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Dermatology
Childhood Skin Sepsis

Red Flags

Shocked or Septicaemic

Background

  • The term 'skin infection' or 'skin sepsis' includes cellulitis, impetigo, and abscesses of the skin and subcutaneous tissue, all of which are caused by bacterial infection.
  • Other conditions which compromise skin integrity including eczema, insect bites and scabies causing bacterial skin infections are included.
  • A comprehensive approach to intervention which addresses underlying social, economic, and environmental factors as well as health service access and quality issues is required in recurrent, persistent or serious skin sepsis.
  • Due to potential serious complications medical treatment with oral antibiotic is recommended for boils, cellulitis, and impetigo bigger than a shirt button or multiplying impetigo. 

Assessments & Treatments

  1. General considerations
    • Is this the first presentation?
    • Are other household members affected?
    • Significant co-morbidities?
    • What home remedies including Rongoā Māori, the traditional healing system, have been tried and may be affecting treatment?
    • Are social or environmental factors impacting on presentation or proposed treatment?
  2. Boils
      • Most lesions may be treated with incision and drainage alone.
      • Antibiotics may be considered if fever, surrounding cellulitis or co-morbidity, e.g. diabetes, or if the lesion is in a site associated with complications, e.g. face.
      • If recurrent boils, e.g., more than ten boils over more than three months, do a nasal swab and if indicated by results, perform staphylococcal decolonisation with a one week course of intranasal mupirocin. (Fusidic acid is not recommended due to risk of resistance). The patient should be advised to shower daily using triclosan body wash, as well as hot drying, ironing or bleaching towels, sheets, and underclothes for the duration of treatment. Consider other household contacts.
      • Staphylococcus aureus
      • Consider MRSA if there is a lack of response to flucloxacillin.
      • 1st choice: Flucloxacillin Dose PO 50 mg/kg/day in four divided doses up to a max. 500 mg/dose on an empty stomach, for seven to ten days
      • A simple guide for flucloxacillin dosage is:
        • <2 years Flucloxacillin 125mg/5ml 2.5ml qid
        • 2-5 years Flucloxacillin 125mg/5ml 5ml qid
        • >5 years Flucloxacillin 250 mg/5ml 5ml qid (using 50 mg/kg/day as a cross check).
      • Alternatives: Erythromycin, co-trimoxazole
  3. Cellulitis
  4. Wound Infection
    • Wound Care
      • Traumatic and surgical wounds including burns, animal and insect bites often lead to skin infections.
      • They should be treated in the same way as impetigo except for animal bites.
      • Use co-amoxyclav (Augmentin) as empirical therapy for both cat and dog bites. It has good activity against staphs, streps, pasteurella and the vast majority of anaerobes.
      • If unsuccessful consider clindamycin (good activity v staphs streps and anaerobes, good oral bioavailability and good tissue penetration) along with ciprofloxacin (good activity v pasteurella and good oral bioavailability).
      • Cat-scratch disease does not need empirical treatment as uncommon and generally self-limiting.
      • If the patient presents with regional lymphadenopathy following a cat scratch/bite then may consider 5 days of azithromycin if lymphadenopathy is severe or prolonged.
      • Infected wounds are treated under ACC and so should have a claim established at presentation.
      • Remember to check tetanus status and improve as needed.
      • Guidelines for the management of tetanus prone wounds
  5. Infected Eczema
  6. Scabies
    • Scabies

    • Scabies infection produces intense pruritus, especially on the trunk and limbs, and at night.
    • There are usually limited visible signs of the infestation, but burrows may sometimes be observed on the wrists, finger web spaces or the sides and soles of the feet.
    • Complaints of intense pruritus should raise a suspicion of scabies, especially if there is a family report of similar symptoms.
      1. Treatment of both the infested person and their close physical contacts should begin immediately, regardless of whether they are symptomatic. Finger and toenails should be cut short to prevent scratching and carriage of mites and eggs.
        • Linen (Sheets, pillowcases, towels) and clothing should also be washed regularly and not shared during infestation.
      2. Permethrin appears to be the most effective topical scabicide and is considered the safest under 6 months. Malathion lotion may also be considered.  Permethrin 5% lotion (A-Scabies®) and malathion 0.5% liquid (A-Lices®, Derbac-M®) are both available fully funded in New Zealand.
      3. Success or failure of therapy for scabies infestation depends much more on correct application of the topical preparation and treating all household contacts, than on which scabicide to use.
        • Topical gamma benzene hexachloride (Lindane or Benhex) has been used in the past but is now not recommended due to toxicity concerns.
      4. Scabicides should be applied to the entire body, from below the chin and ears, concentrating on the areas between the toes and fingers, genitals and under the nails (use a soft brush if required). Treatment should be applied to the face (avoid eye area) and scalp in children aged under two years, people who are immunocompromised and elderly people. Treatment should be reapplied to areas that are washed within the application time e.g. after hand washing. The treatment (both lotion and cream formulae) needs to be left on the body overnight and washed off the following morning. Clean linen and clothes should then be used.
      5. All personal linen (sheets, pillowcases, towels, blankets in direct contact with skin) and clothing worn next to the skin (underwear, T-shirts, socks, pants) should be laundered in a hot wash cycle.
      6. If hot water is not available, place all linen and clothing into plastic bags and store it away from the family for five to seven days. The mite does not survive beyond four days without skin contact.
      7. Children may return to day care or school the day after treatment is completed.
      8. Repeat application of the treatment is often required in 10-14 days. Linen (sheets,pillowcases,towels) and clothing should also be washed regularly.
    • Symptoms of itch can continue for several weeks after treatment. The most frequent complication of treatment with topical scabicides is post-scabies eczema (generalised eczematous dermatitis). Because of the irritant effects of the various formulations, xerosis (dry skin) might increase and worsen eczema, which could be mistaken for drug failure or re-infestation. Therefore, rehydration of the skin using emollients and anti-inflammatory therapy with topical steroids can be useful.
      • Most treatment failures are due to inadequate treatment or reinfection or persistent itch.
      • Ivermectin 3mgs can be used when prior treatment has failed.
      • It is not funded and is moderately expensive.
      • Single dose required at 200microgram/kg.
      • Safety in children under 15kg not established although generally well tolerated.
      • Consider administration second dose within 2 weeks after initial dose if new specific lesions or heavily infected.
  7. Impetigo/School Sores
    • Impetigo is diagnosed clinically and swabs for micro-biological analysis are not usually required unless there is recurrent infection, treatment failure or a community outbreak.
      • Impetigo (aka school sores) is characterised by small infectious blisters, which later develop a honey-coloured scab like crust.
      • Highly contagious skin infection, most common in infants and school children.
      • Often starts at the site of a minor skin injury e.g. graze, insect bite or scratched eczema, although it can also develop in healthy skin.
      • More common in hot, humid weather, conditions of poor hygiene or close physical contact.
      • Can become a recurrent problem within families and households.
      • Most commonly caused by Staphylococcus aureus and Streptococcus pyogenes.
      • Treatment with a topical or oral antibiotic is recommended as although not serious in itself can lead to serious complications.
      • Impetigo generally presents with pustules and round, oozing patches which increase in size each day. There may be clear blisters, which rupture to form a golden yellow crust. It most often occurs on exposed areas such as the face and hands, or in skin folds, particularly the axillae.
      • Systemic signs are not usually present, however if the infection is extensive, fever and regional lymphadenopathy may occur.
    • Impetigo treatment
      • For small, localised patches of impetigo, topical treatment is recommended initially. Mupirocin cream applied for seven days is a suitable choice (NB Fucidin second line due to increased background resistance). Crusts should be gently removed before applying the cream.
      • Oral antibiotics should be used for extensive disease or systemic infection or when topical treatment fails.
    • Flucloxacillin
      1. For seven days is a suitable choice as it is effective against S. aureus and S. pyogenes.
      2. Dose PO 50mg/kg/day in four divided doses up to a max. 500mg/dose on an empty stomach.
        A simple guide for flucloxacillin dosage is:
        • <2 years Flucloxacillin 125mg/5ml 2.5ml qid
        • 2-5 years Flucloxacillin 125mg/5ml 5ml qid
        • >5 years Flucloxacillin 250mg/5ml 5ml qid (using 50mg/kg/day as a cross check).
      3. Remember flucloxacillin is often not palatable in the liquid form.
    • Erythromycin
      • May be used for people who are allergic to penicillins.
      • PO 40 mg/kg/day in four divided doses up to a max. 500mg/dose with or without food.
    • Other antibiotic considerations
      • Broad spectrum antibiotics such as amoxicillin clavulanate are inappropriate because the organisms are usually known and are susceptible to narrow spectrum antibiotics.
      • If there is a history of MRSA infection empirical therapy should be guided by previous susceptibility data.
      1. To remove crusted areas:
        • If patients wish to remove crusted areas, soak a clean cloth in a mixture of half a cup of white vinegar in a litre of tepid water. Apply this compress to affected areas for about ten minutes several times a day and then gently wipe away crust. Topical antibiotic can then be applied. Note: bullous impetigo should not be lanced.
      2. To prevent the spread of infection:
        • Children should stay away from day-care or school until the lesions have crusted over or they have received at least 24 hours of antibiotic treatment. This may be less important for older children (e.g. secondary school) because they may be less likely to spread the infection through touching each other.
        • Cover the affected areas and wash hands after touching patches of impetigo or applying antibiotic cream or ointment.
        • Avoid close contact with other people.
        • Use separate towels, flannels, clothing and bathwater until the infection has cleared. Disinfect linen and clothing by hot wash, hot dry or ironing.
        • Use hand sanitisers and/or careful washing with household soap and water, several times daily.
      • Recurrent infection and community outbreaks of impetigo may result from the nasal carriage of causative micro-organisms or from fomite colonisation e.g. bed sheets, towels and clothing that may be shared.
      • If nasal carriage is suspected (as in recurrent infection), a nasal swab should be taken to confirm this. A topical antibiotic (such as Mupirocin - Fucidin second line due to increased background resistance) may be applied inside each nostril, three times per day for seven days. All household members and close contacts should also be considered.

Management

    1. Hospitalisation
      • Admit ALL children who: 
        • Are neonates.
        • Are toxic (eg fever, tachycardia, hypotension).
        • Are immunocompromised.
        • Have peri-orbital cellulitis.
        • Deep seated abscess for incision and drainage.
        • Suspected septic arthritis or osteomyelitis.
        • Bullae, necrosis or muscle involvement.
        • Have not responded to oral antibiotics within 48hrs.
        • Have families unable to cope with the illness at home for any reason.
        • Require IV antibiotic therapy.
      • Admit MOST children who:
        • Are systemically unwell.
        • Have another serious systemic illness (e.g. diabetes).
        • Have facial cellulitis / abscess.
        • Are young infants.
        • Have failed a trial of appropriate oral antibiotics (not tolerated or compliance problems).
      • Consider a trial of a different antibiotic if the child is stable and there was intolerance or an inappropriate antibiotic used in the first instance. It is also worth checking the dose of the antibiotic prescribed to see that it was adequate.
    2. Community Management
      • Discuss with all:
        1. Expected clinical response including timeframes.
        2. The importance of taking antibiotics as prescribed until course is complete.
        3. The need to seek immediate advice if:
          • Antibiotics are not tolerated.
          • Skin signs worsen or are not improved after 48 hours (although warn them that there may be an initial increase in redness).
          • Systemic symptoms develop or worsen (e.g. high temperature, going off feeds or nausea and vomiting, unsettled behaviour or less alert/sleepy).
        4. General advice
          • Attention to hand washing for all family members and before and after dressing infected skin.
          • Regular bathing but do not share bathwater-showering maybe preferable while infection.
          • Janola (Sodium hypochlorite 1 capful/15mls to 10litres water) baths once or twice weekly.
          • Launder sheets, towels and clothing using disinfectant or hot water or hot iron.
          • Limit sharing of beds, sheets and towels during infection, infestations.
          • Trim finger and toenails.
          • Encourage elimination of mosquito and other insect triggers.
        5. Specific advice
              • To remove crusted areas:
                • If patients wish to remove crusted areas, soak a clean cloth in a mixture of half a cup of white vinegar in a litre of tepid water. Apply this compress to affected areas for about ten minutes several times a day and then gently wipe away crust.4 Topical antibiotic can then be applied. Note: bullous impetigo should not be lanced.
                • To prevent the spread of infection:
                  • Children should stay away from day-care or school until the lesions have crusted over or they have received at least 24 hours of antibiotic treatment. This may be less important for older children (e.g. secondary school) because they may be less likely to spread the infection through touching each other.
                  • Cover the affected areas and wash hands after touching patches of impetigo or applying antibiotic cream or ointment.
                  • Avoid close contact with other people.
                  • Use separate towels, flannels, clothing and bathwater until the infection has cleared. Disinfect linen and clothing by hot wash, hot dry or ironing.
                  • Use hand sanitisers and/or careful washing with household soap and water, several times daily.
              • Advise about symptomatic treatment
                • Use paracetamol or ibuprofen for pain and fever.
                • Drink adequate fluids to prevent dehydration.
                • Rest and or elevate the affected area for comfort and to relieve oedema (where applicable).
                • Advise to keep the child at home until mobility is normal and child is well.
        6. Make arrangements to see those who need a clinician review.
    3. Clinical Review - Indications Fitness for Schools etc.
      • Timing of clinical review will depend on several factors including:
        • Diagnosis +
          • Cellulitis in children will normally warrant clinical review.
          • Consider clinical review for boils that have required incision and drainage or packing.
          • Impetigo may warrant clinical review especially regarding return to school etc and/or if extensive. Children with impetigo should stay away from day-care or school until the lesions have crusted over or they have received at least 24 hours of antibiotic treatment.
        • Site and Severity.
        • Age of patient.
        • Co-morbidities.
        • Knowledge of family and social circumstances.
      • Investigations
        • Investigations may be indicated at first presentation or due to persistence or recurrence.
        • Consider basic nutrition-anaemia and iron status.
        • Consider other medical conditions eg diabetes, and sources of infection eg intertrigo with obesity, tinea pedis, infected eczema, infected scabies.
    4. No progress indicates treatment failure. Admit to hospital
        • Review diagnosis.
        • Consider irritation/exacerbation from topical treatments.
        • Consider swabs.
        • Check compliance and adequacy of dose and course.
        • Consider local outbreaks knowledge.
        • If hospitalization not indicated repeat/extend or improve oral antibiotic or for impetigo change from topical to oral treatment while swabs awaited.
        • Success of Benzathine penicillin monthly for recurrent impetigo implies that sometimes streptococcus is dominant, as only 10% of local staphylococcus are penicillin sensitive now.
        • Link to Recurrent Skin Sepsis pathway
        • Recurrent infection and community outbreaks of impetigo may result from the nasal carriage of causative micro-organisms or from fomite colonisation e.g. bed sheets, towels and clothing that may be shared.
        • If nasal carriage is suspected (as in recurrent infection), a nasal swab should be taken to confirm this. A topical antibiotic (such as fusidic acid 2% ointment) may be applied inside each nostril, three times per day for seven days. All household members and close contacts should also be treated.  
    5. If Progress is evident in clinical review, end treatment.

Information

  • For Patients
    • If a sore or redness has any one of the following:

      • Is the size of a 10 cent coin or bigger
      • Has pus
      • Is getting bigger
      • Has red streaks coming from it
      • Is not getting better within two days
      • Any sore or redness near the eye needs to be seen by a doctor urgently


      HAERE KI TE TĀKUTA

      MĒNĀ TE HAREHARE, TĒTAHI WĀHI WHERO RĀNEI
      E RITE ANA KI NGĀ ĀHUATANA E WHAI AKE NEI:

      • KUA RITE TE NUNUI KI TE 10 HENETI,
      • HE NUI AKE RĀNEI
      • KUA PIRAU
      • KUA NUNUI HAERE KĒ ATU
      • KUA PUTA HE ROPIROPI WHERO
      • KĀORE ANŌ KIA PAI AKE I TE RĀ 2
      • HE TATA KI TE KARU ME TERE TONU TE HAERE KI TE TAKUTA
      (this includes a Bilingual version, acknowledgements to: Wai and Wena Harawira)
    • RPH Clean Cut Cover Postcard 2010
    • Impetigo is a very common infection causing sores/harehare. It is often called school sores because it is most common in school aged children. Impetigo is caused by bacteria getting into the body through breaks in the skin from a cut or insect bites. Impetigo can occur with no visible break in the skin.

      Features of impetigo are:

      • Blisters often filled with pirau/pus.
      • Itchy blisters filled with yellow/honey coloured fluid, they might leak and crust over.
      • Sometime a Red Rash.
      • The Rash can appear all over the skin and spread to different areas.
      • Swollen lumps, usually lymph glands can appear in the neck groin or armpits.
      • Impetigo can sometimes appear on top of a scabies infection, for example in the finger webs. Both conditions need to be treated.

      Untreated infection/pirau may spread to nearby tissues and through the blood causing “blood poisoning”. The inflammation sometimes causes kidney damage, joint infection, skin scarring or in rare cases, spread to the heart or brain.

      Treating Impetigo/harehare:

      1. Wash and dry hands with soap and warm water.
      2. Clean infected area.
      3. Wash until you have taken away the crust and pus using one of the following:
        • A cup of warm water with ½ teaspoon salt added (sea swimming may help too).
        • One cap of Janola (15mls) put in 10 litres of water in a bath. Dab wounds with betadine ointment.
        • If using Kawakawa, soak kawakawa leaves in boiling water, cool, then dab water on sore or use leaves as poultice.
      4. Cover sores with clean gauze, cloth or fabric sticking plaster each time.
      5. Wash your hands and dry thoroughly.

      Stop the spread of Impetigo:

      Impetigo can spread between people by touching and scratching sores. To avoid this you should: Keep fingernails short and clean. Try and have the same person doing the dressings.

    • Scabies is caused, by tiny insects which burrow along in the skin, laying effs as they go. Above the eggs small blisters form, surrounded by red patches – these are very itchy

      Why is it important to treat Scabies?

      Scabies will not go away without treatment.

      • Scratching a lot can lead to serious skin infections.
      • Untreated skin infections can lead to kidney and blood infections.
      • People who have scabies for a long time can get permanent scarring of the skin.
      • Children scratching lot find it hard to concentrate and learn.
      • Preschool and school teachers can ask that children with untreated scabies be kept at home.

      Who gets it?

      • Anyone! Even the cleanest people get scabies.
      • Washing in soap and water or swimming in the sea will not prevent or cure it.

      How do you catch it?

      • Scabies spreads easily to other people in the family, to boyfriends and girlfriends and to children’s friends.
      • By close body contact e.g. holding hands, hugging, sleeping together.
      • By sharing clothes and bedding.
      • Scabies do not live in furniture or carpets.

      How do you know you have it?

      1. Scabies causes a very itchy rash which is worse at bedtime or when you are warm.
      2. The rash is caused by the scabies laying eggs.
      3. Small blisters form surrounded by red patches. You may notice the rash first:
        • on the wrist
        • between your fingers
        • around the waist
        • on the bottom
        • on private parts
      4. If someone in the family has scabies, others may have caught it without noticing a rash or itch.
      5. If you are not sure if you have scabies, talk to your Doctor, Practice Nurse, Public Health Nurse or Plunket Nurse.
    • Scabies flow diagram
    • Toi Te Ora Healthy Skin Resource page
  • Pathlab Local Sensitivities
  • References
  • Pathway developed with by the following people:

    Name Title

    Dr Todd Hulbert

    GP (Lead)

    Dr Hugh Lees

    Paediatrician (Lead)

    Dr Chris Moyes

    Paediatrician

    Dr Claire McNally

    GP

    Dr Tracy Momsen

    Paediatrician

    Dr Evelyn Gerrish

    GP

    Dr Mark Haywood*

    GP

    Dr Geoff Esterman

    GP

    Dr Jeremy Armishaw

    Paediatrician

    Dr John Malcolm*

    Paediatrician

    Dr Justin Wilde

    Paediatrician

    Dr Richard Forster

    Paediatrician

    Dr Joanne Simson*

    GP Liaison

    Jacky Maaka

    Admin Support

    Kerrie Freeman

    Facilitator

    Richard Harrison

    IT Analyst

    Trevor Richardson

    DSA Manager

    *core group contributer


    Other contributors:

    Dr Michael Addidle  

    Pathologist

    Dr Neil De Wet

    Public Health Physician

    Lindsay Lowe

    Communicable Disease Nurse

    Louisa Blamires

    Medical student

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.