Transcript Dr. Nefcy*s Top 10 Rashes - Overseas School Health Nurses

Sandra Leipheimer MSN, APRN, BC-PNP
Heidelberg High School 
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 Continually
renewed
 Stores fat and water
 Provides protection
 Gets rid of waste
 Regulates
temperature
 Largest organ of the
body
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
Bed Bugs:
 Cimex lectularius
(Cimidieae)

Harmful?
 Do not transmit any
infectious agents
 Only stay on skin to feed on a
few drops of blood

Treatment
 Aimed at itch- AH and
corticosteroids
 Treat secondary infections
from scratching
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 Lice

Pediculosis (place)
 Facts
Not “medically
necessary” to
remove NITS
 Most are non-viable
(dead or hatched)
 Personal decision by
parent

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 Lice
feed on human
blood
 Not a sign of poor
hygeine
 Transmitted by direct
contact
 Do not spread
disease
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 What



to put on school fact sheet?
Not a major health issue
Nuisance factor
RX: Least intrusive to Most intrusive treatment
Mechanically remove lice (risk reduction)




OTC treatment ( oovacidal)
Rx
Examine all family members for live (crawling) lice
 If infested –treat
 If not – need not be treated
Myths and Treatment folklore
 ARE
THEY ACTUALLY INFESTED?
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 History





When started?
What else going on?
Other S & S?
Rx = better or worse?
Exposure?
 Associated



Signs & Symptoms
Fever
URI
Previous illness or treatment
 Exam

Skin + other symptoms
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Superficial
Infections
 Bacterial
 Fungal
 Viral
 Tattoos
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 Caused
by S. aureus a
normal skin colonizer
in up to 50% of people
 Yellow, oozing, crusty
sore, often starts in
nose Itch is common
 Requires antibiotic
 Excluded for 24 hrs
and keep covered at
school (contagious)
 1-3 days incubation
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

Bullous
 Staph. aureus- fluid filled
blisters
Non-Bullous
 S. aureus & streptococcus –
crusted
 MRSA becoming more
common
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 Skin
lesions usually caused by different strain
than those causing “strep throat”
 Can cause glomerulonephritis if strain is GrA
B-hemolytic

Blood or brown sugar (maple sugar; coke) urine
 May
culture lesions to be sure what is
infectious agent
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 Caused
by
inflammation to the
hair follicles

shaving/friction from
tight clothes; ingrown
 Typically
infected with
S. aureus
 Avoid trigger
 Antibiotics if infection
suspected
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 Usually
caused by
S. aureus
 Increased frequency
with MRSA and other
antibiotic resistant
organisms
 Need oral antibiotics
and often need
drainage
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 Methicillin
Resistant Staphylococcus Areas
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 Exclusion
Policy for Schools?
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





Spread
 Skin to Skin
 Touching contaminated objects (drainage)
Regular Cleaning and Disinfecting
 No evidence that spraying or fogging rooms or surfaces
with disinfectant works better than focusing on
frequently touched surfaces
Wash hands: soap and water alcohol-based sanitizers
Take showers: immediately after exercise; don’t share
items
Use barriers: cover cuts; towels on items
Wash uniform: dry completely in dryer; wash after each
use
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 Culture
suspicious lesions
 Not return to play until:



Appropriate antibiotic taken for at least 72 hours
Drainage from wound has stopped
No new lesions in past 48 hours
 CDC:




do not exclude unless MD directed…
Sport-specific guidance should be in place
Excluded if wounds cannot be properly covered
“properly covered” = securely attached
bandage/dressing containing all drainage and
remain intact during activity
No water; whirl pools; therapy pools
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Nontuberculous mycobacteria (NTM) “various
types”
 M. chelonae exists in tap water
 MRSA and “others”…
 Persistent inflammatory reaction
 Located within margins of recent intradermal
tattoo
 Cause- ? using tap water or distilled water for ink
 Many believe distilled or reverse-osmosis water
is sterile
Many other reasons…
 Cartilage piercings >> delay healing
 “Allergies” >>> contact dermatitis

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 What
do you think??
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 “THINK
BEFORE YOU INK”
 www.fda.gov Tattoos & Permanent Makeup
 NOV 00 JUN 08 FEB 10 AUG 12 FDA Notices
related to unregulated materials and health
risks
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 Tinea
– sounds like a bug, but really a fungus
(trichophyton, microsporum)
 Name of group of diseases caused by fungus
 Named for location of infection
 Acquired by touching infected person, damp
surfaces, pets
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 Generally
a circular
lesion (hence the
name “ring worm”
 Raised (can be
blistery)
 Itchy
 Red scaly ring with
central clearing
 Treat topically with
anti-fungal ointment
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 Tinea
in the scalp
 Patchy areas of hair
loss or breakage and
scale
 Must be treated with
oral medications
 Can extend to a
kerion (hypersensitivity reaction)
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Non scarring
 Noninflammatory
alopecia
 Twist or pull hair
 Deny behavior
 Done in private
 7 X > kids than adults
 2 X Girls > Boys
 Scalp most common


Eyelashes and eyebrows
 Psychosocial
issues
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 Moist
area between toes
 Itchy, red, blisters, cracking, peeling
 Nails can also become infected= tinea
unguium
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 Itching
in groin, thigh folds, anus
 Red, raised, scaly patches that blister and
ooze


Patches have sharply-defined edges
Redder around outside with normal skin tone in
center
 Usually
starts in creases of upper thigh and
does not involve scrotum/penis but may
spread to anus causing itching and discomfort
 Usually less severe than other tinea
infections but lasts longer
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 Also
known as eczema: “the itch that rashes”
 Hypersensitivity reaction similar to allergy
 Long-term swelling and redness
(inflammation of skin)
 May lack certain proteins in the skin which
leads to greater sensitivity
 Often accompanies asthma
 Eczema = compromised skin barrier @ critical
point in development

Strong link with food allergies
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Eczema + Food Allergies + Asthma
ANAPHYLAXIS
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Very, very itchy
 Red/salmon colored
patches
 Can look like pustules
 Likes the antecubetal
and popliteal fossa
 Actually allergy
mediated
 Treated with
emollients/steroids

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 Subgroup
of disorders results from
hypersensitivity to physical or mechanical
factors
 Cold urticaria
 Pressure -induced urticaria and angioedema
 Aquagenic urticaria
 Solar urticaria
 Exercised- induced urticaria
 History and distribution
 Confirmed by challenge

Cold Challenge ( immediate … 4 hours later)
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 Trauma
–induced pressure
urticaria
 Initial white line
= reflexive vasoconstriction followed by
pruritic, erythematous swelling
 Wheal
or Flare
Reaction
 Chronic ? Cause
Interferes with skin
testing = false +
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 Eye
“rashes” or Conjunctivitis
 Bacterial
 Viral
 Allergic
 Vernal
 Chemical
 Irritant
 Drugs
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 Bacterial
etiology
 Very contagious
 Red conjunctiva,
itchy not painful,
purulent drainage
 Should not be
associated with fever
 Treat with topicals
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Chlamydia

Gonoccocal

Herpes
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 Typically
associated
with an upper
respiratory infection
 Watery, red, irritated
 Doesn’t usually have
any discharge
 Refer anyone who
wears contacts and
has a red eye to a
doctor
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 Typically
occurs in
someone with
seasonal allergies
(hay fever)
 Itchy/bumpy/puffy
and red
 Improves with topical
drops and oral antihistamines
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 Symptoms



URI & Cough
Red, Watery Eyes
Tired
 Koplik’s
spots (2-3 days after above)
 Blotchy Rash (3-5 days after symptoms)



Starts on face at hairline
Spreads downward to neck, trunk, arms, legs,
feet
Fever spike with rash (~ 104 F 40 C)
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 Caused
by infection of human papilloma virus
 Common – fingers and toenails

Subungual (under) periungual ( around) nails
 Plantar-
soles of feet (painful)
 Genital – STI (condyloma)
 Flat – appear wear shaving ( most common in
children however)
 Trends:


Children- warts tend to go away
Adults- tend to stay
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 Viral
etiology
 Difficult to treat
 Can occur anywhere
 Most therapies aimed
at triggering the
immune system
 Treat with topical
irritant/duct
tape/cryo/laser
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Also viral (poxvirus)
 Difficult to treat
 Contagious


Center has viral load
Most advocate leaving
them alone, though can
currette or treat with
topical irritant
 If many lesions- may be
immune system concern

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 Non-specific









reactions
Irritants
Infections
Immune System Disease
Allergies
Cold & Heat
Chemicals
Wind
Sun
Evil Eye
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Typically associated with
an allergic reaction
 Can be seen as a
response to viral
infection, foods,
medications or ?? =
idiopathic
 Refer if S&S of other
system: cough/wheeze
or swelling of
lips/tongue; N & V

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Acute hypersensitivity
reaction
 Can be seen in response
to drugs, illness (viruses,
bacteria) foods and
immunizations
 May look similar to
hives, but typically not
pruritic, look like
targets, can be painful,
and unlike hives, persist
(are fixed)
 No treatment

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


Drugs
 Barbiturates
 PCNs
 Phenytoin
 Sulfonamides
EM Minor – better in 2-6 weeks; can recur
 Herpes simplex
 Mycoplasma
EM Major = SJS
 Reaction to medication
 Infections; radiation Rx; UV light
 Epidermal necrolysis – morality risk high
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 Drug


Atypical antipsychotics
Antibiotics



Sulpha
Penicillins
Other as listed
 Skin



and mucous membranes reaction
Widespread pain
Facial swelling
Tongue swelling
 Top

reaction- Medical Emergency
layer of skin>> necrosis & sloughing
Blistering & Erosion
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 Starts
with a herald
patch (~ 1-3 weeks)

Confused as tinea
 Fine
scaling oval
macules/papules

Pinkish brown
 Christmas
tree
pattern
 Lasts 6-12 weeks, no
treatment
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 Very
itchy in 50 %
 Can be concentrated in
groin, forearms, shin
Some report feeling mildly ill 1- 2 week before
herald patch
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 Herpes



Simplex
Oral = “cold sores” Type 1
Genital = Type 2
But can occur in either area and either type
 Herpes
Zoster
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 Most
infections with
Type I are
asymptomatic
 Most commonly
presents as
gingivostomatitis

Characterized by
fever, and painful
vesicles on oral
mucosa/gingiva
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 Digital
Herpes
Painful
 Contagious
 Virus enters break in skin (torn cuticle) – from
own skin or others


60 % HSV-1 40 % HSV-2
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 Chickenpox
– many
are vaccinated
 Can be fatal for the
neonate
 Fever, painful or
puritic versicles,
typically start on the
trunk and spread
 Shingles = Zoster
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 Reactivation
of
varicella
 Very painful
 Occurs in
dermatomal
distribution
 Can be treated if
recognized early
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


Zoster infects nerve on head
Facial nerve near inner ear
Painful rash on TM, canal,
earlobe, tongue, roof of
mouth, on same side as
weakness or face





Eye closing; motor movements -
Hearing loss on side
Vertigo
Urgent referral
Prompt RX


Steroids
Antivirals
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 Streptococcal
infections (Group A strep or
strep pyogenes)
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 Fever,
sore throat,
malaise, stomach s/s
 Contagious
 Treat with 10 days of
penicillin
 Can go back to school
after 24 hrs on
antibiotics
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

Strept Throat
with rash
 S/T; Fever; H/A


Abd pain; N/V
+ lymph nodes
Rash appears 1-2
days: red and
sandpaper texture
After 7-14 days skin
rubs off / peels

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
Can also cause glomerulonephritis (coke colored urine),
rheumatic fever, impetigo

Also associated with severe invasive infections – pneumonia,
arthritis, sepsis, toxic shock syndrome, etc

Rheumatic Fever
 Appears 2-4 or 1-5 weeks following Strep infection
 Inflammation is the cause of symptoms:
 Inflammation of the heart - chest pain, fatigue, SOB
 Inflammation of the joints - arthritis symptoms
 Inflammation of the skin - skin rashes and nodules
 Inflammation of the CNS (central nervous system) - chorea
(jerking), personality changes

Increased risk of fulminant bacteremia from strep pneumo in kids
with asplenia

Vaccine in US
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 Mumps




and Measles
Must always keep in mind based upon local
immunization policies
World travel – one small planet
Immunization: concern with waning immunity
over time
WHO Travel Advice
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 Viral
infection that
causes systemic
disease and swelling
of the salivary glands
 More severe disease
the older you get
 Not vaccinated
against in some
countries (Japan)
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 Characterized
by
fever, cough, rash,
conjunctivitis
 Encephalitis with
permanent brain
damage 1:1000
 Death 1-3:1000
 Worse if young, sick
and/or malnourished
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 Petechiae,
Purpura and Vasculitis
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 Red
blood cells
outside the vessel
walls – don’t blanch
 Seen with low
platelets
 Can also been seen
with trauma, cough,
increased pressure
(pertussis, asthma)
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 Never
forget about
abuse – bruising or
petechiae, or other
signs of trauma – in
multiple stages of
healing, unusual
places, in strange
shapes
 Obligated to report
!!!!!!!!!!!!!!!!!!!!!!!
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 Large
areas of
cutaneous hemorrhage
 Refer to doctor
 Usually bad, may be
life threatening
 Meningococcemia,
something wrong with
bone marrow
 HSP(Henoch-Schönlein Purpura
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 Tetrad:









Usually Self-Limiting

Usually children

Small minority of cases can
cause severe kidney and
bowel disease
Follows URI ~ 10 days
following
Mean age 5.9 years
Purpura is due to vasculitis
not low platelets (IgA in walls
of blood vessels)
Steroids ease symptoms and
may disrupt abnormal immune
response
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Purpura
Arthritis & Arthralgia
Swelling around joints
Kidney inflammation
Abdominal pain
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 Erythema
 Induration
 Temperature
 Lesion
 Papule
 Pustule
 Macule
 Vesicles
 Hyper
/ Hypo pigmentation
 Linear Oval Circular Target Concentric
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 Size
of each or all lesions
 Color
 Description of shape/distribution of lesion(s)
 Location

What areas are spared?
 Trend

or Changes over time
Mark areas
 Aggravating
or Alleviating Factors
 Associated Signs or Symptoms
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1+1+1=3
 History
 2 Associated

S&S
 Exam



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Potential
Assessment &
Recommendations
79

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 https://identitfy.us.com
SchoolNurse.com CD Head Louse Infestations:
Evidence-Based Strategies & Best Practices for
Tackling Head Lic
 NASN S.C.R.A.T.C.H.
 http://www.cdc.gov/mrsa/groups/
 http://www2.aap.org/new/idphotos.htm
 MedlinePlus
 www.cdc.gov
 www.fda.gov

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