■ Current sexual partners should be examined and Rx’d
■ Contact tracing of partners from the previous 3/12 should be undertaken
Follow up
■ Re-examine for lice after 1 week
■ Rx failure (live lice) use an alternative preparation
■ Dead nits can remain attached to hairs – does not imply Rx failure.
Can be removed cosmetically with a nit comb
References
1. UK national guideline on the management of Phthirus pubis infestation 2007 BASHH Clinical Effectiveness Group
Available at www.bashh.org.uk/guidelines
2. Oxford Handbook of Genitourinary Medicine, HIV and Sexual Health (2nd Ed) Pattman et al
Oxford University Press 2010 ISBN 978-0-19-957166-6 3. British National Formulary Sept 2011
BMJ Group and RPS publishing www.bnf.org
16. Pubic lice
Background
1,2■ Caused by the microscopic parasitic mite Sarcoptes scabiei var hominis
■ mites are blind with no eyes; is 0.4 x 0.3 mm2, is smaller and dies after mating
■ mites burrow into the skin where they lay eggs offspring crawl out new burrows
■ lifespan of 4 to 6 weeks, feed on lymph and lysed skin tissue
■ move rapidly on warm skin: 2.5 cm / min!
■ Spread by skin to skin contact (mites transferred after about 10 to 20 mins of close contact)
■ Can’t survive off human host > 72 hours
■ Unlikely to be spread by clothes, towels, bedding etc. (except Norwegian scabies)
■ Can affect any part of the body – not always sexually transmitted
■ Norwegian scabies
■ Extensive crusted lesions with ‘breadcrumb’-like hyperkeratotic lesions over elbows, palms, knees, soles
■ Immunocompromised or elderly
■ Highly contagious
Symptoms
■ Main one is generalised pruritis, esp at night. Can take 6/52 to develop ( hypersensitivity reaction to excreta, absorbed into skin capillaries)
Signs
■ Erythematous genital papules / nodules
■ Silvery skin burrows (look at inter-digital folds, wrists and elbows, around breast nipples in )
Diagnosis
■ typical signs / Sx
■ scrapings from burrows may be examined under a microscope – not practical in General Practice
17. Genital scabies
See national STI Management
Standards:
Chapter 1
Management
■ If you see signs of scabies on genitals, it may imply genital – genital contact and other STIs may be present, so consider a full STI screen (ie: Chlamydia, gonorrhoea, syphilis and HIV)
■ Advise Pt to avoid close body contact until Pt and recent partner(s) have completed Rx
■ Rx
■ PERMETHRIN 5% dermal cream to whole body from neck downwards, wash off 12 hours later or
■ MALATHION 0.5% aqueous lotion applied to whole body from neck down and washed off after 24 hours3
■ Norwegian scabies is Rx’d with oral IVERMECTIN (named pt basis)
■ If hands washed in soap within 8 hours of Rx, they should be re-Rx’d with cream
■ Do not have a hot bath before applying cream (risk of systemic absorption after vasodilatation)
■ Permethrin is safe in pregnancy and breastfeeding – Rx of choice in these situations
■ Pruritis may persist – use Crotamiton 10% cream and/or oral antihistamines
■ Pruritis persisting for > 2 weeks after Rx may reflect Rx failure , re-infection or drug allergy to anti-scabetics
■ Wash potentially contaminated clothes / bedding at high (> 50°C) temp
■ Current sexual contacts and household or institutional contacts should also be Rx’d at same time
■ An arbitrary time-span is for contacts from the previous 2 months to be traced
References
1. UK national guideline on the management of scabies infestation 2007 BASHH Clinical Effectiveness Group
Available at www.bashh.org.uk/guidelines
2. Oxford Handbook of Genitourinary Medicine, HIV and Sexual Health (2nd Ed) Pattman et al
Oxford University Press 2010 ISBN 978-0-19-957166-6
3. BASHH Clinical Effectiveness Group – Correction to the use of Malathion 0.5% aqueous lotion in scabies Nov 2011
Available at www.bashh.org.uk/guidelines
17. Genital scabies
Background
1,2■ Benign viral skin infection caused by a type of Pox virus
■ Humans are the only natural host
■ Direct skin to skin contact (or autoinoculation through excoriation)
■ Can affect any part of the body. =
■ No cases of maternal – fetal transmission
■ Not a true STI, but because genital lesions imply genital contact, consider screening for other STIs
■ Anecdotal evidence linking adult FACIAL molluscum lesions with HIV infection. Recommend HIV test
Symptoms / Signs
■ 3 to 12 week incubation period
■ Discreet smooth pearly lesions with central dimple
■ Usually < 5 mm diameter (larger if immunodeficiency)
■ If immunocompetent, then spontaneous regression after several months is the norm
Complications
■ 2º bacterial infection if lesions scratched
■ Lesions can become large in HIV
■ 1/3 people experience recurrences over next 1 to 2 years
Management
■ No Rx is an option – spontaneous regression is expected if immunocompetent
■ STIs may co-exist – offer screen for other STIs
■ Facial lesions? May indicate low immunity – HIV test recommended
■ Rx options
■ Cryotherapy, manual expression of core, piercing +/- phenol, curettage / diathermy,
■ Podophyllotoxin 0.5% cream or Imiquimod 5% cream can be self applied in men (unlicensed use)
■ No need for contact tracing unless another STI is found
References
1. UK National guideline on the management of molluscum contagiosum 2007 BASHH Clinical Effectiveness Group
Available at www.bashh.org.uk/guidelines
2. Oxford Handbook of Genitourinary Medicine, HIV and Sexual Health (2nd Ed) Pattman et al
Oxford University Press 2010 ISBN 978-0-19-957166-6
18. Genital molluscum contagiosum
Background
1Balanitis = Inflammation of the glans penis (+ foreskin? = ‘balanoposthitis’)
Causes
Disparate conditions with similar clinical presentations – varying aetiologies
Infections
■ Candida
■ Trichomonas vaginalis
■ Strep
■ Staph
■ Anaerobes
■ Herpes
■ HIV (oral and genital ulcers in seroconversion illness)
■ Syphilis
■ Others
Dermatoses
■ Lichen sclerosus
■ Lichen planus
■ Zoon’s balanitis
■ Circinate balanitis
■ Psoriasis
■ Eczema
■ Seborrhoeic dermatitis
■ Contact allergy
■ Drug reactions (fixed drug eruption or Stevens-Johnson syndrome)
■ Immuno-bullous disorders
■ Others
Miscellaneous
■ Trauma
■ Irritation
■ Poor hygiene
■ Pre-malignant conditions (carcinoma in situ)
■ Others
19. Balanitis
Management
History
■ What is noticed?
■ Time frame (Eg: herpes is acute, dermatoses are more chronic)
■ Itch? Odour?
■ Is foreskin tight (think of lichen sclerosus)
■ Any new potential allergens?
■ Recent new drug?
■ Sexual history
■ Does sexual partner have any Sx (Eg: female with Candida? TV? Herpes?)
■ Sx elsewhere? (Eg: candidal balanitis new diabetic?)
■ Signs
■ Local: colour, texture, ulcers, discharge, oedema, odour, etc
■ General: Any enlarged lymph nodes? Rash elsewhere? Any signs in mouth? Arthritis? Eye Sx?
Phimosis? Meatal stenosis? Signs suspicious of malignancy? Etc.
Investigations
■ Bacterial swab ( m/c/s) often needed. Be guided by report, but
■ Strep B is usually a commensal and wouldn’t necessarily warrant treatment.
■ Candida may be a super-infection and its presence does not exclude an underlying dermatosis.
■ Herpes swab if Sx suggestive
■ Urine dipstick glycosuria?
■ Consider STI screen
■ Chlamydia, gonorrhoea, HIV and syphilis
■ Consider referral to GUM if TV is suspected (difficult to diagnose in GP)
■ Consider urgent ref to GUM if syphilis / HIV suspected
Management
General advice
■ Avoid soaps while inflammation is present
■ Saline bathing often helps
■ If topical creams prescribed, warn that they may weaken condoms
■ Refer if diagnosis uncertain or not responding to initial Rx