Infestations and Infections

1. creepy crawlies bugs and beasties Infestations and Infections

2. Stings and Bites Infestations

3. OUTDOOR BUGS Midges Fleas Mosquitoes (females) Flies Wasps Tics • Bees • Ants • Moths and butterflies • Centipedes • Ladybirds • Spiders

4. What do insect bites look like?

8. Differential Diagnosis Eczema / dermatitis Scabies Dermatitis herpetiformis Chickenpox or shingles Urticaria Delusions of parasitosis Papular drug eruption Polymorphous light eruption

9. 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

11. 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 - don’t wear any

12. 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)

13. INDOOR BUGS Scabies Head lice Pubic lice Body lice Thread worms Fleas Bed bugs

14. Itchy Itchy Itchy Sarcoptes scabiei

15. 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

17. 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.

18. 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

19. 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.

20. 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

22. 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, repeat 1-2 weeks One application 4% dimeticone gel Repellents to minimise re-infestation Hair care to prevent re-infestaion

23. 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

24. 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

25. 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

27. 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

28. 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

29. Close bodily contact Infections

32. 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 isn’t dermatitis or an insect bite

36. 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

38. 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!

40. 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

42. Thrush White plaques that don’t 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

44. 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

46. Warts Anywhere on the body Run in families Last for years Lots of topical treatments but need to remove the dead skin first (freezing, salycilic acid 50%, hydrogen peroxide 1%, occlusion, acupuncture, 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

48. Molluscum Contagiosum Pox virus on the skin Small pink papules with a belly button No symptoms unless they have become infected Can be massive and extensive in eczema or the immune compromised No treatment normally needed Last for months, contagious, no isolation required New otc product available molludab 5% potassium hydrochloride