Skin and soft tissue infections

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
    • 1 month – 2 years: 62.5mg-125mg every 6 hours for 7 days
    • 2–9 years: 125–250mg every 6 hours for 7 days
    • 10–17 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 2% cream
  • Apply 3-4 times day for a maximum of 7 days
Reserve Mupirocin for MRSA
Mupirocin 2%
  • Apply every 8 hours for 5 days

Eczema with signs of infection

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 guidance for detailed advice on the management of infected eczema and treatment options.

Check MRSA status and send swabs if:

  • Previously known MRSA positive
  • Current inpatient of 5 days duration or longer
  • Inpatient within the last 3 months
  • Transferred from another hospital
  • Chronic medical conditions, e.g. haemodialysis or wound care
  • Resident of a nursing or residential home

Cellulitis

Patients with an orbital infection, a high temperature or those who are systemically unwell should be considered for admission into secondary care.

River or seawater exposure: consult microbiologist for advice (possible Vibrio infection).

Check MRSA status and send swabs if:

  • Previously known MRSA positive
  • Current inpatient of 5 days duration or longer
  • Inpatient within the last 3 months
  • Transferred from another hospital
  • Chronic medical conditions, e.g. haemodialysis or wound care
  • Resident of a nursing or residential home

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

Flucloxacillin
  • 500mg - 1g every 6 hours for 7 days, if slow response continue for a further 7 days
Penicillin allergy
Clarithromycin
  • 500mg every 12 hours for 7 days, if slow response continue for a further 7 days
If 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:

Co-amoxiclav
  • 625mg every 8 hours for 7 days, if slow response continue for a further 7 days

Leg ulcer

Ulcers are always colonised.

Check MRSA status and send swabs if:

  • Previously known MRSA positive
  • Current inpatient of 5 days duration or longer
  • Inpatient within the last 3 months
  • Transferred from another hospital
  • Chronic medical conditions, e.g. haemodialysis or wound care
  • Resident of a nursing or residential home

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

If antibiotics are required treat with cellulitis regimen (see above)

MRSA decolonisation

The 5-day decolonisation protocol consists of all or some of the following products, depending on colonised sites. Obtain further advice from Infection Control if necessary.

  • Chlorhexidine 4% Skin Cleanser for bathing/ showering/ washing for five days (for patients with nasal and/or skin carriage). Use as liquid soap with a disposable wipe. Do not use patient's flannel. If the patient's condition allows, also use to wash hair. Specialist dermatology advice should be sought prior to decolonising patients with skin disorders, e.g. eczema, psoriasis. Octenisan may be useful for babies and sensitive skin
  • Mupirocin 2% nasal ointment applied to each nostril three times daily (for patients with nasal carriage and /or skin carriage). Apply using a cotton bud or gloved fingertip
  • Mupirocin 2% cream applied to small superficial wounds three times a day. If wounds are healing despite the presence of MRSA, it will probably be more harmful to disturb the wound three times a day to apply mupirocin – in which case normal wound care should continue. Mupirocin is not appropriate for large or complex wounds

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

Bites (Human or Animal)

Human bites: Thorough irrigation is important. 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
  • Contact Microbiology if the bite is from an unusual animal, or presents more than 24 hours after the bite.

Prophylaxis and treatment

Co-amoxiclav
  • 625mg every 8 hours for 7 days
Penicillin allergy
Metronidazole
  • 400mg every 8 hours for 7 days, plus
Doxycycline
  • 100mg every 12 hours for 7 days

Lyme disease

Evidence of erythema migrans and/or symptoms consistent with early Lyme Disease including disseminated cutaneous disease (multiple disseminated EM like rashes)

Serology not required if erythema migrans is present, in all other cases, serological testing is required.

Serology is advised if there is more than 6 weeks since the bite and patient has developed symptoms that are consistent with Lyme (mainly neuropathy or inflammatory arthritis, not 'tiredness'). Prescribers are asked to supply details of exposure and time since onset of symptoms. There is no need to treat while awaiting the result; and outcome is as good from this approach as early treatment.

Non cutaneous disseminated Lyme e.g. neurological, cardiac and rheumatological disease may need longer courses and/or IV antibiotics and should be discussed with a Microbiologist.

Doxycycline
  • 100mg 12 hourly for 21 days

Or

Amoxicillin
  • 1g eight hourly for 21 days
Children
Amoxicillin
  • Refer to cBNF for dosing information, for 14 days
Penicillin allergy
Azithromycin
  • Adult:
    • 500mg on 3 consecutive days each week for 3 consecutive weeks
  • Child:
    • 10mg/kg on 3 consecutive days each week for 3 consecutive weeks

Scabies

Treat all home and 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. Reapply if hands are washed in this 48 hour period
  4. 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 liquid 0.5% aqueous liquid
  • Two applications one week apart

Dermatophyte infection

Skin: localised infection

The use of OTC dusting powders and creams 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 infections; 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 visible clearance (i.e. 4-6 weeks) to reduce relapse
Miconazole 2%
  • Topical: apply every 12 hours for 1-2 weeks after visible clearance (i.e. 4-6 weeks) to reduce relapse
Clotrimazole 1%
  • Topical: apply 2-3 times daily for 1-2 weeks after visible clearance (i.e. 4-6 weeks) to reduce relapse

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
  • Oral: 250mg daily for 4 weeks
Itraconazole
  • Oral: 200mg daily for 7 days
  • Use twice daily for palm or sole infections
  • See warnings below

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
  • Oral: 250mg daily
  • Treat fingernails for 6 to 12 weeks
  • Treat toenails for 12 weeks

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

Itraconazole
  • Oral: 200mg twice daily for 7 days of each month
  • Treat fingernails with 2 courses
  • Treat toenails for 3 courses
  • See warnings below

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.
    2. 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 tablets
  • 800mg five times daily for 7 days
  • Child doses see cBNF

Cold sores

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

 

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

 

  • First line
  • Second line
  • Specialist
  • Hospital