DermHelpCentral

Swimmer's Ear

Swimmer's ear is an infection of the skin lining the ear canal. The cause is prolonged contact with water (any type of water). When water gets trapped in the ear canal the lining becomes damp, swollen,and prone to infection. Ear canals were meant to be dry. Children are more likely to get swimmer's ear from swimming in lake water, compared with swimming pools or the sea.  Narrow ear canals also increase the risk of swimmer's ear.

We found a useful handout for at-home management online. Swimmer's Ear (Otitis Externa)
Download Vinegar Water Ear Drop

Choosing an Antibiotic for Skin Infections

by Michael R. Wessels, M.D.
NEJM  March 19, 2015

"Since the mid-1990s, methicillin-resistant Staphylococcus aureus (MRSA) has become the predominant pathogen responsible for suppurative skin infections (i.e., furuncles, carbuncles, and skin abscesses) in the United States and in many other countries. Emergency department visits for skin abscesses have increased during this period, as MRSA has become endemic in the community, but a similar increase in visits for cellulitis (i.e., infectious inflammation of the skin without a drainable collection of pus) has not occurred."  Download Choosing an Antibiotic for Skin Infections - NEJMe1500331

This article indicates that clindamycin, trimethoprim-sulfamethosaxzole (TMX-SMX), or a first generation cephalosporin (cephalexin or cefadroxil) are all equally effective for cutaneous abscesses that warrant an antibiotic.

[In the NEJM article this editorial addressed, clindamycin was given as two 150-mg tablets three times daily and TMP-SMX was given at doses of 160 mg of trimethoprim and 800 mg of sulfa-methoxazole administered as two single-strength tablets twice daily.]

 

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.

Babesiosis

"A potentially serious infection caused by tick bites has gained a foothold on the East Coast, particularly in the Lower Hudson Valley and in coastal areas of the Northeast.

The condition, called babesiosis, is a malariua-like illness that results from infection with Babesia microti, a parasite that lives in red blood cells and is carried by deer ticks. Though far less common than Lyme disease, babesiosis can be fatal, particularly in people with compromised immune systems.

So. In addition to Lyme Dissease, one can contract Ehrlichiosis and Babesiosis from tick bites.  The NT Times had a reasonably good introduction to babesiosis in the June 21 issue:  "Once Rare, Infestion Spreads By Tick Bites."  We will post something on Ehrlichiosis soon.

For more on Babesiosis see:  eMedicine.com (although you may need to register for a free account. 

Infections and the Gym

by Jane Brody, NY Times, August 3, 2010

"When you go to the gym, do you wash your hands before and after using the equipment? Bring your own regularly cleaned mat for floor exercises? Shower with antibacterial soap and put on clean clothes immediately after your workout? Use only your own towels, razors, bar soap, water bottles?"

In these days when so many of us exercise in gyms outside of our homes there is risk of acquiring skin infections. Jane Brody's column "Be Sure Exercise Is All You Get at the Gym" is well-worth reading as it gives good advice on how to avoid many of these problems.

Preventing Lyme Disease

Prophylaxis with Single-Dose Doxycycline for the Prevention of Lyme Disease after an Ixodes scapularis Tick Bite
The Tick Bite Study Group

ABSTRACT

Background It is unclear whether antimicrobial treatment after an Ixodes scapularis tick bite will prevent Lyme disease.

Methods In an area of New York where Lyme disease is hyperendemic, we conducted a randomized, double-blind, placebo-controlled trial of treatment with a single 200-mg dose of doxycycline in 482 subjects who had removed attached I. scapularis ticks from their bodies within the previous 72 hours. At base line, three weeks, and six weeks, subjects were interviewed and examined, and serum antibody tests were performed, along with blood cultures for Borrelia burgdorferi.

Results Erythema migrans developed at the site of the tick bite in a significantly smaller proportion of the subjects in the doxycycline group than of those in the placebo group (1 of 235 subjects [0.4 percent] vs. 8 of 247 subjects [3.2 percent], P<0.04). The efficacy of treatment was 87 percent (95 percent confidence interval, 25 to 98 percent). Objective extracutaneous signs of Lyme disease did not develop in any subject, and there were no asymptomatic seroconversions. Treatment with doxycycline was associated with more frequent adverse effects (in 30.1 percent of subjects, as compared with 11.1 percent of those assigned to placebo; P<0.001), primarily nausea (15.4 percent vs. 2.6 percent) and vomiting (5.8 percent vs. 1.3 percent). Erythema migrans developed more frequently after untreated bites from nymphal ticks than after bites from adult female ticks (8 of 142 bites [5.6 percent] vs. 0 of 97 bites [0 percent], P=0.02).

Conclusions A single 200-mg dose of doxycycline given within 72 hours after an I. scapularis tick bite can prevent the development of Lyme disease.

Gram Negative Infections

Rising Threat of Infections Unfazed by Antibiotics
By ANDREW POLLACK
Published: February 26, 2010

This is an important article in the NY Times about hospital-acquired Gram Negative Infections.  Keep in mind that this rarely applies to community acquired infections with these organisms.

The same issue of the Times has an article on "Deadly Germs Largely Ignored By Drug Firms" which explains why so few new drugs are being developed for infectious diseases.

See The Checklist Manifesto by Atul Gawande which describes a simple method to cut down on the frequency of hospital-acquired infections.

Lyme Disease - Jane Brody

Lyme Disease is becoming more wide-spread and common.  There have been many articles and even books on the subject.  Jane Brody devoted her column this week to Lyme.  It's a fine introduction and a good source of references.  She writes:
"The disease can be maddeningly difficult to diagnose. Only 50 to 70 percent of patients recall being bitten by a tick. Ordinary laboratory tests are rarely helpful. Tests for antibodies to the bacterium or for its genetic footprints result in many false-negative and false-positive findings."

To access her article, go to:  Lyme Permalink.

Ms. Brody also cites a recent Mayo Clinic Proceedings article: Diagnosis and Treatment of Lyme Disease which can be accessed at MCP Lyme or this pdf:   Download lyme_mayo.pdf

S.A.D.: Severe Atopic Dermatitis

In today's NY Times, there is an incredible article about S.A.D. by science writer Ingfei Chen.  It touches on the role of staph in exacerbating the eczema, the need for soothing baths, the role of antibiotics in treatment and more.  Ms. Chen's article could be a primer for starting to learn about SAD.

In some way, SAD, and related inflammatory dermatoses, are orphan diseases.  At present, they don't have really expensive therapies that would induce drug companies to throw money at them (for secondary gain).  These patients take time and are very complex, and we dermatologists want to see a new patient everey ten to fifteen  minutes.

If you want to start to understand S.A.D. please read this article.  It can be accessed at Permalink.

MRSA Protocol

First Line Treatment:

Nasal Carriage Only
The most effective treatment of nasal carriage is mupirocin (Bactroban
nasal). This should be applied three times daily to the anterior nares.
Treatment should continue for 5 days.

If the strain identified is resistant to mupirocin, the Consultant Microbiologist will advise on alternative treatments.

Once a negative nasal swab has been achieved/noted, Bactroban nasal
should be discontinued.

Carriage At Other Sites:

If MRSA is present on other skin sites the patient should be washed daily for  5 days using an antiseptic detergent, Hibiclens Scrub (chlorhexidine)   The solution should be applied to the skin in place of soap using disposable wipes.

Hair should be washed twice weekly using this solution. Normal shampoo may be used after the antiseptic detergent.

If patients are known to suffer with eczema or develop any skin irritation the Infection Control Team should be notified to discuss alternative preparations.
On index patients where the extent of carriage is unknown, antiseptic wash and nasal bactroban should be commenced - once screening results are available treatment will be reviewed and discontinued as necessary.