Infestations and Infections

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Infestations and Infections

• creepy crawlies
• bugs and beasties

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Infestations

• Stings and Bites

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OUTDOOR BUGS

• Midges
• Fleas
• Mosquitoes (females)
• Flies
• Wasps
• Tics

• Bees
• Ants
• Moths and butterflies
• Centipedes
• Ladybirds
• Spiders

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What do insect bites look like?

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Differential Diagnosis

• Eczema / dermatitis
• Scabies
• Dermatitis herpetiformis
• Chickenpox or shingles
• Urticaria
• Delusions of parasitosis
• Papular drug eruption
• Polymorphous light eruption

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Treating Insect Bites

• Bees bicarbonate of soda
• Wasps vinegar
• Insects oral antihistamines, topical
  hydrocortisone 1 cream, calamine lotion, aloe
  vera
• Tics remove the tic after suffocating with
  toothpaste or vaseline, think of Lyme disease if
  a rash is present

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Prevention is better than cure

• Mozzie net impregnated with permethrin
• Deet at least 50
• Lemon/citronella rubbed on exposed skin
• Clothing - avoid bright colours
• Perfume - dont wear any

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Diseases caused by insects

• Malaria (Anopheles mosquitoes)
• Lyme disease (tics)
• Tick borne encephalitis (tics)
• West Nile fever and Dengue fever (Aedes mosquito)
  
• Chikungunya fever (Aedes mosquito)
• Viral encephalitis (Culex mosquito)
• Filariasis (Culex mosquito)
• Tularemia (deer fly and black fly)
• Cat-scratch disease (cat fleas)
• Plague (fleas)
• Leishmaniasis and bartonellosis (sandflies, fleas
  and lice)
• Onchocerciasis (black fly)
• Trypanosomiasis (kissing bugs, tsetse fly)

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INDOOR BUGS

• Scabies
• Head lice
• Pubic lice
• Body lice
• Thread worms
• Fleas
• Bed bugs

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Sarcoptes scabiei

• Itchy Itchy Itchy

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Scabies

• The infestation mainly affects hands, wrists and
  genitals.
• Burrows are pinkish grey, 5-10 mm, most easily
  identified on the sides of the fingers, finger
  webs or under the wrist.
• Using magnification, the mites can be seen in the
  distal end of their burrows.
• Symptoms may take up to 6 weeks to come out

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Scabies in AdultsWithin days to weeks a
generalised itch and/or non-specific erythematous
papular rash appears, sparing the head and neck.
Later, papules may be found on the shaft of the
penis and dermal nodules in the axillae and/or
inguinal regions. Mites live up to 3 hours off
the body
Scabies in Babies is characterised by
vesicles and pustules on the palms and soles
which can persit after treatment. May have
hundreds of burrows if too young to scratch.
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Scabies treatment

• Treat everybody in the household and others with
  skin contact (remember split families)
• Permethrin 5 cream applied to the whole body
  below the hairline for 12 hours, repeat in 1
  week. 60g cream for an adult, 30g for a child
• Malathion lotion left on for 24 hours
• Crotamiton cream (eurax) applied daily for 2
  weeks
• Exclusion from school/work/nursery not necessary
  after first treatment

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Scabies treatment failure

• Incomplete application of insecticide
• Premature removal of insecticide
• Inadequate penetration of insecticide through
  thickened skin or crusts
• Re-infestation by untreated contacts.
• Drug resistance
• All household contacts should be treated at the
  same time. It is wise to re-treat once a week for
  two or three weeks.
• Manage itch and eczematisation with emollients,
  topical steroids (or eurax) and oral
  antihistamines.

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Head Lice

• Common, usually head to head contact, also live
  on brushes, toys or clothes for 3 days
• Moving brown or black specks like a sesame seed
  3mm long
• Nits are the eggs left on the hair shaft
• Itchy
• Secondary infection from scratching
• Brush hair over a white cloth to see them, head
  inspection is unreliable
• Up to 60 of school children have them

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Head lice treatment

• Combing wet or dry daily for 2 weeks
• Malathion or permethrin scalp solution applied
  overnight and then washed out, choose aqueous
  preparations to avoid irritation
• Repellents to minimise re-infestation
• Hair care to prevent re-infestaion

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Pubic lice

• Same kind of beastie as the head louse
• Treat in the same way
• Treat sexual partners and bed fellows together
• Perform sti screen
• May also migrate to other body hair
• Use vaseline on eye lashes

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Body Lice

• Uncommon unless homeless or self neglect
• Look like head lice
• Live in bedding or clothes and lay eggs in the
  seams
• Clothes need to be boil washed, tumble dried or
  dry cleaned to get rid of lice
• Skin is very itchy and bites may be invisible
  under a layer of blood and crust
• Permethrin 5 cream can be used on the skin
• Treat eczematisation with emollients and
  infection with oral antibiotics or topical
  antiseptics

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Thread Worms

• 1cm long thin white threads seen on toilet paper,
  on pooh or at anus
• Female worms emerge at night and lay eggs around
  the anus and vulva which becomes itchy
• Spread by oro-faecal route
• Treat whole family together if over 6/12 with
  single dose mebendazole 100mg chewable tablet and
  under 6/12 with piperazine repeated after 14 days

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Fleas

• Live on the family pet
• Live on the neighbours and friends pets
• Live on soft furnishings and carpets
• Bite ankles mostly as they are closest to the
  floor
• Bite the body if the body is on the floor
• Bite the lap if stroking the pet on your knee
• Treat the furniture, carpet and the pet

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Bedbugs (second hand furniture)

• Bedbugs feed on humans and live in furniture,
  sheets, clothes, suitcases, skirting boards
• They come out to feed at night and scuttle back
  into hiding afterwards

• Bites start as burning
• wheals with a central
• haemorrhagic dot
• These turn into firm
• papules, often in lines

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Infections

• Close bodily contact

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Cellulitis

• Unilateral
• Painful
• Hot, red, sore, acute, spreading
• Patient unwell or feverish
• Treat with penicillin 500mg and flucloxacillin
  500mg orally for at least a week
• Make sure it isnt dermatitis or an insect bite

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Impetigo

• Yellow scabs or crust
• Vesicles or blisters
• Red base
• Itchy, spreading
• Usually staph or strep
• Topical mupirocin, fucidin, or oral antibiotics
• Can spread like wild fire nb hygiene and
  isolation, antiseptic washes can help
• Swab if very persistent and consider MRSA

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Ringworm

• Topical fungal infection
• Small red papules in an enlarging ring, healing
  from the centre out
• Topical clotrimoxazole, miconazole or nystatin
• Hydrocortisone cream will help you decide what it
  is!

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Athletes foot

• Cheesy, wet, white skin, smells of sweaty socks,
  cracked or peeling skin
• Lateral toe webs between 4th and 5th toes most
  common
• Check the groin in men
• Topical clotrimoxazole, miconazole or terbinafine
  cream
• Secondary infection

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Thrush

• White plaques that dont move on a red background
• Can burn, itch and sting, sometimes very sore
• Classically cheesy white vaginal discharge
• Alters taste in mouth
• Treat with Miconazole gel, nystatin drops or
  pastilles, oral fluconazole
• Recurrent chronic condition for many needing
  repeated treatment.
• Think of steroid inhalers and immunodeficiency

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Herpes

• Cold sores can be anywhere on the body
• Itchy and painful red spots which develop
  vesicles, often eroded
• Primary infection always the worst
• Genital herpes may be cold sores
• Shingles and chicken pox can easily be mistaken
  for insect bites

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Warts

• Anywhere on the body
• Run in families
• Last for years
• Loads of topical treatments but need to remove
  the dead skin (freezing, salycilic acid 50,
  acupuncture, occlusion, efudix, imiquimod)
• Idea is to cause inflammation in skin so that the
  immune system finds the wart and then kills it
• OTC treatments safe and ok

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Molluscum Contagiosum

• Pox virus on the skin
• Small pink papules with a belly button
• No symptoms unless they have been picked and
  infected
• Can be massive and extensive in eczema or the
  immune compromised
• No treatment normally needed
• Last for months, contagious, no isolation required

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