This document summarizes several common bacterial and fungal skin infections. It describes the etiology, signs and symptoms, and management of conditions like impetigo, folliculitis, furuncles, carbuncles, hidradenitis suppurativa, acne, cellulitis, erysipelas, lymphadenitis, and gas gangrene. It also covers fungal infections caused by dermatophytes, including tinea capitis, corporis, unguium, and cruris. Effective treatment involves identifying the causative organism and using appropriate topical or systemic antifungal/antibacterial medications along with wound cleaning and drainage when necessary.

1. Skin Disorders

3. Bacterial Infections
• Bacteria are single celled micro-organisms
– Spherical, doublets, and spirochetes
• Staphylococcus
– Gram positive bacteria that appears in clumps in skin and
upper respiratory tract
• Streptococcus
– Chain bacteria often associated with systemic disease and
skin infections
• Bacillus
– Spore forming, aerobic, and occasionally mobile
– Can cause systemic damage

4. • Impetigo Contagiosa
– Etiology
• Caused by A-beta-hemolytic streptococci, S aureus or
combination of these bacteria
• Spread through close contact
– Signs and Symptoms
• Mild itching and soreness followed by eruption of small
vesicles and pustules that rupture and crust
• Generally develops in body folds that are subject to friction
– Management
• Cleansing and topical antibacterial agents
• Systemic antibiotics

6. • Furunculosis (Boils)
– Etiology
• Infection of
hair follicle
that results in
pustule
formation
• Generally the
result of a
staphy.
Infection
• Usually, the cause is
bacteria such as
staphylococci that are
present on the skin.

7. – Signs and Symptoms
• Pustule that becomes reddened and enlarged as well
as hard from internal pressure
• Pain and tenderness increase with pressure
• Most will mature and rupture
– Management
• Care involves protection from additional irritation
• Referral to physician for antibiotics
• Keep athlete from contact with other team members
while boil is draining

8. • Carbuncle
• A carbuncle is a skin infection that often
involves a group of hair follicles. The
infected material forms a lump, which
occurs deep in the skin and may contain
pus.
• most commonly Staphylococcus aureus, or
Streptococcus pyogenes,

9. – Etiology
• Similar in terms of early stage development as furuncles
– Signs and Symptoms
• Larger and deeper than furuncle and has several
openings in the skin
• May produce fever and elevation of WBC count
• Starts hard and red and over a few days emerges into a
lesion that discharges yellowish pus
– Management
• Surgical drainage combined with the administration of
antibiotics
• Warm compress is applied to promote circulation

12. • Folliculitis
– Etiology
• Inflammation of
hair follicle
• Caused by non-
infectious or
infectious agents
• Moist warm
environment and
mechanical
occlusion contribute
to condition
• Psuedofolliculitis
(PFB)

13. – Signs and Symptoms
• Redness around follicle that is followed by
development of papule or pustule at the hair
follicle
• Followed by development of crust that sloughs off
with the hair
• Deeper infection may cause scarring and alopecia
in that area
– Management
• Management is much like impetigo
• Moist heat is used to increase circulation
• Antibiotics can also be used depending on the
condition

14. • Hidradenitis Suppurativa : a chronic suppurative inflammatory
disease of the apocrine sweat glands
Etiology
• Primary inflammation event of the hair follicle resulting in
secondary blockage of the apocrine gland
• Post-pubescent individuals are more likely to exhibit HS.[8]
• Plugged apocrine (sweat) gland or hair follicle
• Excessive sweating
• Sometimes linked with other autoimmune conditions[9][10]
• Androgen dysfunction
• Genetic disorders that alter cell structure
• Patients with more advanced cases may find exercise intolerably
painful, which may increase the rate of obesity among sufferers.

15. – Signs and Symptoms
• Begins as small papule that can develop into deep
dermal inflammation
– Management
• Avoid use of antiperspirants, deodorants and shaving
creams
• Use medicated soaps and systemic antibiotics

17. • Acne Vulgaris
– Etiology
• Inflammatory disease of the hair follicle and the
sebaceous glands
• Sex hormones may contribute
– Signs and Symptoms
• Present with whiteheads, blackheads, flesh or red
colored papules, pustules or cysts
• If chronic and deep = may scar
• Psychological impact
– Management
• Topical and systemic agents used to treat acne
• Mild soaps are recommended

19. • Paronychia and Onychia
• An infection that develops along the edge of
the fingernail or toenail is called a paronychia
– Etiology
• Caused by staph, strep and or fungal organisms that
accompany contamination of open wounds or hangnails
• Damage to cuticle puts finger at risk

20. – Signs and Symptoms
• Rapid onset; painful with bright red swelling of
proximal and lateral fold of nail
• Accumulation of purulent material w/in nail fold
– Management
• Soak finger or toe in hot solution of Epsom salt 3 times
daily
• Topical antibiotics, systemic antibiotics if severe
• May require pus removal through skin incision

24. • Tetanus Infection
– Etiology
• Acute infection of the CNS caused by tetanus
bacillus
• Bacteria enters through the blood and open
wounds
– Signs and Symptoms
• Stiffness of the jaw and muscles of the neck
• Muscles of facial expression produce contortion
and become painful
• Fever may become markedly elevated
– Management
• Treat in intensive care unit
• Childhood immunization

26. • Connective tissue
• dermis and
subcutaneous tissues
• acute spreading
• pain, erythema,
edema, and warmth
Cellulitis：Characteristic

27. • trauma or surgery
• causing a lesion in the skin
• may have no discernible dermal injury
• develops over a period of several days
Cellulitis：History

28. The affected area
• Warmth
• Erythema
• Edema
• Tenderness
The proximal to the area
• Ascending lymphangitis
• lymphadenopathy
Cellulitis：Signs & Symptoms

29. • Significant erythema
• An eroded area near the
center
• Irregular margins but
not raised
• An ulcerated area in the
center
• Painful and warm to the
touch
Severe Cellulitis：

30. • normal
– group A streptococci & Staphylococcus aureus
• Infants
– group B streptococci
• Immunocompromised
– Pneumococcus gram-negative rods or fungi
• Wounds
– Aeromonas hydrophila, gram-negative rod
Etiology： Microorganism

31.  Obesity
 Diabetes
 Poor hygiene condition
 Intravenous drugs
 Immunodeficiency
High Risk Factors

32. • Bacteremia
• Local abscess
• Superinfection with gram-negative organisms
• Lymphangitis
• Thrombophlebitis
• Facial cellulitis in children (meningitis in 8%)
• Gas gangrene(amputation & mortality in 25%)
Cellulitis：Complications

33. • Escherichia coli in nephrotic syndrome
• Cellulitis of the lower extremities in geriatric
patients (thrombophlebitis)
• Pseudomonads in immunocompromised children
Cellulitis：Special Concerns

34. Antibiotics:
• penicillinase-resistant synthetic penicillin
• first-generation cephalosporin
• clindamycin
• metronidazole
Management：

35. • caused by group A beta-hemolytic streptococci
• Involving dermis and lymphatics
• more superficial subcutaneous infection than
cellulitis
• characterized by intense erythema, induration, and
a sharply demarcated border,
Erysipelas：Characteristic

36. 70-80% in lower extremities
Erysipelas：Characteristic

37. 5-20% in face
Erysipelas：Characteristic

38. • Abrupt onset of illness (Painful rash)
• Initial fever and chills (1-2 days later)
• Muscle and joint pain
• Nausea
• Headache
• Systemic infectious manifestations
• Skin discomfort
Erysipelas：History

39. • Fever
• Dermatologic signs
• Painful, erythematous, and edematous rash
• Sharply-raised border with abrupt demarcation from
healthy adjacent skin
• Lymphangitis
• Erythema (irregular extensions)
• Desquamation
• Vesicles
• Lymphadenopathy
Erysipelas：Signs & Symptoms

40. Sharply-raised
border with abrupt
demarcation from
healthy adjacent skin
Erysipelas：Signs & Symptoms

41. •Painful
•Erythematous
•Edematous
rash
Erysipelas：Signs & Symptoms

42. • Group A streptococci (the most)
• Group G, C, B streptococci (less)
• Staphylococci (rarely)
Etiology： Microorganism

43. • Antibiotics (as soon as possible)
• Penicillin
• Erythromycin
• Cephalexin
• Symptomatic treatment
• Antipyretic
• Analgesics
• Hydration (oral intake if possible)
• Cold compresses
Management：

44. • Gangrene & Amputation
• Bacteremia & Sepsis
• Scarlet fever
• Pneumonia
• Abscess
• Embolism
• Meningitis
• Death
Complications：

45. • The infection of lymph nodes (glands)
• usually associated with the site of the
underlying infection, tumor, inflammation
• common result of a cellulitis or other
bacteria infection
Lymphadenitis：Characteristic

46. • swollen, tender, hard nodes
• smooth or irregular to touch
• or soft and "rubbery" (fluctuant) if an abscess has formed
• the skin over a node may be reddened and hot
Lymphadenitis：Signs & Symptoms

47. • Infection of lymph vessels/channels
• Commonly results from cellulitis or abscess in the
skin or soft tissues
• A progressing infection raising spread of bacteria
to the bloodstream
– life-threatening infections
• Be confused with a clot in a vein (thrombophlebitis)
Lymphangitis：Characteristic

48. • red streaks
– from infected area to the armpit or groin
• throbbing pain
– along the affected area
• lymph nodes
• fever and chills
• malaise,loss of appetite, headache, muscle aches
Lymphangitis：Signs & Symptoms

49. • Physical examination
• Biopsy (LN)
• Blood culture
Lymphadenitis and lymphangitis may spread within
hours, spreading to the bloodstream may be fatal.
Diagnosis：

50. Treatment should begin promptly
• Specific antibiotics
• Surgical drainage
• Hot moist compresses
Management：

51. Necrotizing Fasciitis
It is a progressive, rapidly spreading,
inflammatory infection located in the deep
fascia with 2ry necrosis of the subcutaneous
tissue.

52. Risk Factors
• Immunocompression illnesses
e.g.: DM, Cancer, alcoholism, vascular
insufficiency, organ transplant, HIV or neutropenia.
• Trauma or foreign bodies in surgical wound.
• Idiopathic as scrotal or penile necrotizing fasciitis.

53. Causative Agents
It is a mixed microbial flora:
# microaerophilic streptococci.
# staphylococci.
# aerobic gram –ve
# anaerobes ( peptostreptococi –
bacteroids)

54. Pathophysiology

55. Mortality & Morbidity
The overall morbidity & mortality is 70 – 80%
Fournier’s gangrene has a reported mortality as
high as 75%

56. Sex: Male : Female 3:1
Age:
* the mean age is 38 to 44 years.
* pediatric cases are rare but
reported from countries where
poor hygiene in.

57. Clinical Features
Symptoms:
*sudden onset of pain and swelling at the
site of trauma or recent surgery.
*in some cases, the symptoms may begin
at the site distant from the initial traumatic
insult.
*Fournier's gangrene begin with pain and
itching of the scrotal skin.

58. Clinical Features (cont.)
Sings:
* pt. appears moderately to severely toxic (but sometimes might looks
well)
* typically, erythema that quickly spread over a course of hours to days.
* the redness quickly spread & the margin of infection move out into
normal skin without being raised nor sharply demarcated.
* anesthesia
# Note:
*I.M. injections & I.V. infusions may lead to necrotizing fasciitis.
*minors insect bites may set the stage for necrotizing infections.

61. Investigations
Lab: CBC, U&E, Glu, Creatinine, Blood &
tissue cultures, Urine analysis, &
ABG.

62. Investigations (cont.)
Imaging Studies:
# X-ray  gas in the subcutaneous
fascia planes.
?? D.D. of subcutaneous gas in a
radiograph.
# C.T.  demonstrating necrosis with
asymmetric fascial thickening
& gas in the tissues.
# MRI.

64. Investigations (cont.)
Microbiology:
Gram stain & wound culture
Procedures:
Biopsy is the best method to use to obtain
proper cultures for micro-organisms.

66. Emergency Department care
• A
• B
• C
• D

67. Management
If streptococci are the identified major pathogens, the
D.O.C is Penicillin-G with clindamycin as an
alternative.
To ensure adequate treatment, we have to cover
aerobic & anaerobic bacteria.
The anaerobic coverage can be provided by
Metronidazole or 3rd generation cephalosporin's.

68. Management (cont.)
Gentamicine combined with clindamycine or
chloramphenicol has been reported as a
standard coverage.
Ampicilline may be added to the basic regimen
to treat enterococci if suspected by gram
stain.

69. Further In-Patient Care
• Surgical debridment.
• Fasciotomy.
• H.B.O.

70. Complications
• Renal Failure.
• Septic Shock with cardiovascular collapse.
• Scarring with cosmetic deformity.

71. Microbiological emergency
Caused by exotoxin-producing
Clostridium perfringens
usually after direct inoculation of
contaminated, ischaemic wound
Gas Gangrene
Myonecrosis, gas production, sepsis
Rapid onset and toxaemia / shock
Crepitus, brawny oedema
Foul-smelling discharge, brown skin
discoloration, bullae,
May advance 1“ per hour!
Disproportionate pain.
Mortality > 25%

73. Fungal Infections
• Group of organisms that include yeast and
molds which are usually not pathogenic
• Grow best in unsanitary conditions with
warmth, moisture and darkness
• Infections generally occur in keratinized
tissue found in hair, nails and stratum
corneum
• Dermatophytes (Ringworm fungi)
– Cause of most skin, nail and hair fungal
infections

74. • Tinea of the Scalp (tinea capitis)
– Signs and Symptoms
• Ringworm of the scalp begins as a small papule that
spreads peripherally
• Appears as small grayish scales resulting in
scattered balding
• Easily spread through close physical contact
– Management
• Topical creams and shampoos are ineffective in
treating fungus in hair shaft
• Systemic antifungal agents are replacing older
agents due to increased resistance
• Some topical agents are used in conjunction

76. • Tinea of the Body
(tinea corporis)
– Signs and
Symptoms
• Commonly involve
extremities and
trunk
• Itchy red-brown
scaling annular
plaque that expands
peripherally
– Management
• Topical antifungal
cream

77. • Tinea of the Nail (tinea unguium/
onchomycosis)
– Signs and Symptoms
• Fungal infection of the nail -- found commonly in
those engaged in water sports or who have chronic
athlete’s foot
• Nail becomes thick, brittle and separated from its bed
– Management
• Some topical antifungal agents have proved useful
• Systemic medications are most effective
• Surgical removal of nail may be necessary if extremely
infected

79. • Tinea of the Groin
(tinea cruris)
– Etiology
• Symmetric red-
brown scaling
plaque with snake-
like border
– Signs and
Symptoms
• Mild to moderate
itching

80. – Management
• Treat until cured
• Will respond to many of the non-prescription
medications
• Medications that mask symptoms should be avoided
• Failure to respond to normal management may
suggest a non-fungal problem (such as bacteria) and
should be referred to a physician
• May require additional topical medications and oral
prescriptions

81. • Athlete’s Foot (tinea pedis)
– Etiology
• Most common form of superficial fungal infection
• Tricophyton species are most common cause of
athlete’s foot
• Webs of toes may become infected by a
combination of yeast and dermatophytes
– Signs and Symptoms
• Extreme itching on soles of feet, between and on
top of toes
• Appears as dry scaling patch or inflammatory
scaling red papules forming larger plaques
• May develop secondary infection from itching and
bacteria
– Management
• Topical antifungal agents and good foot hygiene

83. • Candidiasis (Moniliasis)
– Etiology
• Yeast-like fungus that can produce skin, mucous
membrane and internal infections
• Ideal environment includes hot humid weather, tight
clothing, and poor hygiene
– Signs and Symptom
• Infections w/in body folds
• Presents as beefy red patches and possible satellite
pustules
• White, macerated border may surround the red area;
deep painful fissures may develop at skin creases
– Management
• Maintain dry area
• Use antifungal agents to clear infection

85. • Tinea Versicolor
– Etiology
• Caused by a yeast
• Appears commonly in areas in which sebaceous glands actively
secrete body oils
– Signs and Symptoms
• Fungus produces multiple, small, circular macules that are pink,
brown, or white
• Commonly occur on chest, abdomen, and neck
• Do not tan when exposed to sun and usually are asymptomatic
– Management
• Straightforward treatment - recurrences are common
• Use selenium shampoo (Selsun) and topical econazole nitrate (or
something similar)
• When microorganism has been eradicated, re-pigmentation of the
area will occur

87. Viral Infections
• Ultramicroscopic organisms that require host
cells to complete their life cycle
– May stimulate cell chemically to produce more
virus until host cell dies
– Lies within bud-like structure that does not
damage cell or virus, w/out causing infection
• A number of skin infections are caused by
viruses

88. • Herpes Simplex Labialis, Gladiatorum, and
Herpes Zoster
– Etiology
• Highly contagious and is usually transmitted directly
through a lesion in the skin or mucous membrane
• Resides in sensory nerve neurilemmal sheath
following initial outbreak
• Recurrent attacks stimulated by sunlight, emotional
disturbances, illness, fatigue, or infection
• Type I vs. Type II
– Signs and Symptoms
• Early indication = tingling or hypersensitivity in an
infected area 24 hours prior to appearance of lesions
• Local swelling followed by outbreak of vesicles
• Athlete may feel ill w/ headache, sore throat, swollen
lymph glands and pain in area of lesions

90. – Signs and Symptoms (continued)
• Vesicles generally rupture in 1-3 days spilling serous
material
• Heal in generally 10-14 days
• If an athlete has an outbreak they should be
disqualified from competition due to contagious
nature of condition
– Management
• Herpes simplex lesions are self limiting - reduce pain
and promote early healing
• Use of antiviral drugs can reduce recurrence and
shorten course of outbreak
– Complications
• Can lead to secondary infection

91. Verruca Virus and Warts
• Varied of forms exist
– verruca plana (flat wart), verruca plantaris (plantar
wart), and condyloma acuminatum (venereal wart)
• Different types of human papilloma virus have
been identified
– Uses epidermal layer of skin to reproduce and
growth
• Wart enters through lesion in skin

92. • Common Wart
– Signs and Symptoms
• Small, round, elevated lesion with
rough dry surfaces
• Painful if pressure is applied
• May be subject to secondary bacterial
infection
– Management
• If vulnerable, they should be protected until treated by
a physician
• Use of electrocautery, topical salicylic acid or liquid
nitrogen are common means of managing this condition

93. • Plantar Warts
– Etiology
• Spread through papilloma virus
– Signs and Symptoms
• Located on sole of foot, on or adjacent to areas of
abnormal weight bearing
• Areas of excessive epidermal thickening
• Discomfort, point tenderness
• Hemorrhagic puncta (black seeds)
– Management
• While in competition, protect and prevent spreading
• Pair away callus and apply keratolytic
• Following season, wart can be removed by freezing it or
by electrodessication (maintain protection until removal)

95. • Molluscum Contagiosum
– Etiology
• Poxvirus infection which is more contagious than
warts (especially during direct body contact)
– Signs and Symptoms
• Small, flesh or red colored, smooth-domed papules
with central umbilication
– Management
• Physician referral is necessary
• Cleansing and destructive procedure (counterirritant
such as cantharidin, surgical removal or cryosurgery)

97. Allergic, Thermal, and Chemical
Skin Reactions
• Allergies are immunologically mediate responses
to molecules in dyes and proteins against which
the body’s immune system is sensitized
• Allergens may be food, drugs, clothing, dusts,
pollens, plants, animals, heat, cold, or light
• The skin will reflect an allergy in many ways such
as reddening and swelling of the tissue, uticaria or
hives, burning or itching
• ATC’s must recognize gross signs of allergic
responses and be prepared to remove allergens and
treat topically or systemically with antipruritic
agents

98. • Contact Dermatitis (allergic and irritant)
– Etiology
• Plants are the most common cause (poison ivy, poison oak, sumac,
ragweed, primrose)
• Topical medications
• Chemicals found in fragrances and preservatives of soaps, detergents
– Signs and Symptoms
• Onset may range from 1 day to 1 week
• Redness, swelling, formation of vesicles that ooze fluid and form crust,
constant itching
• May change from redness and blistering to erythematous scaling,
lichenified papules and plaques
– Management
• Avoid allergen
• Tap water compresses or soaks, topical corticosteroids

100. • Milaria (Prickly Heat)
– Etiology
• Continued exposure to heat and moisture causing
retention of perspiration by sweat glands
– Signs and Symptoms
• Itching and burning vesicles and pustules
• Occurs most often on arms, trunks, and bending
areas of the body
– Management
• Avoidance of overheating, frequent bathing with
non-irritating soap, wearing loose-fitting clothing
and use of antipruritic lotions

102. • Chilblains (pernio)
– Etiology
• Caused by excessive exposure to cold
– Signs and Symptoms
• Tissue does not freeze but reacts with edema,
reddening and possibly blistering along with a
sensation of burning and itching after exposure to
cold
– Management
• Exercise and gradual warming of the part
• Massage and application of heat are contraindicated
• Some systemic drugs can be used in severe cases

104. • Sunburns
– Etiology
• Inflammatory response to injury caused by
ultraviolet solar radiation
• Must be cautious of physical characteristics,
chemicals, food and drugs that make individuals
more susceptible
– Signs and Symptoms
• Varies from erythema to severe blistering
• May experience shock if severe enough
• Can cause malfunctioning of organs w/in the skin
• Will appear 2-8 hours following exposure, with
symptoms becoming most severe at 12 hours
• S&S will dissipate w/in 72-96 hours

106. • Sunburns (continued)
– Management
• Can be prevented through the use of sunscreen (sun
protection factor or SPF)
– Filters ultraviolet light
– Water/sweat resistant sunscreen is recommended
• Treat a burn according to the degree of
inflammation
• Cool water, aloe based solutions
• More severe burns may require bathing in a bath of
cornstarch or vinegar
• Severe burns require physician assistance

107. • Psoriasis
– Etiology
• Exact cause is unknown -- genetic factors may play a
role in condition
• Infection, smoking, some drugs and possible hormonal
factors may cause an outbreak
– Signs and Symptoms
• Lesion begins as reddish papules that progress to
plaques
• Lesions progress to yellowish white scaly condition
that tends to be located on the elbows, knees, trunk,
genitalia, and umbilicus

109. • Psoriasis (continued)
– Management
• Teaching patient self management
• Glucocorticoids and kerolytic agents can be used in
conjunction with each other
• Long term oral medications may be necessary
• Counseling may be necessary for psychological
aspects of condition

110. Infestation and Bites
• Scabies
– Etiology
• Caused by mites which cause extreme nocturnal itching (tunnels
and lays eggs)
– Signs and Symptoms
• Appear as dark lines between fingers and toes, body flexures,
nipples and genitalia
• Excoriations, pustules and papules caused by itching tends to hide
true cause
• Skin develops hypersensitivity to the mite
– Management
• Permethrin 5% is treatment of choice
• Washing of bedding and clothes is necessary
• Topical corticosteroids may be necessary to treat itching

112. • Lice (Pediculosis)
– Etiology
• Manifestation by the louse (louse of head, pubic
region and body)
– Signs and Symptoms
• Bites cause itching dermatitis through subsequent
scratching -- promotes pustule and excoriations to
develop
– Management
• Cure is rapid with use of any number of agents
• Good hygiene is paramount
• To prevent re-infestation all clothing and bedding
should be washed in hot soapy water or discarded

114. • Fleas
– Etiology
• Small wingless insects that suck blood
• Can transmit systemic diseases
– Signs and Symptoms
• Great deal of discomfort can be felt if come into
contact with a high number of fleas
• Concentrate bites on ankles and lower legs
– Management
• Following a bite, itching must be prevented with
antipruritic lotion
• Avoid scratching to prevent secondary infection
• Insecticides can also be effective

116. • Ticks
– Etiology
• Parasitic insects that have an affinity for blood
• Carriers of a variety of microorganisms that can
transmit Rocky Mountain spotted fever and Lyme
disease
– Signs and Symptoms
• Headaches, fever, malaise, myalgia, and rash,
perechiae and prupura, enlarging annular red ring w/
or w/out central red papule
– Management
• Remove tick (mineral oil or fingernail polish)
– Grasping head of tick is an acceptable method
• Systemic treatment is necessary to prevent morbidity
and mortality associated with RMSF and Lyme
disease

118. • Mosquitoes
– Etiology
• Unless carrying a disease, mosquitoes produce bites that
cause only mild discomfort
• Attracted to lights, dark clothing and warm moist skin
– Signs and Symptoms
• Small reddish papule with associated itching
– Management
• Topical medication
• Use of repellents can also be used on the skin to prevent
contact with mosquitoes

119. • Stinging Insects
– Etiology
• Bees, wasps, hornets, yellow jackets -- inflict
venomous sting
• Hypersensitive individuals may experience an
allergic reaction
– Signs and Symptoms
• If an allergic reaction occurs an increase in heart rate
and breathing will occur, along with chest tightness,
dizziness, sweating and even LOC

120. • Insect Stings (continued)
– Management
• To prevent, avoid wearing scented lotions or
shampoos, brightly colored clothes, jewelry, suede, or
leather, and avoid going barefoot.
• If an athlete is susceptible to anaphylactic reactions
instructions on use of an EpiPen are necessary
• If uncomplicated, the stinger should be removed with
tweezers or a credit card and soothing medications
should be applied
• Soap detergent will also lessen symptoms
• In cases of anaphylactic reaction immediate physician
referral is necessary

122. Taking history

123. • The diagnosis of skin disease begins with
taking a history.
• This is followed by careful physical
examination.
• If at this stage a diagnosis has not been
made, further examinations should be
carried out.

124. • 3 History of presenting condition How long
has the lesion(s) been present? This is the
most important question in the history. Acute
lesions presenting for less than two weeks
need to be distinguished from those that are
chronic.

125. • Do the lesions come and go?
• Do they occur at the same sites or different sites?
This is important if a diagnosis of urticaria or herpes
simplex is being considered.
• Was the lesion caused by trauma/insect bite?
• Is there any associated discharge or odour?
• Has the patient travelled abroad recently?

126. 3 Relationship to physical agents A past history of living or working in a hot
climate may be the clue you need to diagnose skin cancer.
• Sun exposure is often indicated by a rash on the face or back of the hands.
The important question here is the time interval after sun exposure until
the rash appears. In solar urticaria, the rash appears within five minutes
of sun exposure and is gone within an hour; in polymorphic light eruption,
the rash occurs several hours after sun exposure and lasts several days.
• Ask about irritants on the skin if the patient has hand eczema. Common
irritants include detergents, oils and some solutions that are found in the
workplace (hairdressers, dental workers).

127. • Are the hands in direct contact with irritants?
• What makes the skin condition better?
• What makes the skin condition worse?
• What treatment has been used to date
(medical, herbal and over the counter (OTC))?

128. • 3 Pruritus (Itching) Pruritus (itchy skin) is the single most common
symptom of many inflammatory skin conditions.
• Dry skin itself is itchy and requires management with emollient therapies.
• While itching is distressing to the patient, it may not help you reach a
diagnosis.
• Excoriation (scratch marks) on the skin provide evidence of pruritus.
• Severe itch, especially at night, may be caused by scabies.
• Management of pruritus is an essential component of overall
management of the skin condition

129. • 3 Past medical history Conditions which may
be associated with skin disease include
diabetes, cancer, renal/liver disease and
immunodeficiency.

130. • Family history -
• This will indicate that either the skin disease is
genetically determined (e.g., atopic eczema,
psoriasis, ichthyosis) or contagious (e.g.
scabies or impetigo).

131. • Social history/hobbies/occupation/recent
travel to foreign country: For instance, does
hand dermatitis get better at the weekend,
or on holiday?
• Hobbies may indicate contact with irritant
products or chemicals, etc. Travel to a warm
climate may expose the person to tropical
infection.

132. Examining the skin and describing
lesions

133. • The entire skin surface, as well as hair, nails and
mucosal surfaces, should be examined.
• In order to carry out the examination, you may
require the patient to undress down to underwear.
• If the patient has a widespread rash, it may seem
obvious to them that you have to examine their skin
in its entirety.
• They may however question the need for a full skin
examination if they present with an isolated lesion.

134. • There may be other lesions the patient has not seen,
perhaps on the back or buttocks. It is important to
explain this to the patient without alarming them.
• A gown or blanket should be available. The room
should be warm with good lighting. An additional
light source and magnifying lens are also useful.
• It is important to be aware of, and sensitive to,
cultural and religious differences, and a chaperone
may be required in some circumstances

135. Common presentations of skin lesions

137. • To make an accurate diagnosis, skin examination should follow a pattern. It
is important to carry out the following.
Describing a lesion Note the distribution and colour of lesions. Are they:
• localised (e.g. a tumour)?
• widespread (e.g. a rash)?
• if widespread, is it symmetrical and, if so, central or peripheral?
• does it involve the flexures (e.g. atopic eczema)?
• does it involve the extensor aspects (e.g. psoriasis)?
• is it limited to sun-exposed sites?
• is it linear?
• is it regional (e.g. groin or axilla)?
• does it follow a dermatomal (corresponding to root nerve distribution)
pattern (e.g. shingles)?

138. Examine the morphology
• Examine the morphology (form and structure) of individual lesions. A
magnifying lens is helpful. Consider:
• size
• shape (e.g. linear, grouped, annular, koebner phenomenom (an
inflammatory skin response at the site of previous trauma))
• border change (e.g. pearly edge, rolled edge)
• depth − are lesions dermal or epidermal?
• is it macular (flat) or forming papules?
• is it fluid filled – serous fluid or pus?
• is it indurated (hardened) or forming plaques?
• is it forming crusts, scabs, vesicles: if scaly, does surface flake off easily; if
crusted, what is underneath?

140. Palpation
• Palpate to check consistency. This should be done by
compressing the lesion between the finger and
thumb (in widespread rashes, this may not be
necessary) :

146. Investigations
• Swab for bacterial investigations – ensure swab tip is
moistened, roll swab in a zig-zag motion rotating
between fingers.
• Swab for viral investigations – pierce vesicle and
swab fluid inside.
• Mycology for fungal or yeast infection investigations
– skin scrapings, nail clippings, hair debris.
• Common blood tests as shown

148. Key points
•Examine the entire surface area including scalp, axillae, groin
and finger/toe webs.
• Good lighting and a hand lens are important.
• Use a systematic approach to assessment: describe the
lesion(s) and their distribution, examine morphology, palpate the
lesion(s), note any change in colour.
• Note changes or abnormalities in nails, hair and mucous
membranes.
• Carry out relevant investigations or refer to dermatology if
more specialised investigations are required.