Skin and soft tissue infections

For recurrent boils and cellulitis, always send swabs for culture with as much clinical information as possible. This will aid identification of infections caused by Panton-Valentine Leukocidin (PVL) toxin producing Staph aureus. Risk factors include: nursing homes, contact sports, sharing equipment & eczema.

Invasive Group A Streptococcal infections have increased in incidence and need to be assessed rapidly in hospital. Maintain a high index of suspicion in patients with a high fever, severe muscle aches, confusion, unexplained D&V, local muscle tenderness, or severe pain out of proportion to external signs, hypotension, a flat red rash over large area of the body, conjuctival suffusion.

Impetigo

Extensive, severe or bullous impetigo

As resistance is increasing avoid topical antibiotics and reserve for single small, and very localised lesions

Flucloxacillin
  • Adult:
    • 500mg every 6 hours for 7 days
  • Child:
    • 2–10 years: 125–250mg every 6 hours for 7 days
    • 10–18 years: 250–500mg every 6 hours for 7 days
Penicillin allergy
Clarithromycin
  • Adult:
    • 500mg every 12 hours for 7 days
  • Child 1 month–12 years (give every 12 hours for 7 days)
    • Body-weight under 8 kg: 7.5mg/kg
    • Body-weight 8–11 kg: 62.5mg
    • Body-weight 12–19 kg: 125mg
    • Body-weight 20–29 kg: 187.5mg
    • Body-weight 30–40 kg: 250mg
  • Child 12–18 years:
    • 250mg every 12 hours for 7 days, increased if necessary in severe infections to 500mg every 12 hours for up to 14 days

Very localised lesions

Fusidic acid (topical)
  • apply every 8 hours for 5 days
  • Local resistance rates to fusidate in S. aureus are high (greater than 15%)
Reserve Mupirocin for MRSA
Mupirocin 2%
  • apply every 8 hours for 5 days

Eczema

If there are no visible signs of infection use of antibiotics (alone or with steroids) encourages resistance and does not improve healing. In eczema with visible signs of infection, use treatment as in impetigo (see above).

See Eczema guidelines for detailed advice on the management of infected eczema and treatment options.

Cellulitis

Discuss with a Microbiologist if exposure to river or sea-water.

Inflammation about leg ulcers is often mistaken for cellulitis. There is no evidence that swabbing leg ulcers routinely or treating them with antibiotics is useful unless there is genuine ascending cellulitis.

Bilateral cellulitis is rare and may require a re-evaluation of diagnosis. A low CRP may suggest a non-infectious aetiology in difficult cases.

Swabbing of any broken skin, or between toes for foot cellulitis, may be helpful if done prior to starting antibiotics.

A nose swab should be collected to look for MRSA carriage if the patient has been in hospital recently.

The formulary gives dose and duration of treatment for adults unless stated otherwise.

In mild to moderate cellulitis
Flucloxacillin
  • 500-1000mg every 6 hours for 7 days
Penicillin allergy
Clarithromycin
  • 500mg every 12 hours for 7 days
If patient currently taking statins
Clindamycin
  • 300-450mg every 6 hours for 7 days

If severe and/or failure with suitable oral antibiotics consider outpatient IV antibiotics. Eligible patients are those who are haemodynamically stable and with no unstable co-morbidities.

Plymouth: Liaise with Acute GP service

Torbay: Liaise with Ambulatory Care or discuss with on call Microbiologist

In facial cellulitis

If the cellulitis is clearly not associated with mucosal structures such as the facial sinuses or teeth then treat as standard cellulitis, see above. If mucosal facial structures are involved use co-amoxiclav.

Have a low threshold for referral in the event of signs and symptoms suggesting orbital involvement, for example

  • Blurring / reduced visual acuity or colour perception
  • Ophthalmoplegia (restricted eye movements, double vision)
  • Proptosis
  • Pupillary dysfunction (relative afferent pupil defect)
  • Sclera changes
Co-amoxiclav
  • 625mg every 8 hours for 7-14 days

Leg ulcers (active infection)

Ulcers are always colonised.

Culture swabs and antibiotics are only indicated if cellulitis is present. Treat with cellulitis regimen (see above).

Antibiotics should only be used in active infection (increased pain, pyrexia, erythema beyond 2cm, localised heat). If antibiotics given, review with culture results.

MRSA decolonisation

Please refer to: Methicillin Resistant Staphylococcus Aureus (MRSA) guidance

An MHRA patient information leaflet is available on the Public Health England (HPA) website

Bites (animal and human)

Human bites: Thorough irrigation is import. Assess risk of tetanus, HIV, hepatitis B&C- follow inoculation policy. Antibiotic prophylaxis is advised.

Cat / dog / bat bites: Assess risk of tetanus and rabies- follow inoculation policy.

Give prophylaxis if:

  • All cat bites
  • Puncture wound from any animal
  • Bite to hand, foot, face, joint, tendon, ligament. If the bite is near a joint or tendon, refer to plastics
  • Immunocompromised / diabetic / asplenic / cirrhotic
  • Presence of prosthetic valve or prosthetic joint
  • Presents more than 24 hours after the bite

Prophylaxis and treatment

The formulary gives dose and duration of treatment for adults unless stated otherwise.

Co-amoxiclav

625mg every 8 hours for 7 days

If penicillin allergic

Metronidazole
  • 400mg every 8 hours for 7 days plus
Doxycycline
  • 100mg every 12 hours for 7 days

For children allergic to penicillin and unable to take co-amoxiclav, discuss with microbiologist

Scabies

Treat all home & sexual contacts within 24 hours.

Application notes

  1. Take an ordinary tepid bath.
  2. After drying the skin apply to the whole body including face, neck, scalp & ears.
  3. Wash off after 8-12 hours (permethrin) or 24 hours (malathion)
  4. Reapply if hands are washed in this period.
  5. 24 hours later take another bath and change underclothes, nightclothes, sheets and pillow cases.
Permethrin 5% cream
  • two applications one week apart

If allergy

Malathion 0.5% liquid
  • two applications one week apart

Dermatophyte infection

Skin: Localised infection

The use of OTC dusting powders can be recommended to help prevent re-infection of athlete's foot.

Many of these products are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet

Oral therapy is indicated in scalp infection, discuss with specialist.

Terbinafine is fungicidal and the treatment time is shorter than with fungistatic imidazoles.

Terbinafine 1%
  • Topical: apply every 12 hours for 1-2 weeks after healing (i.e. 4-6 weeks)
Miconazole 2%
  • Topical: apply every 12 hours for 1-2 weeks after healing (i.e. 4-6 weeks)

Skin: Extensive infection or failure to respond to topical anti-fungal

Take skin scrapings for culture for intractable infections, and if infection confirmed consider oral terbinafine/ itraconazole.

Terbinafine
  • 250mg daily for 4 weeks
Itraconazole
  • Tinea corporis / tinea cruis
    • 100mg once daily for 15 days, or
    • 200mg once daily for 7 days
  • Tinea pedis / tinea manuum
    • 100mg once daily for 30 days

Proximal fingernail or toenail (adults)

Take nail clippings and only start therapy if infection is confirmed by laboratory.

Oral terbinafine is more effective than oral azoles (fungicidal agent). Idiosyncratic liver reactions occur rarely with terbinafine.

Terbinafine
  • 250mg daily
  • Treat fingernails for 6 to 12 weeks
  • Treat toenails for 3-6 months

Pulsed itraconazole monthly is recommended for infections with candida and non-dermatophyte moulds.

Itraconazole
  • 200mg twice daily for 7 consecutive days repeated at 21 day intervals
  • Treat fingernails with 2 courses
  • Treat toenails for 3 courses

Warnings on itraconazole use

  1. Itraconazole has a negative inotropic effect:
    1. It should not be used in patients with heart failure or at risk of it
    1. It should not be used with other negatively inotropic drugs such as calcium channel blockers
  2. Itraconazole has a range of clinically important drug interactions such as statins, anti-epileptics, anti-arrhythmics, antihistamines, calcium channel blockers, HIV drugs. This list is not exhaustive and the BNF or other texts should be consulted
  3. Absorption of itraconazole is pH dependent. It is reduced by antacids and PPIs. Avoid antacids for 2 hours. If on a PPI, take itraconazole with an acidic drink
  4. Do not use itraconazole if there is a past history of hepatic disease

Viral infections

Varicella zoster/chicken pox and herpes zoster/shingles

Pregnant/ immunocompromised/ neonate exposed to chicken pox or shingles: seek urgent specialist advice.

Chicken pox, consider aciclovir:

  • If onset of rash less than 24 hours & over 14 years of age or
  • Severe pain or
  • Dense/oral rash or
  • Secondary household case or
  • Taking steroids or
  • A smoker

Shingles,treat if over 50 years of age and:

  • Within 72 hours of rash (post herpatic neuralgia is rare if under 50 years of age) or
  • Active ophthalmic or
  • Ramsey Hunt syndrome or
  • Eczema
If indicated:
Aciclovir
  • 800mg 5 times a day for 7 days

2nd line for shingles only if compliance a problem (less cost effective)

Valaciclovir
  • 1000mg every 8 hours for 7 days.
  • Children: See BNFc for dose

Cold sore/Herpes simplex

Cold sores resolve after 7–10 days without treatment.

A number of products containing antivirals can be purchased over the counter without a prescription. They are cheap to buy and are readily available, along with advice, from pharmacies. Some self-care medicines are available in shops and supermarkets. Please click here for further information and a patient leaflet

Topical antivirals applied prodromally reduce duration by 12-24 hours

Lacerated wounds

Thorough irrigation is recommended. Drinkable tap water, boiled and cooled water, and normal saline are all comparable wound cleansing agents. Assess risk of tetanus.

Antibiotic therapy is usually not indicated unless:

  • Crushed and deep punctures
  • Wounds to the hands, face or genitals
  • Immunocompromised
  • Cirrhotic, asplenic, or hyposplenic

In these cases prompt irrigation and co-amoxiclav 625mg every 8 hours for 5 days.

If symptoms and signs of infection develop after closure of the laceration:

  • If previously contaminated - co-amoxiclav 625mg every 8 hours for 5 days
  • If not previously contaminated – flucloxacillin 500mg every 6 hours for 7 days

 

Home > Formulary > Chapters > 5. Infections > Skin and soft tissue infections

 

  • First line
  • Second line
  • Specialist
  • Hospital