DermHelpCentral

MRSA Guidelines

(These are notes taken at the New England Dermatological Society meeting of 12/3/11)

PDF of Guidelines: Download MRSA Guidelines

MRSA Guidelines: 
Talk BU Dept of Dermatology
December 3, 2011
Kalpana Gupta and Carol Sulis

One needs to consider the difference between Hospital Acquired and Community Acquired (CA-MRSA)

80% of CA-MRSA are soft-tissue infections. Usually are pustular
4% of household pets have CA-MRSA, often contracted from owners.

There is a question of how valuable decolonization really is.

If one has a CA-MRSA abscess it is clear that I &D is better than antibiotics.

For CA-MRSA the antibiotic of choice is Bactrim/Septra.  Second choice is doxycycline/minocycline and clindamycin is # 3.

Most CA-MRSA are now resistant to erythromycin.

Topical Antibiotics:
50% are now resistant to Bacitracin and Neomycin.
In the outpatient setting, at present, 0% are resistant to mupirocin.

If consider decolonization:
1) Mupirocin + chlorhexidine scrub for 5 = 10 days
2) Bactrim + Rifampin
There is poor data for the value of decolonization.

Molluscum

It's a common scenario.  A mother brings in a young child with a number of (usually) asymptomatic bumps on the torso, extremities, or face.  Often, they know the diagnosis, sometimes not.  These are molluscum contagiosa, a common, benign, self-limited viral infection of children.  For a brief overview, go to DermNet

It is our feeling that these lesions are vastly over-treated.  The disease poses no threat to the child, the therapies can be painful or can take weeks to months, and the disorder runs its course over time.  It is likely that if one lets nature take her course life-long immunity ensues.  Aggressive therapy may prevent this and set the scenario for molluscum to recur when a child becomes sexually active.  At that time, molluscum are more psychologically troublesome.

For an indepth discussion, Prodigy Guidance is super.

You may feel differently and want your child treated.  This is your decision and you should discuss your goals with your pediatrician or dermatologist. 

Post-Herpetic Neuralgia

A Personal View

David Elpern -- Dermatologist

Around 15 - 20% of patients who have shingles will develop pain that lasts for months after the acute lesions subside.  By definition post-herpetic neuralgia (PHN) is the term used for pain that is present six weeks after the blisters have resolved.  Wikipedia has a fine section on PHN .  So does The National Library for Health's Prodigy system if you want more in-depth and evidence-based information.

I would like to add some ex-cathedra comments.  I have helped care for patients with PHN for over 30 years and read about this disorder with great interest. It is unusual in young persons who have had shingles.  These individuals seem to perceive pain differently.  In patients who are depressed, sad or chronically ill initially the incidence of PHN is higher.  These people seem to focus on their pain and don't let go of it.  Understanding the Gate Control Theory of Pain helps one to understand this.

"In their seminal  paper "The Tragedy of Needless Pain," Melzack and Wall assert that pain is a fundamental human experience, and requires an integrative understanding of that whole experience, and every choice we have made, that has formed our own "gates". They frame the choice to deal with pain or ignore it as moral: if the brain can control pain, we who know that must make use of that capacity, and in turn take control of pain.  Only by doing so can we achieve control of the larger causes of all of the pain that humans cause each other by carelessness, hatred, and failures of empathy - which might extend beyond humans.

The impact of this theory on medical treatment for pain has been profound, and has made it a multi-disciplinary field. A major advantage of the theory is that those being taught pain control techniques can actually be told why they work. This seems to play a major role in achieving results - which is explained most readily by psychoneuroimmunology, in which the nerves are seen as the link between the immune system and sensory and cognitive experience."

Please read about the Gate theory if you are interested.  But what does this mean for post-herpetic neuralgia?

In my opinion PHN is a scourge for people who focus on the pain of shingles and then believe they will not get better.  In some cases, this is a self-fulfilling prophesy.  The media, pain clinics and some physicians nurture this fear by promising interventions which inadvertently may actually prolong the pain.  It is very important to work with shingles patients early on to help prevent them from focusing on the pain.

I tell them to be active.  To go to work if they can.  To keep one's mind off the pain.  Watch funny movies, get out if they can, go to dinner with one's partner or friends.  Don't sit around feeling sorry for yourself.  Yes.  This is difficult, but there does seem to be something to this.  It may well explain why older individuals (who are retired and can sit around if they need to) or people with chronic disease suffer more than active busy people.

I know this is controversial and there have been few or no studies.  These have been my observations and I think they explain why kids and young adults rarely develop PHN (most are just to busy to do so!).  Besides, these techniques are benign, cheap and have no down side.

Shingles

Shingles aka Herpes zoster

Herpes zoster, or shingles, is a common skin disease characterized by a painful, one-sided band like blistering eruption. It may occur at any age, but is more common in the elderly.

The disease represents reactivation of the chicken pox virus which remains dormant in the body after that infection. It is estimated that by age 85 at least half of the population will have had one attack of Herpes zoster. Second attacks, although uncommon, may occur  in around 1% of individuals.

Patients with shingles are infectious to people who have not had chicken pox; thus an immunologically naive person may contract chicken pox from a person with shingles. Patients with advanced cancer may also be at risk and should be isolated from patients with Herpes zoster.

The first symptom of shingles is pain or an abnormal sensation in the area which will later develop the rash. This may last for a few days before the rash occurs, and may be mistaken for a number of medical or surgical problems: such as, pleurisy, heart attack, ulcer disease, appendicitis, disc problems, and others.

The rash, when it occurs, is distinctive. It is band-like and does not cross the mid-line of the body, being entirely on the right or left side. It is made up of blisters which vary in size from patient to patient, some being quite small and clear, others being large and occasionally blood-filled. The rash spreads for 1-4 days, dries, and crusts for 7-10 days, and heals over 2-3 weeks. It tends to be more severe in older patients.

Treatment:
The uncomplicated case requires no special treatment. Pain medications (aspirin, acetaminophen, or codeine) are sometimes necessary. Cool compresses and calamine lotion may speed up drying of the blister, and the application of olive oil to the crusts will help to loosen them. In the 1980s, it  was demonstrated that acyclovir (and more recently Famvir and Valtrex) can  shorten the duration of zoster. This is only true if the drug is started within three days (72 hours)  of the onset of the rash. It is important to keep in mind that acyclovir are not very effective in preventing post-herpetic neuralgia and that for thousands of years people have recovered from herpes zoster without any therapy.

Complications:
1. Pain may last for months to years after an attack. This is rare in patients less than age 50, but more common in patients over 60.  The name for this syndrome is "Post-Herpetic Neuralgia."
2. Dissemination: 2 to 10% of patients with H. zoster may have many blisters outside of the original band covering wide-spread areas of the body. This is usually not serious.
3. Secondary infection may occasionally occur in zoster lesions. This is by no means the rule, but one must look for it.
4. When shingles occur on the forehead and especially the tip of the nose, the possibility of eye involvement exists. Your doctor will know when to refer you to an eye specialist, as involvement of the eye with H. zoster requires prompt treatment.
5. There are a number of other rare complications which may occur. Most of these are related to the muscles and nerves. Consult your doctor if anything unusual occurs with or shortly after your zoster.
6. Zoster may be more severe in HIV positive patients. Special attention should be given to zoster patients at risk for HIV infection.

Common Warts

WARTS AND ALL -- Festina Lente

Warts are benign growths on the skin which are the result of a specific viral infection. Although they may occur at any age, they are most common in the 10-20 year-old age group. It is estimated that 10% of teenagers have warts. Almost everyone will get one or more warts in their lifetime. As with other infections, warts may be transmitted from one individual to another. They may also be contracted from inanimate objects (for example, the cements around a swimming pool).

Warts may occur on any location of the skin. In different locations, they have different appearances. This accounts for the many confusing names given to warts. For instance, the plantar warts are merely warts found on the soles (plantar area) of the feet.  Genital warts are called "condyloma."

"The strangest thing about warts is that they tend to go away. Fully grown, nothing in the body has so much the look of toughness or permanence as the wart, and yet, inexplicably and often very abruptly, they come to the end of their lives and disappear." *  Warts resolve because the body's immune response destroys them as it does with other infections. Thus, an immunity to the wart virus develops. Because warts vanish without treatment in most cases, the routine treatment of every wart is unnecessary, undesirable and can be traumatic for some patients, especially young children.

In general, the therapy of warts is nonspecific, destructive, and often painful. For these reasons, it is often wise to proceed slowly and with gentle methods at first, especially in children. Some of the methods we use are the destructive chemicals (Duofilm, Canthardin, and for genital warts, Podophyllin). Liquid nitrogen, an electric needle, and Zonas tape occlusion. Recently, there have been some studies on Duct Tape Occlusion (some positive, others not).  Some people believe suggestion or hypnosis may cure warts. No matter what treatment, 1 in 3 treated warts will recur. However, in most cases, after a few treatment sessions, the patient will be free of warts.

*From : "On Warts" Lewis Thomas, The Medusa and the Snail Download ON WARTS

Duct Tape for Molluscum

Molluscum contagiosum is a common viral infection which can occur at any age, the greatest incidence occurs in children.  See Dermnet NZ for particulars.

Recently the efficacy of duct tape was compared to cryotherapy in the treatment of common warts. We opted to try duct tape occlusion in the treatment of recurrent molluscum contagiosum.  This is the report on one case -- it may not be applicable to you or your child, but it is worth trying if you want to proceed with a safe inexpensive approach.

Method:
Duct tape was cut to the size of each lesion and applied after the patient bathed and towel dried. It was reapplied after each bath or if it fell off. After 3 weeks of therapy, most of the lesions were crusted over. Occlusion therapy continued for 2 months. By the end of therapy  the lesions had disappeared. This treatment was very well tolerated, with no reported pain or irritation. Compared to topical salicylic acid or glycolic acid therapy minimal scarring occurred.

The use of duct tape occlusion therapy for molluscum contagiosum has several advantages over conventional treatment. Treatment is nondestructive and painless or
minimally painful. Duct tape is widely available and affordable compared to the costs of traditional over-the-counter and prescription medications. The tape is applied at home, obviating office visits. Molluscum contagiosum is self- limiting and can remit spontaneously. However, when  lesions persist, the use of duct tape occlusion may be a
more acceptable, nontoxic treatment option, especially for  young children.

This was adapted from a letter in the medical literature by:
MARK S. LINDAU, M.D.
MYRNA Y. MUNAR, PHARM.D.
Portland, Oregon