Avoid topical Benzoyl peroxide

Refer to dermatology specialist patients who have failed to respond to two courses of 6 months oral treatment.

Self-care advice: wash with mild soap or cleanser and lukewarm water not more than twice a day; avoid vigorous scrubbing and excessive use of makeup and cosmetics; benzoyl peroxide is a useful topical over-the-counter preparation, refer to minor ailments scheme if appropriate.

If topical treatment ineffective or acne is moderate to severe, oral antibiotics are preferred. Consider swab in failure of clinical response.

Severe acne, cases unresponsive to prolonged antibiotics, the presence of scarring or psychological problems should be referred to a dermatologist.

Adequate wound toilet is essential and the mainstay of treatment. Consider surgical debridement if required.

Assess rabies risk for animal bites occurring abroad.

Assess tetanus immunisation status.

Assess HIV and Hepatitis B and C risk for human bites.

Penicillin allergy: review at 24 and 48 hours, as not all pathogens are covered.

Note Consider risk of blood borne virus transmission. Further guidance available from Public Health England.

Also, see recurrent boils

Swabs to confirm nasal carriage of Staphylococcus aureus. Ask for PVL testing to be carried out. Mupirocin resistance should be discussed with a specialist.

Class II cellulitis – patient febrile and ill, or comorbidity, admit for intravenous treatment, or use OPAT: consider admission if febrile and unwell. Outpatient Parenteral Antimicrobial Therapy may be available for those assessed for suitability for the service according to strict criteria. See OPAT

Class III cellulitis – if toxic appearance, admit.

If river or sea water exposure, discuss with a microbiologist.

Review response to treatment after 7 days. If slow response, continue for further 7 days.

Review response to treatment after 7 days. If slow response, continue for further 7 days.

Orbital cellulitis: urgent referral to hospital

Varicella zoster virus (VZV) is highly communicable.

Admit patient urgently if immunocompromised.

Seek urgent advice from obstetrician for pregnant women with chickenpox.

Contacts of VZV (chickenpox or shingles): for babies under one month of age, non-immune pregnant women and immunocompromised contacts maybe offered immunoglobulin - contact virologist or microbiologist urgently for advice.

Send hair and scalp scrapings for laboratory confirmation before commencing systemic therapy. Commence treatment if microscopically positive and review once culture results available. Refer to dermatologist

Refer to a dermatologist if extensive.

Skin scrapings for culture and microscopy are not indicated: in cases of uncomplicated athlete’s foot, mild skin ringworm or mild groin infections. Samples for fungal culture are indicated when oral treatment is being considered (e.g. scalp ringworm or nail disease); in severe or extensive skin fungal infections (e.g. moccasin-type athlete’s foot); in skin infections refractory to initial treatment; when the diagnosis is uncertain.

Commence treatment if microscopically positive and review once culture results available.

Encourage self-care with over the counter medicines for self limiting conditions.

Most cold sores resolve after 5 days without treatment. Topical antivirals applied prodromally can reduce duration by 12 - 18 hrs.

Encourage self-care with over the counter medicines for self limiting conditions

Advise on the importance of personal hygiene e.g. not to share communal items such as towels, flannels etc. Avoid topical steroids or long-term topical antibiotic use. Further advice may be obtained from the community infection control nurse.

Wound debridement and swab.

Lateral nail ablation recommended when infection settled if the problem is recurrent.

Hot wash (50°C) all clothes and bedding or dry clean following first treatment.

Apply to all hairy parts of the body. Repeat after 7 days. Consider other sexually transmitted infections.

Encourage self-care of this condition

A course involves two treatments one week apart.

Reinfection is more probable than treatment failure. Combs should be thoroughly cleaned after each use.

Use different insecticides for subsequent course following treatment failure. Avoid shampoos and do not use insecticides as prophylaxis

Treat erythema migrans. Suspected Lyme disease with focal symptoms, uveitis, or cardiac complications should be disused with a specialist.

Prophylaxis is not routinely recommended in Europe. Risk increased if high prevalence area and the longer tick is attached to the skin. Only give prophylaxis within 72 hours of tick removal. Give safety netting advice about erythema migrans and other possible symptoms that may occur within one month of tick removal.

The most common cause of mastitis is an ineffective attachment at the breast. It is essential that this is corrected otherwise the problem will persist and secondary problems may result despite antibiotic treatment

Infection within 30 days of surgery should be referred back to the responsible Trust.

Swab wound for culture and sensitivity. Consider nature of the operation and likely pathogens including MRSA status.

Consider hospital admission and discuss with a medical microbiologist.

Post-operative infections involving a prosthetic implant avoid prescribing antibiotics and refer urgently back to the surgeon.

Infants aged less than 2 years and the elderly aged over 65 years require head and face application (avoiding eyes) initially. Unlicensed use in less than 2 months of age, refer to paediatric dermatologist.

Itch may persist for 4-6 weeks following effective treatment; crotamiton or aqueous cream may be beneficial. Sedative antihistamines may help with nocturnal itch.

Hot wash (50°C) all clothes and bedding or dry clean following first treatment.

If patient institutionalised refer to Community Infection Prevention and Control Team

Refer to Dermatology for specialist advice including prescribing oral ivermectin (unlicensed).

Refer to ophthalmologist urgently if ocular involvement.

Antiviral treatment if not within 72 hours of rash: consider up to one week after rash onset if high risk of severe shingles or complications (continued vesicle formation, older age, immunocompromised, severe pain).

Wound debridement if suspected foreign body and swab.

Empirical antibiotic treatment

Refer all patients immediately to the community podiatry team as per local guidance stating clearly that the patient has diabetes and a new ulcer.

Decision triggers for referral

1. New foot ulceration
2. Recurrent foot ulceration
3. Unexplained foot pain, swelling and deformity
4. Cellulitis of the foot
5. Suspected osteomyelitis of the toes
6. Suspected Charcot neuroarthropathy
7. Severe neuropathic pain
8. Deteriorating foot ulcer, despite earlier assessment by MDT

Clinical emergency

1. Critical limb ischaemia
2. Acute Charcot suspected
3. Spreading cellulitis
4. Gangrene
5. Significantly deteriorating foot ulceration

This list is not exhaustive, use clinical judgement

Ulcers are always colonised. Check MRSA status. Antibiotics do not improve healing unless active infection. If active infection, send pre treatment swab. Review antibiotics after culture results.

Signs of active infection: cellulitis, increased pain, pyrexia, purulent exudate, odour

Refer to local district nurse team as per local guidance.