 12.5–25 mg/kg/dose 6 hourly for 7 days.
    • Child < 2 years: 125 mg.
    • Child 2–10 years: 250 mg.
    • > 10 years: 500 mg.

Penicillin allergy
Macrolide, e.g.:

  • Azithromycin, oral, 10 mg/kg/day, for 3 days.

For pain:

  • Paracetamol, oral, 15 mg/kg/dose, 6 hourly as required.

If needed ADD

  • Ibuprofen, oral, 5–10 mg/kg/dose, 6-8 hourly for 72 hours.
    • Child < 30 kg, maximum dose: 500 mg/day.

REFERRAL

  • Urgent: necrotising fasciitis.
  • Poor response to therapy.
  • Recurrent cellulitis.

ECZEMA

L20.9

DESCRIPTION

An inflammatory itchy skin condition characterised by:

  • Vesicles, weeping and crusting during the acute stage.
  • Scaling and lichenification during the chronic stage.

DIAGNOSTIC CRITERIA

  • Family history of allergies.
  • Reaction after exposure to allergens.
  • Typical distribution: face, flexures of knees and elbows, and creases of neck.

GENERAL AND SUPPORTIVE MEASURES

  • Avoidance measures: use neutral soaps and rinse clothes properly after wash.
  • Keep fingernails short to prevent scratching.
  • Wrap with dressings soaked in sodium chloride 0.9%.
  • Avoid sunlight and recommend use of sunscreen.

MEDICINE TREATMENT

Antihistamine

For children 2 years and older:

  • Cetirizine, oral, as a single dose.
    • Children 2 - 6 years: 5 mg.
    • Children 6-12 years: 10 mg.

For children less than 2 years:

  • Chlorphenamine, oral, 0.1mg/kg/dose as a single dose at night. (Maximum 4mg).

To relieve skin dryness:

  • Emulsifying ointment.

For baths, as a soap substitute:

  • Aqueous cream.

For the face and skin folds:

  • Hydrocortisone 1%, topical, 12 hourly.

For the body:

  • Betamethasone 0.1%, topical, undiluted applied once daily for 7 days.
    • Moisturise with emulsifying ointment during therapy and in subsequent weeks.

Secondary infection:

Bacterial

  • Cephalexin, oral, 6.25–12.5 mg/kg/dose, 6 hourly.

Viral
If HSV suspected:

  • Aciclovir, oral, 250mg/m² /dose 8 hourly for 7 days

Note:

Short term use of topical steroids is recommended.

Oral corticosteroids do not have a role in the management of this condition.

REFERRAL

  • Recalcitrant cases.
  • Concomitant food allergy (allergy clinic).

CANDIDIASIS

B37.2

DESCRIPTION

Skin infection involving axillae, neck and perineum. Commonly occurs in immunocompromised individuals. Involvement of mouth and perineal regions suggests systemic disease.

DIAGNOSTIC CRITERIA

Clinical

  • Red, raw-looking patches with satellite white pustular lesions on an erythematous base.
  • Mucosal involvement.

Investigations

  • Wet preparation with potassium hydroxide or biopsy and culture.

GENERAL AND SUPPORTIVE MEASURES

  • Control underlying immunosuppressive state, e.g. diabetes, HIV.
  • Personal hygiene of mothers prior to breast feeding.

MEDICINE TREATMENT

  • Imidazole cream 1%, e.g. clotrimazole, topical, applied 8 hourly for 14 days.

If no response:

  • Fluconazole, oral, 3–6 mg/kg/day for 14 days.

REFERRAL

  • Recalcitrant infection.

PSORIASIS

L40.9

DESCRIPTION

An inflammatory condition of the skin and joints.

DIAGNOSTIC CRITERIA

  • Scaly, red, itchy papules and plaques over scalp, perineum, and skin folds and extensor surfaces.
  • Nails may be opaque, deformed and crumbling.
  • Occasional pustules are seen.

GENERAL AND SUPPORTIVE MEASURES

  • Avoid precipitants, e.g. medication (such as antiepileptic and antimalarial agents).

MEDICINE TREATMENT

Local plaques

To remove scales in children 12 years and older:

  • Salicylic acid 2% and coal tar in white soft paraffin, applied 8 hourly.

OR

  • Face: Hydrocortisone 1%, topical, applied 12 hourly.
  • Body: Betamethasone 0.1%, topical, applied 12 hourly.

For scalp lesions:

  • Mild coal tar shampoo.
    OR
  • Betamethasone 1% scalp application, apply 12 hourly

Severe pustular psoriasis

(in consultation with a specialist)

  • Prednisone, oral, 1–2 mg/kg as a single daily dose for 7 days.

REFERRAL

  • Severe psoriasis and recalcitrant cases.
  • Intolerance to salicylic acid.
  • No response to treatment.

URTICARIA

L50.9

DESCRIPTION

An itchy, inflammatory skin and mucosal condition recognised by wheal and flare reaction. May be acute or chronic, often due to irritants, insect bites or allergens. Secondary infective features include excoriation, vesicles and pigmentary changes. Chronic papular eruptive urticaria is often seen in HIV infected individuals.

DIAGNOSTIC CRITERIA

  • History of a recent infection or parasitic infestation.
  • History of allergen exposure.
  • Wheal and flare reaction (“hives”).
  • Positive skin test if due to allergy.

GENERAL AND SUPPORTIVE MEASURES

  • Limit exposure to precipitants, e.g. drugs, allergens and toxins.
  • Limit exposure to insects by using topical insect repellent which contains more than 10% diethyltoluamide (DEET).
  • Search for and treat an underlying infection or parasitic infestation.
  • Wrap with dressings soaked in sodium chloride 0.9%.

MEDICINE TREATMENT

  • Chlorphenamine, oral, 0.1 mg/kg/dose as a single dose at night.

AND

  • Betamethasone 0.1%, topical, applied twice daily as required.
    • Useful when applied immediately after insect bite.

Severe chronic urticaria

For children 2 years and older:

  • Cetirizine, oral, as a single dose.
    • Children 2 - 6 years: 5 mg.
    • Children 6-12 years: 10 mg.

REFERRAL

  • Recurrent cases.
  • Recalcitrant and chronic cases.

TINEA CAPITIS

B35.0

Refer to the Primary Healthcare Standard Treatment Guidelines and Essential Medicines List, 2014: