Common skin conditions and skin NTDs

Who / when

• Children and adults with itch, a rash, sores, patches, lumps, ulcers or a swollen limb.
• Examine all the skin in good light, including hands, feet, genitals and scalp. Ask what has already been applied: strong steroid creams bought without prescription can hide or worsen infections.

Assess

• Itch: worse at night, and others at home itch too: think scabies.
• Patches: test sensation in every patch with a wisp of cotton or the tip of a pen. Pale or reddish patch with reduced feeling: think leprosy and feel for enlarged nerves (behind the elbow, below the knee).
• Lumps: how many, where, firm or soft, painful or not. Ulcers: painless with undermined edges (Buruli ulcer), raised edges on exposed skin (leishmaniasis), raspberry-like crusted lump (yaws), on a numb foot (leprosy or diabetes).
• Swollen limbs: one or both legs, scrotal swelling (lymphatic filariasis); both legs below the knee in barefoot farmers (podoconiosis). Swelling of both legs with breathlessness: think heart failure.
• Test HIV status where skin disease is severe, extensive or keeps coming back.

Classify

Treat

Scabies: treat everyone in the household at the same time

• Permethrin 5% cream (age over 2 months): apply to the whole body, including between fingers and toes, under nails, genitals and buttocks (and face and scalp in children); wash off after 8 to 12 hours; repeat after 7 days. Reapply to hands if washed.
• Alternatives: benzyl benzoate 25% (over 2 years; not first choice), sulfur ointment.
• Oral ivermectin 200 micrograms/kg as one dose, repeated (IMAI: after 2 weeks). Not in pregnancy or children under 15 kg. Crusted scabies: ivermectin plus a topical agent, and refer.
• Wash clothes and bedding. Itch can last 2 to 3 weeks after treatment; this is not failure.

Other common conditions

• Tinea of body, groin, feet: clotrimazole or miconazole cream, or Whitfield ointment twice daily until the skin has shed (usually at least 4 weeks). Scalp ringworm: oral griseofulvin 10 to 20 mg/kg (maximum 1 g) daily for at least 6 weeks; do not share caps or combs.
• Impetigo: soak off crusts; mupirocin up to 3 times a day for up to 10 days, or an antiseptic such as povidone iodine or gentian violet. Widespread or with fever: oral antibiotic (for example cloxacillin) per national formulary.
• Eczema: emollient every day; soap substitute; a medium-strength steroid cream for 2 to 4 weeks on flares; avoid irritants; treat infection first.
• Skin NTDs: treatment is through national programmes: leprosy multidrug therapy (rifampicin, dapsone, clofazimine; free) for 6 months with 1 to 5 skin lesions, or 12 months with more than 5; yaws a single oral dose of azithromycin; Buruli ulcer 8 weeks of rifampicin and clarithromycin, with wound care.

Follow-up

• Scabies: if itch persists beyond a few weeks or new burrows appear, check the application and that every contact was treated at the same time.
• Impetigo and tinea: review if not improving with treatment, or sooner if spreading or with fever.
• Leprosy: check hands, feet and eyes for loss of feeling at every visit, and teach daily self-care of numb skin.
• Lymphoedema: daily washing and drying of the limb and between the toes, treat cracks and athlete's foot, exercise, raise the leg.

Counsel

• Scabies spreads by close skin contact; everyone at home must be treated on the same day even without itch.
• Impetigo and ringworm spread in homes and schools: keep sores covered and do not share towels, caps or combs.
• Do not use strong steroid or bleaching creams without advice.
• Leprosy is curable and WHO provides the medicines free. A person stops spreading it once treatment starts, so there is no need to separate them from family or work.

This rash is scabies, caused by a tiny mite. Everyone in your house must use the cream on the same night, and again after one week, or it will come back. The itch can last a few weeks after the mites are gone.

Sources