Remote Primary Health Care Manuals

Skin infections

Red Flags — Urgent Medical Consult
  • Child under 6 years with cellulitis
  • Boils and unwell
  • Severe cellulitis, unwell and/or poorly controlled diabetes
  • Non-healing sores/ulcers

For skin infections occurring at the same time

  • Impetigo (school sores) and scabies — treat for both at same time
  • School sores and boils — give antibiotics recommended for boils 
  • Infected lice or scabies sores — treat as for impetigo (school sores)

Prevention of skin infections

  • In community — wash clothes and bedding regularly, wash hands with soap and wash children every day with soap, eg bath, shower, swimming
  • In clinic — use good infection control practices

Impetigo (school sores)

  • Yellow/brown crusted sores, often surrounding redness. May be pus under crust
  • Common, very infectious — must treat as can lead to serious problems (eg PSGN and ARF/RHD)

Ask

  • Ask about sores on other household members, especially crusted scabies

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • U/A
  • Head-to-toe exam — with attention to scabies, headlice and tinea
  • Immunisation status

Do not

  • Do not use topical mupirocin — resistance develops quickly
  • Do not send wound swab unless not responding to treatment

Do

  • Treat sores 
    • Clean with soap and water
    • Give benzathine benzylpenicillin* (Bicillin L-A) IM — adult 1,200,000 units/2.3mL (900mg), child — doses — single dose
    • OR trimethoprim-sulfamethoxazole oral — adult 160+800mg — doses — twice a day (bd) for 3 days
    • Medical consult if allergy to penicillin or person declines injection
    • If benzathine benzylpenicillin used in the last 7 days give  trimethoprim-sulfamethoxazole oral — adult 160+800mg, child 4+20mg/kg/dose up to 160+800mg — doses — twice a day (bd) for 3 days
  • Dress (cover) sores
  • Treat other condition at the same time — see

Follow-up

  • Make sure sores are covered and kept clean
  • If not getting better or frequent reoccurrences    
    • Ask about sores on other household members, especially crusted scabies
    • Send swab for MC&S — check swab results
    • Medical consult about antibiotic to use
  • If non-healing sores/ulcers — consider melioidosis especially in tropical northern Australia

Head lice (nits)

  • Problems include infected sores and distress from scratching
  • Good ways to keep numbers low include
    • Regular combing with fine-tooth comb with conditioner in hair
    • Keeping hair short or tied back
    • Avoid head-to-head contact where possible

Ask

  • Any previous treatments
    • If insecticide-based product — could be treatment failure
    • Could be reinfection
  • Are other members of family affected

Check

  • Look for live lice — use a good light
  • If live lice seen — infestation confirmed. Start treatment
  • If no live lice seen 
    • Comb or brush hair to remove tangles
    • Put conditioner through dry hair and comb with fine-tooth comb
    • Wipe comb on tissue after each stroke to check for live lice
    • If live lice found — infestation confirmed. Stop combing and start treatment
  • Look for eggs (nits) stuck on hairs near scalp — common above ears and around hairline
  • Look for infected sores
  • Encourage person/carer to check other children and adults in household — treat if needed

Do

  • Treat infestation
    • Completely cover clean dry hair with dimeticone 4%
    • If using lotion — allow to dry and leave on for at least 8 hours OR if using fast-acting gel spray — leave on for at least 15 minutes. Check product instructions as new products become available
    • Wash out of hair
  • Put conditioner in dry hair and use fine-tooth comb to remove lice, if needed
  • If infected sores — treat as for impetigo (school sores) 

Follow-up

  • Repeat dimeticone 4% treatment after 1 week
  • Encourage family to continue fine-tooth combing

Boils, carbuncles, abscesses

  • Boil — painful, pus-filled bump under the skin caused by infected, inflamed hair follicles. Need incision and drainage — most do not need antibiotics
  • Carbuncle —  cluster of boils — will need drainage, medical consult
  • Abscess — confined pocket of pus collected in tissues, organs or body spaces — needs drainage and may need antibiotics

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Head-to-toe exam —  attention to swollen, tender, red skin lumps. Feel if soft or hard
  • Immunisation status

Do

  • If person unwell — medical consult
  • Give pain relief
  • If severe or several boils — swab pus for MC&S
  • Incision and drainage is the best treatment for large boils (2cm lump or 5cm area of redness) — See Cutting and draining an abscess
  • If very large or in sensitive place (face, hands, perineum) send to hospital to be drained
  • Use good hand hygiene — boils can spread
    • Use alcohol-based hand rub after every contact
    • Give person bottle of alcohol-based hand rub and show how to use
  • Keep boils covered with occlusive dressings — important to prevent cross-infection to other parts of body
    • Change dressing every day until healed
  • Tell people never to touch own boils
    • Have someone else dress boils, using good hand hygiene

Most boils (70%) get better after they are drained — give antibiotics if person has

  • Impetigo (school sores) as well as boils
  • Weakened immune system (eg young child, elderly, diabetic)
  • Recurrent boils and abscesses
  • Severe boils and abscesses — fever, tender lymph nodes, redness spreading from boil or lots of boils 
    • Give trimethoprim-sulfamethoxazole oral — adult 160+800mg, child 4+20mg/kg/dose up to 160+800mg — doses — twice a day (bd) for 5 days
    • If allergy — medical consult
  • Ask family to wash all clothes and bedding with laundry detergent and dry in the sun

Follow-up

If  not getting better

  • Medical consult — may be deeper infection which needs drainage in hospital and IV antibiotics
  • If antibiotics were given — check swab result to make sure antibiotic effective
  • Consider alternative diagnosis, eg melioidosis

 If keeps getting boils or abscesses

  • Medical consult — may need different approach
  • Can be caused by re-infection from self, household members, companion animals
  • Remind about importance of keeping boils covered, washing hands, daily bathing, preventing transmission to other household members, eg separate towels
  • Give antibiotics if not given in first treatment

Cellulitis

Check

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Head-to-toe exam — with attention to
    • Area of skin — painful, red, hot
    • Local lymph nodes — may be swollen, tender
    • Cracks/infection — between toes, insect bites, scabies, school sores (start of infection)
    • Underlying boil/s, tender lump — may need to be treated as a boil

Do

  • Medical consult if

    • Child under 6 years — could be bone infection
    • On face — could be Haemophilus influenzae type b (Hib)
    • Joint involved — could be joint infection
    • Involves most of hand, arm or leg
    • Happened after contact with water, eg fishing, swimming
    • Person unwell, fever, poorly controlled diabetes — treat as severe cellulitis
  • Give pain relief
  • Give trimethoprim-sulfamethoxazole oral — adult 160+800mg, child 4+20mg/kg/dose up to 160+800mg — doses — twice a day (bd) for 7 days
    • OR procaine benzylpenicillin (procaine penicillin) IM — adult 1.5g, child 50mg/kg/dose up to 1.5g — doses — every 24 hours for 3–5 days
  • If allergy to sulfonamides — medical consult to give clindamycin oral — adult 450mg, child 10mg/kg/dose up to 450mg — doses — 3 times a day (tds) for 7–10 days

Follow-up

  • If not improving after 2 days 
    • Treat as severe cellulitis
    • Medical consult

Severe cellulitis

  • If unwell, fever, poorly controlled diabetes — medical consult — consider sepsis
  • Give cefazolin IV — adult 2g, child 50mg/kg/dose up to 2g — doses — once a day
  • AND probenecid oral — adult 1g, child 25mg/kg/dose up to 1g — doses — once a day
  • If allergy to penicillin — medical consult
  • If not improving after 1 day — medical consult to send to hospital

Herpes simplex (cold sores)

  • Small watery blisters, often on mouth or face
  • First infection may be severe

Check

  • Make sure not impetigo (school sores) or hand, foot and mouth disease

Do

  • Give topical pain relief — ice,  lidocaine (lignocaine) gel
  • Make sure person is hydrated — may need IV fluids if severe
  • Clean with normal saline to prevent secondary infection
  • Can use aciclovir 5% cold sore cream, 5 times a day for 5 days
    • Use as soon as symptoms start — before blister forms
  • If severe or recurrent — medical consult. May need antiviral treatment

Molluscum contagiosum

Small round skin lumps caused by Molluscum contagiosum virus

Check

  • One or more smooth firm pearl-coloured lumps
    • Hard central core of waxy material
    • Hole or dimple in centre

Do

  • Reassure that lesions are harmless and will get better by themselves
  • Treatment is not needed — it will usually go away in 6–9 months
    • May last long longer in patients with atopic dermatitis — improving condition of skin may help
  • Advise to avoid scratching or picking at lumps as this can make them spread

Supporting resources

  • Skin conditions visual treatment guide
  • National healthy skin guidelines