Protocol · WHO skin NTDs
Common skin conditions and skin NTDs
A few conditions (bacterial infections such as impetigo, fungal infections, scabies and eczema) make up most skin disease seen in clinics, and they respond to cheap, widely available treatment. The same consultation is the best chance to find neglected tropical diseases (NTDs) of the skin early, while they are curable and before disability. Look at the skin in four ways: lumps, ulcers, swollen limbs and patches, and always ask about itch and test sensation.
- Based on WHO skin NTDs
- For doctors, clinical officers, nurses and community health workers
- Reviewed October 2026
1Who / 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.
2Red flags: refer now
- Fever and a spreading hot, red, painful area (cellulitis), or a fluctuant abscess with fever.
- Widespread blistering or peeling skin, or skin and mouth sores after a new medicine.
- Sick child with skin pustules or boils and any IMCI danger sign.
- Crusted (thick, scaly, often non-itchy) scabies: very infectious.
- Facial swelling, dark urine or reduced urine after skin sores (possible kidney inflammation).
3Assess
- 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.
4Classify
| What you see | Likely condition | Action |
|---|---|---|
| Itchy papules and burrows on fingers, wrists, waist, genitals; family itch | Scabies | Treat person and household |
| Ring-shaped scaly patch; scaly scalp with hair loss | Tinea (ringworm) | Topical azole; oral for scalp |
| Honey-coloured crusts or pustules | Impetigo | Clean, topical treatment |
| Dry, itchy patches in elbow and knee creases; thick dark skin where scratched | Eczema | Emollient and steroid cream |
| Patch with reduced sensation, or enlarged nerves | Leprosy | Refer for diagnosis and free MDT |
| Painless ulcer or nodule; chronic ulcer; swollen limb; itchy leopard skin | Buruli ulcer, leishmaniasis, yaws, filariasis, mycetoma, onchocerciasis | Refer to the NTD programme |
5Treat
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.
6Follow-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.
7Counsel
- 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.
8When to refer
- Same day: any red flag above.
- Any suspected skin NTD (leprosy, Buruli ulcer, yaws, leishmaniasis, mycetoma, filariasis, onchocerciasis) to the programme or a specialist service.
- Leprosy with painful nerves or new weakness or numbness.
- Not better after correct treatment, or diagnosis unclear after using the WHO diagnostic charts.
9Sources
- World Health Organization. Recognizing neglected tropical diseases through changes on the skin: a training guide for front-line health workers. 2018 (ISBN 9789241513531). Four skin signs (lumps, ulcers, swollen limbs, patches) with itch and sensation; disease descriptions; Tables 3 to 5 (diagnostic clues, NTD treatments, common skin diseases); warning about strong steroid creams; lymphoedema entry-point care.
- World Health Organization. Leprosy fact sheet. 2026. Cardinal signs (patch with definite loss of sensation; thickened nerve; smear), PB 1 to 5 lesions and MB more than 5, MDT 6 or 12 months, free MDT, no transmission after starting treatment.
- World Health Organization. Scabies fact sheet. 2023. Signs, crusted scabies, kidney complications, treatment options, ivermectin restrictions, household treatment, repeat dosing, persisting itch.
- World Health Organization. IMAI district clinician manual: hospital care for adolescents and adults, volume 1. 2011 (ISBN 9789241548281). Permethrin application, ivermectin 200 micrograms/kg repeated after 2 weeks, crusted scabies, mupirocin, terbinafine.
- World Health Organization. WHO model formulary for children. 2010. Permethrin (over 2 months), benzyl benzoate (over 2 years, not first choice), Whitfield ointment, gentian violet, griseofulvin doses.
- World Health Organization. WHO Model List of Essential Medicines. 2025.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.