PREVALENCE AND RISK FACTORS OF ERECTILE DYSFUNCTION

1.1       BACKGROUND

Erectile Dysfunction(ED) was defined in 1992 by the National institute of Health Consensus panel on ED as the repeated inability to develop or maintain erection of penis sufficient for a satisfactory sexual intercourse or activity in the absence of an ejaculatory disorder such as premature ejaculation.[1]

Erectile dysfunction is a common public health problem that is said to affect 152 million men worldwide. It was initially called impotence but was reversed due to set backs incurred as it causes confusion and lead to inability to interpret result in both clinical and basic science investigations.[2] It is more prevalent in patients with associated medical conditions such as diabetes and hypertension and among cigarette smokers.[3] For many men, erectile dysfunction creates mental stress that affects their interactions with their family members and associates. However, its various aspects remain poorly understood by the general population and by most health care professionals. The fact that results have not been effectively communicated to the public has compounded this situation.⁴

1.2       STATEMENT OF THE PROBLEM

Prevalence varies according to individual characteristics- age, race, ethnicity, socioeconomic status, and concomitant disease conditions.

It was estimated in 1995 that over 152 Million men worldwide have experienced erectile dysfunction and was projected that by the year 2005, about 322 Million men would be affected with the largest projected increase in the developing world i.e. Asia, Africa, and South America.

In France, the estimated prevalence of ED is 32%; 56% in West Virginia, USA; 37.55% of men ranging from 40-70 years in Thailand; 37% in Korea; 52% among men with chronic disease in Japan; 49% of men with chronic prostration in Anhui, China;  88% of men with end-stage renal disease in Ontario, Canada; 69% of  men with Peyroni’s disease in Porto Alegre, Brazil; 47% of men with hypertension in Valencia, Spain; 68% of men with Diabetes Mellitus in Japan; and 48% of men with Rheumatoid arthritis in USA and Canada⁵.

Prevalence of ED in developing countries is largely unknown. However, the age adjusted prevalence rates of ED among men attending primary health care clinic is 57.4% in Nigeria, 63.5% in Egypt, 80.8% in Pakistan and 47% in Burkina Faso.⁶

An assessment of andropause (also known as androgen decline in ageing male) and erectile dysfunction awareness among married men with diabetes mellitus in Ile-Ife, Nigeria has a prevalence of 51.3%.⁷

Andropause has implications on the reproductive health and quality of life in older males. However, very few studies have been recorded among the Nigerian populace on andropause related issues.

In Nigeria, sufferers are unable to freely discuss the problem of ED with their doctors because of the fear of stigmatization. Also, data on the issue of erectile dysfunction is generally scarce on the scientific literatures and studies on clinical roles in the diagnosis and management of ED are extremely limited.

In USA, it has been established that ED affects 50% of males older than 45 years with various degrees of dysfunction. Approximately 152 million men worldwide suffer from the disease and the prevalence may be as high as 30 million in USA alone.  An increase in prevalence in ED in ageing male is well documented in studies such as Massachusetts male aging study and others. Several recent studies have looked at the prevalence of ED. The Massachusetts male aging study ,conducted from 1987-1989 in areas around Boston , was a cross- sectional random sampling community based survey of 1290 men ages from 40- 70. ED was self reported and the condition was classified as mild, moderate or complete. The combined prevalence of mild, moderate and complete ED was 52%; the study demonstrated that ED increases in prevalent with age, at age 40, there is an approximately 40% prevalence rate, increasing to almost 70% in men at age 70. The prevalence of moderate ED increases from 17% to approximately 34% the prevalence of complete ED increases from 5% to 15% as age increases from 40 to 70 years⁸.

The prevalence in an Italian Study increased from 2% for men aged 18-39 years to 48% in those over 70 years.

URTICARIA / PAPULAR URTICARIA

Urticaria is a reactive phenomenon which is characterised by itching
wheals (hives). These may be any shape or size, appear anywhere on the
body and as angioedema in the face, at any interval. Sometimes there is
a single attack of urticaria, sometimes there are attacks every few hours.
Urticaria may come and go during a few days or persist for many years.
There are many types of urticaria and possible causes of urticaria: contact
urticaria (e.g. stinging nettles, caterpillars, formaldehyde); physical
urticaria (cold, heat, pressure); cholinergic urticaria (sweat, exerciseinduced);
Drug-induced non-allergic urticaria (aspirin, pethidine, morphine,
hydralazine); allergic urticaria by drugs (see drug eruptions), food
(fish, milk, nuts, tomatoes, citrus fruits, cocoa, strawberries), insect allergens
(bee, wasp), vaccines, worm infestations, and internal diseases.
This list is not complete.
Papular urticaria is a specific form of urticaria which occurs again and
again in susceptible children. It presents as very itchy persistent hives
and papules, sometimes with vesicles on top. It is an exaggerated
response to contact with insects, their vomits and bites. When extensive
the rash may resemble HIV related papular pruritic eruption (though this
usually occurs in adults) or scabies (in papular urticaria other family
members are not affected).
Management of urticaria /
papular urticaria
- Avoid or treat the cause if possible.
A thorough history is essential.
- Calamine lotion or phenol-zinc lotion.
- Antihistamines, a low or high dose may be
required, this varies per patient.
- Topical steroids if necessary.
- Avoid the use of aspirin.
- Papular urticaria: Insect repellents and
impregnated bednets.

PSORIASIS

Psoriasis is a chronic recurrent, inherited, non-infectious skin disease
caused by an abnormally fast turnover of the epidermis. The turnover may
be up to 40 times the normal and as a result the epidermis is not able to
develop normally. All layers become too thick and the most obvious one
is the horny layer, the outer layer of the skin. The skin is red, inflamed,
and the scales are thicker than normal. They produce a so-called candlewax
phenomenon: when you scratch such a patch it becomes silverywhite.
Psoriasis also displays a Koebner phenomenon, i.e. it appears in
traumatised skin. Classical psoriasis occurs on the scalp, the extensor
areas of extremities (esp. elbows, knees), the umbilicus and the buttocks.
Finger- and toenails may show pitting, thickening of the nailbed or distal
onycholysis (brownish oil-like changes on the distal nail where the nail is
detached from the nailbed). Palms and soles may also show thickening;
callus, scales and cracks. Treatment is often effective but you can never
cure the patient of the disease as such. It may always recur, after weeks,
months or years. Psoriasis may flare up after an infection (flu, angina) or
drug use (e.g. antimalarial drugs, beta blockers, lithium). There is also a
pustular psoriasis and an inverse form with lesions in skin folds rather
than extensor areas, the latter may be difficult to distinguish from seborrhoic
eczema.
Psoriatic arthritis of the small joints of the hands and feet occurs in 5-
10% of patients. The arthritis may be mutilating and eventually become
widespread.
Management of psoriasis
- Explain to the patient the recurrent nature of the disease.
- Salicylic acid 2-10% ointment twice daily to reduce scaling.
- Coal tar 5-10% ointment or sulphur 5% in coal tar 5-10% ointment nightly.
- Moisturise (vaseline, urea 10% ointment or cream) and expose to sun. In psoriasis
coal tar ointment may be tried in combination with sunlight.
- Salicylic acid and coal tar should not be applied on body folds unless the skin is
dry and thickened. They can be mixed together as ointments, or with zinc paste.
- In body folds sulphur added to a mild steroid cream is often effective.
- A strong topical steroid once or twice daily, cover with salicylic acid 2-10% ointment
if necessary.
- Urea 10% cream or ointment as an emulsifier, aqueous cream in folds.
- Treat any superinfection with betadine or antibiotics if necessary.
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- Psoriatic arthritis: NSAID’s e.g. ibuprofen 400 mg 4-6 x daily, indomethacin 75-100
mg daily, naproxen 500-750 mg daily or salazosulphapyridine 250 - 500 mg twice
daily.
- Methotrexate is often effective in severe and arthropathic psoriasis and may be
used in HIV infected patients.

PORPHYRIA CUTANEA TARDA

Porphyria cutanea tarda is a chronic disturbance of the metabolism of
porphyrins, manifested by liver damage and skin lesions. The disease
affects more men than women, generally over the age of 40. Skin which
is exposed to the sun is affected, mainly the face and the backs of the
hands. Exposure to sunlight or trauma induces small blisters which lead
to erosions, crusts, atrophy, flat or depressed scars and pigmentation
changes. Milia are often present. Increased hairgrowth is also a feature.
The urine of these patients is red in colour after sun exposure due to
increased porphyrin excretion.
Management of porphyria cutanea tarda
- Avoid triggering agents, e.g. alcohol, drugs, oral contraceptives.
- Avoid trauma, avoid sun exposure.
- Phlebotomy, not to be performed in liver cirrhosis. A specialist should decide.
- Chloroquine in low doses (e.g. 150 mg weekly) for a long time.

PEARLY PENILE PAPULES

Pearly penile papules are not a disease, they are an anatomical variant.
Small, usually whitish or skin coloured papules are found at the border of
the glans penis, just before the coronary sulcus. They are very regularly
spaced and regular in size. They are often a great worry to young men
who think they have penile warts or another sexually transmitted
infection and may have caused them to seek all sorts of treatments.
Management of pearly penile papules
Explain to the patient that no treatment is necessary

PAPULAR PRURITIC ERUPTION

The phrase "papular pruritic eruption" defines an itchy, persistent or chronic
recurrent rash which is found in HIV-infected patients and for which
no other cause (e.g. urticaria, scabies, folliculitis etc.) can be found.
There are usually widespread inflammatory papules, hyperpigmented
scars and scratch marks. The patient may or may not show other signs of
HIV-infection.
Management of papular pruritic eruption
Treatment is symptomatic, any of the options below may be tried:
- Calamine lotion, phenol zinc lotion, menthol 0,5% cream or lotion or
phenol 1% + menthol 0.5% preparation.
- Antihistamines e.g. promethazine 25 mg nightly or chlorpheniramine 4 mg
2 or 3 times daily.
- Betadine scrub in case of infected lesions.
- Hydrocortisone or betamethasone cream once to twice daily.
- Dapsone 100 mg once daily may be tried in severe cases.

MALIGNANT MELANOMA

This is a very malignant tumour which in Africans usually arises on the
foot, less often on the hand (usually acro-lentiginous melanoma). It can
start as a small pigmented papule or nodule which grows, often showing
typical blue-grey-black shades of colour, and sometimes bleeding or ulcerating.
It spreads to other organs rapidly and the diagnosis is often made
when the tumour has already spread to at least regional lymph nodes and
it is too late for cure. Early diagnosis is therefore important. Keep a
melanoma in mind when someone presents with a chronic ulcer on the
foot especially when it shows typical pigmentation or when it does not
respond to ulcer-treatment.
An incision biopsy should not be performed in a lesion which is suspect
for malignant melanoma, the lesion needs to be excised in total.
Management of malignant melanoma
- Wide surgical excision and histological examination.
- Refer to a specialised centre.

KELOIDS

Keloids are fibrous tumours caused by overgrowth of connective tissue.
They usually occur in a scar, weeks to months after the skin is
traumatised. The keloid spreads beyond the boundary of the original
injury to form a hard, irregular, shiny, sometimes painful or itchy ridge or
plaque. In primary keloids there is no apparent preceding trauma. Once
formed keloids remain stationary for years after which, some become
partially flattened. They are especially common in Africans.
Management of keloids
- Treatment is difficult, especially in older lesions. Surgical excision will lead to
recurrence and more severe deformity!
- Strong topical corticosteroids under occlusion are sometimes effective as are
intralesional corticosteroids, with or without cryotherapy. Radiotherapy is an option
in some cases. Pressure garments may be used to prevent and treat keloids
especially after extensive trauma e.g. burns.

INFANTILE ACROPUSTULOSIS

Infantile acropustulosis is a condition of unknown cause which occurs in
infants, usually under the age of 1 year. Intensely itchy vesicles which
quickly progress to pustules appear on the soles and the sides of the feet
and on the palms, often in the first 3 months of life. The pustules last for
one to several weeks and then subside only to reappear two to four
weeks later. Attacks recur with diminishing severity and frequency in
time and stay away at the end of the second or third year. The pustules
are sterile and the condition does not warrant antibiotic treatment, which
is a common misconception. Anti scabies treatment is also ineffective.
The condition often sééms to appear after successful treatment of scabies,
which should make you wonder whether it was scabies which was
treated in the first place.
Management of infantile acropustulosis
- Early use of topical corticosteroids is usually effective for itch and lessens the
severity of the attack.
- For severe itch antihistamines may be required.
- Antibiotics and antiscabies treatment are ineffective

HEMANGIOMA (CONGENITAL)

Congenital hemangioma’s are benign tumours of blood vessels which
become manifest in the first few days of life. They can be single or multiple
and vary in size from less than 1 cm to more than 10 cm. The preferred
site is the face though they can occur anywhere on the skin. The
mucous membranes i.e. the lip and tongue can be affected.
Hemangioma’s may grow rapidly in the first months causing great concern
to the parents. However, they regress spontaneously in about 70%
of the patients. Regression starts in the first year of life and takes 5-10
years. Sometimes a hemangioma may bleed easily or it may become
(partly) necrotic after trauma or during a period of fast regression.
Regression may show no scarring, there may be a slack, baggy area of
skin if the hemangioma was large or the skin may be hypopigmented and
atrophic.
Management of congenital hemangioma
- In most cases no treatment should be given. The parents need to be told that
spontaneous regression is to be expected and that this gives the best cosmetic
outcome. This is in contrast to surgery which may leave disfiguring scars.
Treatment is indicated in:
1 a lesion which does not disappear or gets bigger in a child > 7 years of age,
2 impaired function of vital organs, e.g. vision (by large lesions in the orbital region
or on the eyelid), hearing, breathing,
3 bleeding and/or ulcerating lesions.
Refer to a skin specialist or paediatrician for treatment. In some cases
intralesional steroids may be tried.

DRUG ERUPTIONS

Most common are maculo-papular exanthema’s, which are usually itchy.
Drugs with a > 1‰ incidence of drug-induced exanthema are: penicillins,
sulphonamides (fansidar, trimethoprim), NSAID’s (like aspirin,
indomethacin), isoniazid, erythromycin, hydantoin derivatives (e.g. phenytoin),
carbamazepine, allopurinol, streptomycin and gold salts. They
may occur soon after taking the drug (in previously sensitised patients),
on finishing a course of drugs, or up to 3 weeks after taking a drug.
Urticaria is also a common reaction, often caused by penicillins,
NSAID’s, acetylsalicylic acid and X-ray contrast media.
Fixed drug eruptions recur on exactly the same spot every time the
responsible drug is taken. There is usually one, sometimes two or more
macules or plaques, reddish-purple in colour. They may show blistering
and leave persistent hyperpigmentation on healing. Most frequent
causes: barbiturates, paracetamol, pyrazolon derivatives, sulphonamides
and tetracyclines.
Some drugs cause photosensitivity, commonly implicated are:
amiodarone, chlorothiazide, fluoroquinolone derivatives, NSAID’s,
phenothiazines, psoralens, sulphonamides and tetracyclines.
Stevens-Johnson syndrome and toxic epidermal necrolysis are
serious blistering eruptions which may affect large areas of skin and
mucous membranes and may be fatal. Common causes: sulphonamides,
hydantoins, pyrazolon derivatives, carbamazepine and NSAID’s.
Erythema exsudativum multiforme (EEM) shows characteristic
"target" or "iris" lesions and is considered a minor form of Stevens
Johnson syndrome. EEM and Stevens-Johnson syndrome are commonly
caused by herpes simplex infections, only in second instance by drugs
and other infections such as mycoplasma infections.
Patients with HIV-infection are more susceptible to all drug eruptions.
Nearly all drugs can cause drug eruptions. Only the most commonly
implicated drugs have been mentioned here.
Management of drug eruptions
- Identify the responsible drug and stop the use of that drug.
- For itchiness and drying in: Calamine lotion with or without menthol 0.25% and/or
phenol 1% , or zinc oxide cream.
- Burn cream or honey.
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- Oral antihistamines e.g. promethazine 25 mg once or twice daily or
chlorpheniramine 4 mg 3 times daily.
- In severe reactions a short course of prednisolone may be given starting at 30-60 mg
daily and quickly reducing the dose in 2 weeks.
- When there is extensive skin loss the patient should be hospitalised, given i.v. fluids
and treated like a burn case i.e. given betadine baths, dressed with silver
sulphadiazine 1% burn cream and given antibiotics and analgesics as required.

DERMATOSIS PAPULOSA NIGRA

A very common papular eruption in Africans which is probably genetically
determined. Dark brown to black papules appear on the upper part of the
face, especially on the cheeks and the temples. The first papules may
appear from early teens and they increase in number with age. Forty
percent of Africans over 30 years of age have this eruption in a limited or
extensive form. It is more common in women than in men.
Management of dermatosis papulosa nigra
Treatment is not necessary and usually not requested.
- Cauterisation / diathermy which may be followed by curettage is possible. This may
however leave undesired hypo- or hyperpigmentation. In extensive cases it is
therefore advisable to treat a few lesions as a trial first.

ALBINISM

Albinism is an inherited disorder of melanocytes, which do not
synthesise melanin (pigment). This results in absence of pigmentation of
skin, hair and eyes, combined with photophobia and nystagmus from
birth. The skin is white, the hair white or yellow and the iris light blue.
These patients are very light sensitive because they have no UVabsorbing
melanin, which usually protects people from solar damage.
After short term sun exposure sunburn, freckling, and early ageing of the
skin already occurs and actinic keratoses with a tendency towards
malignant transformation appear. Squamous cell carcinoma is seen at an
early age, even in children.
Management of albinism
Sunprotection to prevent solar damage:
- Wear protective clothing (long sleeves, long skirts and trousers), a sunhat with a
wide rim, providing protection for face, ears and neck, and sunglasses.
- Stay indoors as much as possible during the hot hours of the day.
- Children with visual impairment should be seated in front rows in classrooms.
- Use sunscreens with a high sun protection factor (SPF), e.g. PABA (para amino
benzoic acid) which has SPF 15. Total sunblockers have even higher SPF’s. Zinc oxide
cream/paste/ointment blocks out sunlight and can be used for the lips. Apply
sunscreen whenever going outdoors.
Regular skin check-ups for early detection and treatment of pre-cancerous
keratoses and skin cancer. Single keratoses can be treated with liquid nitrogen,
curettage and electro-dissecation, shave excision followed by electrosurgery.
Multiple and/or extensive lesions can be treated with topical 5%
5-fluoro-uracil. The extract from the fruit of the sausage tree (Kigelia Africana)
is an effective alternative (ready-made cream at many pharmacies). The rough
skin can be softened with urea 10% ointment or salicylic acid 2-5% ointment.

ACNE VULGARIS

Acne is very common in puberty and it usually regresses in early adulthood.
Sometimes it persists up to age 30 or lifelong. Sebum production
(patients complain of "oily skin") is the most important factor in acne. It
occurs on the face and the upper trunk as blocked sebaceous gland ducts
(forming comedones= blackheads and whiteheads), which may progress
to inflammatory papules, pustules and nodules. Acne may be very mild to
very severe. In severe acne conglobata, acne lesions blend together to
form large inflammatory areas with cysts and scar formation.
Management of acne
- Stop the use of vaseline, oil or ointments and greasy cosmetics which further block
sebaceous ducts.
- "Peeling" of the comedones with benzoylperoxide 5-10% gel or tretinoin 0.01-0.1%
cream or gel, apply at night since both are photosensitisers. Salicylic acid 1-10% in
an alcoholic solution. Alcoholic solutions remove excess sebum. Dilute methylated
spirits with an equal amount of water to a 35% solution.
- For pustular/inflammatory lesions: topical clindamycin 1% lotion, erythromycin 2%
lotion. If severe, use systemic tetracyclines, e.g. doxycycline 100 mg twice daily until
substantial improvement (may be a month or more) followed by 100 mg once daily
until acceptable or cleared, which may take many months.

VITILIGO

Vitiligo is a relatively common, sometimes familial disorder in which
depigmentation of the skin occurs. It may start at any age but often starts
in young adults. Lesions start as small white macules and become
progressively larger and confluent, leading to bizarre shapes. Common
localisations are the hands and feet and the skin around body openings,
e.g. around the eyes, nose, mouth and lips, the umbilicus, and around the
genitals and the anus. Vitiligo also occurs in traumatised skin and can
affect hair bulbs, leading to streaks of white hair. The condition is usually
slowly progressive and seldom regresses spontaneously. Vitiligo of the
genital area should be distinguished from lichen sclerosis, in which
depigmentation and atrophy are usually limited to this area.
Management of vitiligo
- There is no satisfactory treatment. Reassure the patient; there is only colour
change, vitiligo is not a sign of abuse.
- Sometimes the combination of topical steroids and sun exposure results in
repigmentation.

LICHEN PLANUS

Lichen planus presents with very typical itchy papules, which are small
(1-3 mm) and are demarcated by the natural skin lines, making them
polygonal. They have a sharp, elevated border, a flat surface (hence the
name "planus") and they shine by reflecting light. They are often a shade
of red, later reddish blue to purple and show "Wickham’s striae", a fine
milky-white network on the papule’s flat surface. Neighbouring papules
may join together to form plaques which resemble lichen growing on
trees, explaining the name "lichen". They may occur anywhere on the skin
but are most common on joint flexures (especially wrists), genitals, sacral
region and inner thighs. A Koebner phenomenon is present. The oral
mucosa and lips may be affected and show a network of white lines.
Actinic lichen planus occurs on sun-exposed areas. In hypertrophic lichen
planus there are thick, hyperkeratotic papules and nodules or thickened
wart-like plaques on the shins. Lichen planus is self-limiting, it will disappear
spontaneously, sometimes in months but it may take many years.
Management of lichen planus
Treatment can be very difficult.
- For severe itch: calamine lotion and/or antihistamines.
- Coal tar 2-6% ointment nightly.
- Strong topical steroids combined
with salicylic acid 5% once to twice
daily.
- Refractive lesions: Apply strong
steroid at night and cover with
plastic 2 nights a week (see lichen
simplex). This improves penetration
of the steroid.
- Widespread, severe forms: a short
course of prednisolone may be tried:
start with 30 mg daily for a week
then reduce to zero in two weeks

CHRONIC DISCOID LUPUS ERYTHEMATODES

Chronic discoid lupus erythematodes (CDLE) is a chronic scarring skin disease
which occurs on sun-exposed areas. The face is the commonest
site, but scalp, upper trunk and distal extremities may also be affected.
On the face there may be a "butterfly distribution" on the cheeks and
bridge of the nose, the lips may also be affected. The lesions are welldefined
reddish patches with thick or hyperkeratotic scaling and hyper-,
hypo- or depigmentation, they feel rough on palpation. They slowly increase
in size and form atrophic hypopigmented scars. Exposure to sunlight
aggravates the lesions and causes an increase in symptoms, such as itch
and irritation.
Management of chronic discoid lupus erythematodes
- Sunprotection! Wear a sunhat, protective clothing, and stay out of the sun as much
as possible. Use a sunscreen when outdoors (see albinism).
- Topical steroids e.g. betamethasone 0,1% once daily. If this is not effective after
2 months, this treatment should be stopped, as there is already a high risk of
skin atrophy.
- Chloroquine 150 mg/hydroxychloroquine 200 mg once daily for 6-8 weeks. If
improving continue until maximum improvement (i.e. no active lesions, scars will not
disappear), then slowly decrease the dosage (over months). If no improvement
occurs a double or triple dose may be tried for a short time. Do not use antimalarials
for more than 9 months at a time.
- Sometimes dapsone, with or without antimalarials is effective.

CHRONIC BULLOUS DERMATOSIS OF CHILDHOOD

This is a chronic blistering disease which occurs in children. It usually
starts before the age of 5 years. Small and large blisters appear predominantly
on the lower trunk, genital area and thighs, often also on the
scalp and around the mouth. They may spread all over the body. New
blisters form around healing old blisters, forming "a cluster of jewels".
There is often some itchiness. The course is chronic, spontaneous remission
usually occurs after an average of 3-4 years.
Management of chronic bullous dermatosis of childhood
- Dapsone in doses from 12,5 to 125 mg daily or Sulphapyridine 250 mg to 3 grams
daily usually control the eruption. After it clears you can slowly reduce the dosage to
a maintenance dose but you may need to increase it again when disease activity
flares up.
- Treat any superinfection with betadine, GV paint or if severe antibiotics.
- If there is no response to the above treatment, topical (strong) or systemic corticosteroids
may need to be added. Take care not to overtreat, especially regarding the
side effects of systemic steroids in children.

ALOPECIA AREATA

Alopecia areata occurs in adults and in children and generally presents
as one or more round or oval bald patches on the scalp or beard area. The
hair is lost suddenly, the bald patch extends until it is usually some centimetres
in diameter, and as a rule after weeks to months new hairs
begin to grow within the lesion. The skin remains normal, showing hairfollicle
openings without scaling or atrophy. The re-growing hair may be
white in colour, giving the impression of "turning white overnight" when
a large area is affected.
In progressive cases new bald patches develop as others heal, or patches
do not heal for years. In alopecia areata totalis there is baldness of the
whole head; in alopecia areata universalis all body hair including scalp,
beard, eyebrows, eyelashes, pubic and axillary hair falls out.
Management of alopecia areata
- Explain to the patient that the condition is not serious and that the hair is likely to
grow back after some time. This may take weeks or months and is different in each
individual.
- A topical irritant such as garlic may be tried.
- People with very extensive alopecia areata or alopecia which does not heal may be
referred to a skin specialist.

ONCHOCERCIASIS

Onchocerciasis or river blindness is a chronic infection of the skin and the
eyes by the filaria Onchocercus volvulus. It is transmitted by female
blackflies which are typically found near fast moving water. People living
in these areas get infected again and again, thereby accumulating
hundreds to thousands of microfilariae in the skin and the eyes, where
they move around freely. In the skin this causes severe itch as the major
presenting complaint. In the first stages there are only a few erythematous
hyperpigmented papules and scratch marks. Later the whole skin
thickens and becomes dry and lichenified. There is loss of elasticity
(hanging groins). Skin hyper-, hypo- and depigmentation may occur in
chronic cases. Onchonodules, which represent the adult worms, can be
seen and palpated, in particular above the hipbones but also elsewhere.
Biopsy or skin snip may show microfilariae. Eye involvement is a well
known cause of blindness.
If the history is suspect but microfilariae have not been demonstrated a
Mazotti test can be performed. Under careful conditions (cave:
anaphylactic shock) 50-100 mg diethylcarbamazepine (DEC, Hetrazan) is
given. A positive test yields intolerable itch within a few hours.
Management of onchocerciasis
- Treat secondary infection with antiseptics or antibiotics as impetigo and secondary
lichenified eczema as lichen simplex.
- Ivermectin kills microfilariae with a single oral dose. The adult worms are not
affected however. A patient staying in an endemic area will therefore need repeated
treatment every 3 to 12 months depending on the amount of itching. If the patient
moves out of the endemic area repeated treatment may cure the infection as the
adult worms will die after a few
years.
-When there is eye involvement
steroid treatment should preceed
ivermectin.
- Single dose of ivermectin (6 mg
tablets) according to body weight in
kilograms: under 30 kg: 0,5 tablet,
30 to 50 kg: 1 tablet, 50 to 70 kg: 1,5
tablet, over 70 kg: 2 tablets.

LYMPHATIC FILARIASIS

Elephantiasis in the tropics may have a number of causes ranging from
bacterial or fungal lymphangitis and adenitis to Price’s disease. In the
latter silicates in red volcanic soil which enter the skin through the soles
cause an immune reaction which blocks the lymph nodes. A common
cause of elephantiasis is the parasitic worm Wuchereria Bancrofti, which
is transmitted by mosquitoes. It presents after an incubation period of 5
to 15 months with mild lymphangitis and lymphadenitis, and pitting
oedema of one or more extremities or genitals. The lymphadenitis is
descending rather than ascending. At first there are attacks of swelling
but later the symptoms become chronic. Adult worms are present in the
lymphatics and the resulting inflammatory response is thought to be the
cause of the obstruction. The late effects include firm lymphoedema of
the extremities, the vulva, scrotum, arms and breasts. The legs at this
stage often have a warty appearance with folds and cracks in the lower
legs and feet. Active infection can be diagnosed with a rapid card test
using fingerprick blood.
Management of lymphatic filariasis
- Keep clean and manage intercurrent infections.
- Exercises to improve lymphatic flow.
Lymphmassage, intermittent compression,
elastic compression bandages and stockings or
lace-up boots may all be helpful.
- Ivermectine 12 mg plus albendazole 400 mg in a
single dose for adults (see onchocerciasis) will
kill microfilariae but not the adult worms.
This treatment therefore needs to be repeated
yearly until all adult worms have died of old age
(3-4 years).

LEISHMANIASIS

Leishmaniasis is caused by an infection with the leishmania parasite,
after the bite of an infected sandfly. After an incubation period of two
weeks to four months an erythematous or skin coloured nodule appears.
This ulcerates and then becomes crusted or even verrucous, in most
cases eventually leaving an ugly scar. The sandfly likes to bite on moist
areas, preferably around the eyes, ears, nose and mouth. Lesions may be
found on the skin, the mucous membranes or both. The latter,
mucocutaneous leismaniasis, may completely destroy the nose and does
not heal spontaneously.
Leishmaniasis may cause lymphadenitis or become visceral, Kala Azar.
After Kala Azar it may cause PKDL, Post Kala Azar Dermal Leishmaniasis.
In a few cases leishmaniasis becomes generalised, showing infiltration
and nodules over the whole body. This persists for life.
Management of leishmaniasis
The sore type of leishmaniasis:
- Cryosurgery.
- Excision.
- In some cases itraconazole or ketaconazole may be tried.
Leishmaniasis with lymphadenitis:
- Pentavalent antimonium prepararions
(stibogluconate) Glucantine or Pentostam
20 mg/kg/day for 20-30 days i.v. or i.m.
- Pentamidine isothionate 4 mg/kg/week for 4 weeks to
8 months.
- Amphotericine B 1 mg/kg on alternate days for
2 months
PKDL: stibogluconate.
Diffuse generalised leishmaniasis: repeated
courses of pentamidine isothionate

NORWEGIAN (CRUSTED) SCABIES

This is a variant of scabies where the skin lesions are extremely massive
and extensive. Thick, grey keratoses and crusts develop on the hands,
elbows, knees and ankle joints and also extend to areas not normally
affected by scabies such as the face and scalp, and nail beds. Norwegian
scabies is seen in severely immunocompromised patients such as in
AIDS patients. The crusts are teeming with scabies mites and thus very
infective to others.
Management of Norwegian scabies
- Treatment is as for scabies though it may need to be prolonged.
- Keratolytics need to be applied to remove the thick crusts: salicylic acid 5-10%
ointment or urea 10% ointment.
- Ivermectine 3-12 mg depending on bodyweight plus sulphur 5-20% ointment.

SCABIES

Scabies is an infection caused by the mite Sarcoptes scabiei, which lives
and moves in the skin producing burrows (S-shaped ridges), small blisters
and papules. Itching is especially severe at night, and causes scratch
marks and very commonly secondary infection with pustules and crusts.
Lesions occur preferentially between the fingers, on the sides of the
hands and feet, on the flexor sides of the wrists, in the armpits and on
the genitals and buttocks. In infants and small children palms, soles,
head and neck are often affected. Scabies is primarily spread through
close personal contact but may be transmitted through clothing, linen, or
towels.
Management of scabies
Whichever treatment is chosen, it is essential to treat all close contacts of the
patients, e.g. people sharing the same household. Also linen and clothing should be
washed or aired for at least 24 hours at the time of treatment. Secondary infection
should be treated like impetigo for 5 days. Lesions should be closed before applying
scabies treatment.
- Gamma benzene hexachloride (GBH) 1% lotion or cream. Apply from the neck down.
Allow to dry and wash off after 24 hours. Give 10 ml for adults and 5 ml for children
over 12 years. Do not use in pregnancy, breastfeeding mothers or babies < 6 months.
- Treat children with benzyl benzoate 25% emulsion diluted with one part water (1:1).
Dilute with 3 parts water (1:3) for infants. Apply for 3 nights, wash off each morning.
- Sulphur 5-20% ointment twice daily for 1-2 weeks.
- Scabies epidemics in institutions (prison, army camp, boarding school) may be
treated with ivermectin.
- Post-scabies itch often occurs. This can be mistaken for inadequately treated
scabies. Treat with topical steroids.

CREEPING ERUPTION / LARVA MIGRANS

The larvae of hookworms of cats and dogs usually cause this disease.
They enter the skin accidentally and migrate through the skin leaving a
very itchy, winding red trail of inflamed skin behind them. Larvae may
travel 1 to 5 cm or more daily. Sites of penetration are those in contact
with the ground, usually the feet or especially in small children the thighs
and buttocks. The larva can also be transmitted via towels or clothes,
which have been in contact with the infected soil. Scratching often
causes secondary infection and eczema. If untreated, the larvae
eventually die after some weeks or months.
Management of creeping eruption
- Freezing the skin about 1 cm ahead of the visible trail, this is where the head of the
larva is found. Chlorethyl spray, liquid nitrogen, solid carbon dioxide may be used,
even plain ice can be tried. This is only effective in experienced hands.
- Albendazole 400 mg twice daily for 3 days for adults and children > 2 years of age,
200 mg twice daily for 3 days for children < 2 years of age.
- Thiabendazole 10-15% cream or ointment 4 times daily until 2 days after the
burrows have disappeared (usually 1-2 weeks).
- Treat superinfection with betadine scrub, potassium permanganate solution, gentian
violet paint or if severe antibiotics (see impetigo).
- Ivermectin 3-12 mg in a single dose depending on bodyweight.

MOLLUSCUM CONTAGIOSUM

These infectious dome-shaped papules are caused by a pox-virus. They
have a central dimple in which often typical whitish cheesy material can
be seen, it looks like a little white ball. Molluscum normally occurs in
small children in areas of warmth, moisture and friction such as the
armpits and the groins, and on the face. Generally they are self-limiting
and will disappear within a year without treatment. If they persist for a
longer time or if they cause complaints they may be treated. When they
occur in adults, particularly when there are multiple and large lesions,
there may be immunosuppression.
Management of molluscum contagiosum
- Prick the centre with a sharpened matchstick and press out contents.
- Curettage with a sharp curette or lance with a pin.
- Use betadine solution or scrub after the above until dry.
- Caustic pencil (silver nitrate pencil) for small molluscum.
- Caustic treatment with 80% phenol or 50-88% trichloro acidic acid.
- Freeze with liquid nitrogen.

GENITAL WARTS / CONDYLOMATA ACUMINATA

Condylomata acuminata or genital warts are caused by HPV and are
transmitted by direct contact, usually through sexual intercourse,
sometimes by infected hands. Transmission is also possible from mother
to child during childbirth. Genital warts may show accelerated growth in
pregnancy followed by spontaneous reduction after childbirth. Excessive
growth occurs in immune suppressed patients. Patients should have
syphilis serology checked. Women with genital warts should have a Pap
smear taken.
Management of condylomata acuminata
- Podophyllin 10-25% solution. Protect the skin surrounding the warts with vaseline.
Apply podophyllin carefully to the warts with the back of a matchstick. Leave it on
for 4 to 6 hours then wash off with water and soap. Repeat weekly until cleared.
Podophyllin is contra-indicated in pregnancy!
- Trichlorocacetic acid 50-88% solution, applied in the clinic, may be used in pregnancy.
- Cryosurgery with liquid nitrogen .
- Cauterisation of large and/or refractive genital warts. This can be a very useful
procedure but is controversial in immune suppression because the warts tend to
recur quickly and extensive. When patients are severely disabled by their genital
warts, you may however not have much choice.
- Topical 5% 5-fluoro-uracil cream (Efudix) may be used once daily to once weekly for
up to 6 months after any of these treatments to prevent recurrences.
Efudix is contra-indicated in pregnancy.
- Examine partners and perform syphilis serology.

PLANE (FLAT / JUVENILE) WARTS

These warts usually occur on the face in children and may spread to the
upper trunk and arms or rarely to other parts of the body. They are very
small (1-3 mm) slightly raised (palpate them!) papules which tend to present
in large numbers. They exhibit a positive Koebner phenomenon
which means that they appear in scratched or otherwise traumatised
skin. In most children they eventually clear spontaneously.
Plane warts usually do not appear in adults but may do so in large numbers
when they are immunocompromised, as in HIV infection.
Management of plane warts
- Salicylic acid 2-5% ointment twice daily for 4-8 weeks.
- If there are a limited number of lesions curettage with a sharp curette.
- Electrosurgery may be carefully tried but may leave hypopigmented scars.
- Caustic pencil (=silver nitrate pencil) daily.
- If lesions are widespread and salicylic acid 2-5% ointment is not successful it is best
to leave them alone.

PLANTAR WARTS

These are also common and they usually give no complaints. When this
is the case they are best left alone. Sometimes they cause pain or
discomfort urging the patient to seek treatment. It is then best to
recommend non-aggressive therapy.
Management of plantar warts
- Regular flattening of the wart with a pumice stone, callus file or knife is usually
enough to keep the warts asymptomatic.
- If there is only one or a few lesions curettage can be successful.
- Salicylic acid 50% ointment ( 25% in children) or preparations of salicylic acid
5-20% and lactic acid 5-20% in collodion can be used daily. Apply the keratolytic
in the evening, cover with plaster and leave until the next evening. Then cut or
scrape the warts with a stone or a knife. Soak the foot in hot water for
5 minutes before re-applying the keratolytic treatment.
- Avoid destructive electrosurgery and sharp scalpel excision. Although they may
(or may not) remove the wart, the patient may not be able to walk properly for
months and the resulting scar often becomes a more difficult problem to treat
than the wart itself.

COMMON WARTS

Warts are caused by infection with Human papilloma virus (HPV). There
are many types of HPV which cause different types of warts. They are
found at any age but are most common in teenagers. They can spread by
contact or auto-inoculation. The infected person’s immune system clears
the warts within 2 years in 2/3 of cases so treatment is often
unnecessary. Treatment results vary greatly. In some people there is
instant success, in others it may take many months or have no success at
all. In immunodeficiency warts may spread quickly and fulminantly and
become extremely difficult to treat.
Management of common warts
- Keratolytic therapy with salicylic acid 25% ointment twice daily followed by cutting
or scraping the warts with a pumice stone, callus file or a knife twice a week.
Preparations of salicylic acid 5-20% and lactic acid 5-20% in collodion are easier to
use. This treatment may need to be repeated for months.
- Light electrodissecation and curettage.
- Freeze with liquid nitrogen when available.

KAPOSI’S SARCOMA

The incidence of Kaposi’s sarcoma (KS) has increased dramatically with
the current HIV epidemic. Although cases of classic (endemic) KS still
occur, the vast majority we see today is HIV-related. KS, which has now
been related to the oncogenic Human Herpes Virus-8, is a tumour of the
cells of the vascular wall of blood and lymph vessels. Classic KS
presents as purple-black papules and plaques usually on one leg which
progress very slowly or remain stationary, even over 20 years or more.
HIV related KS progresses much faster and more aggressively.
HIV-related KS often presents with generalised lymph node
enlargement or pleural lesions. Purple-black nodules and plaques appear
on the face, the trunk, the genitalia or the proximal limbs, especially the
thighs. Lesions may also be warty, tumorous, may ulcerate and they may
cause gross oedema, especially in the face and of the penis and scrotum.
Infiltration of the skin makes it "as hard as wood" on palpation. Plaques,
nodules and tumours in the mouth, especially on the hard palate and
tonsils are very common, always examine the mouth of a suspected KS
patient.
Management of Kaposi’s sarcoma
Treatment options depend on extent of tumor and growth rate, HIV viral load, and
general condition of the patient. Limited skin disease may be treated with cryotherapy,
or intralesional vinblastine or vincristine or radiation therapy. The extensively affected
patient will need referral for radiotherapy or chemotherapy

HERPES SIMPLEX - LIPS & GENITALS

The common presentations of a herpes simplex virus infection are the
"cold sores" or "fever blisters" on the lip (herpes labialis) and the genital
herpes infection. After a few days of prodromal burning sensation, a
group of blisters appear, which quickly break down to form superficial
ulcers. The primary infection may be accompanied by constitutional
symptoms such as fever, malaise and anorexia and take up to 3 weeks to
heal. If recurrences occur symptoms are less severe, usually without constitutional
symptoms and they heal within 7 to 10 days. In most people
they too are preceded by a burning sensation for a few days. Recurrences
are triggered by:
- exposure to sunlight (herpes labialis)
- trauma (e.g. fighting-lip; sexual intercourse-genitals)
- fever
People with immunodeficiency as in HIV infection may have more severe
infections and more frequent recurrences. Genital herpes may become
chronic, persisting for months, ulcerating and may cover large parts of
the genitals and surrounding skin, causing severe pain and disability.
Herpes simplex infection is spread by direct contact. It is highly contagious
when lesions are visible and it has been shown that people shed
virus even when there are no symptoms.
Management of herpes simplex infections
- Primary infections are very painful: analgesia is indicated.
- Lips: zinc oxide ointment or zinc oxide and castor oil; soothes and protects from
sunlight.
Antiseptic mouthwash e.g. chlorhexidine mouthwash 3-4 times daily and topical
antiseptic or antibiotic e.g. betadine ointment or oxytetracycline ointment 3 times
daily for bacterial superinfection.
Use a lip cream / stick with a sunblocker daily to prevent recurrences.
- Genital herpes: Betadine or potassium permanganate solution sit baths 3 times
daily. Zinc oxide and castor oil to soothe, or sulphur 5% in zinc oxide. Alternatively
betadine ointment or oxytetracycline ointment 3 times daily.
- Severe infections or infections in immunodeficient patients: if available give
acyclovir 200-400 mg 5 times daily for 5-10 days.

HERPES ZOSTER

Herpes zoster or shingles is the recrudescence of a latent varicella-zoster
infection in the partially immune host. After a short period of itch, tenderness
or pain along one or occasionally several dermatomes on one
side of the body papules and plaques appear which quickly change into
blisters. Most often thoracic and cervical dermatomes are affected. If the
ophthalmic branch of the trigeminal nerve is involved a keratoconjunctivitis
may develop and can lead to blindness. After 1-2 weeks crusts begin
to fall off. Over 10% of patients develop post-herpetic neuralgia, a persistent
burning sensation or pain in the area which has healed. This can
last from a few months to many years.
Herpes zoster may appear in otherwise healthy persons, especially the
elderly, but is much more common in people with underlying malignancies
and HIV-infection. It is an early indicator of HIV-infection in young
people. Delayed healing, dissemination and complications are more common
and severe in immunocompromised persons.
Management of herpes zoster
- Analgesia with NSAID’s, e.g. indomethacin 25 mg 3 times daily or ibuprofen 400 mg
3 times daily.
- Antibiotics for superinfection, as this is the main cause of keloidal scarring.
- Use betadine scrub/shampoo as a soap, do not use vaseline.
- Calamine or phenol-zinc lotion for vesicular stages.
- If the eye is involved refer to an eye-clinic
- In immune compromised persons if available acyclovir 800 mg 5 times daily for
1 week. Start acyclovir or other available antiviral (e.g. valaciclorir) early in the
course of the disease.
Postherpetic neuralgia:
- 3 to 5% phenol in cream or
ointment 2-6 times daily.
- Amitryptiline 75 mg nightly or
- Carbamazepine 600-800 mg once
daily or
- Amitryptiline 75 mg nightly +
thioridazine 25 mg 4 times daily.
Try any of these for at least 4-6
weeks before deciding whether
they are effective.
48
Fig. 55. Herpes Zoster in
more than one
dermatome in a 30 year old
HIV positive man.

CHICKENPOX

Chickenpox or varicella is a primary infection with the varicella-zoster
virus. It is a common, very contagious infection in children. After a mild
prodrome with sometimes fever and malaise the exanthema appears
suddenly. Red macules, papules and shortly thereafter vesicles, pustules
and crusts develop on the trunk, scalp and mucous membranes, less so
on extremities and face. New crops of lesions appear over the next few
days and lesions in all stages of development are seen at the same time.
Itch is the main complaint. Scratching is the main cause of bacterial
superinfection and may cause scarring. Crusts fall off in 1-3 weeks.
Signs, symptoms and complications become more severe with age. In
adults, fever and constitutional symptoms practically always precede the
exanthem. Possible complications include nephritis, myositis, otitis and
meningo-encephalitis.
In immunocompromised persons chickenpox becomes a life-threatening
disease.
Management of chickenpox
- Calamine lotion or phenol-zinc lotion
as necessary for itch and drying in.
- Antihistamines for extreme itch.
Give rest. Isolate patient if possible.
- Use betadine scrub and chlorhexidine
1% mouthwash if necessary.
- In severe superinfection a systemic
antibiotic e.g. cloxacillin or erythromycin.
- Immunocompromised patients:
if available acyclovir 200-800 mg
5 times daily for 5-10 days.

PITYRIASIS ROSEA

This is probably an ide reaction to a viral infection ("a flu of the skin").
There is sometimes a flu-like prodromal episode. Skin symptoms start
with a large "herald patch" or "mother patch" on trunk or arms, which
many patients can point out to you. Soon after, many smaller oval lesions
which scale at their borders appear on the trunk and (upper) arms.
Typically the lesions take on the direction of the skin lines forming a
"Christmas tree pattern" on the back. They generally cause no pain or itch
and disappear spontaneously within 2 months.
It is difficult to differentiate between pityriasis rosea and secondary
syphilis, therefore serological tests for syphilis should always be
performed.
Management of pityriasis rosea
No causal treatment is available. It is essential to explain the self-limiting nature of
the disease to the patient.
- Calamine lotion or rarely antihistamines for itch.
- Aqueous cream, emulsifying ointment or urea 10% cream for dry skin and scaling.

HIV INFECTION

HIV INFECTION
HIV related skin diseases occur throughout the course of HIV infection in
90% of the infected persons. During seroconversion an exanthema may
occur together with fever and constitutional symptoms. After
seroconversion there will be a period of symptomless HIV infection.
Herpes zoster is an early clinical sign which in young age-groups (under
50 years) is very strongly related to HIV infection. Severe and chronic
seborrhoic eczema may also be an early manifestation. Other cutaneous
manifestations of HIV infection are molluscum contagiosum, papular
pruritic eruption, severe herpes simplex or human papilloma infection,
severe bacterial, mycobacterial and fungal infections and Kaposi’s
sarcoma. Infestations such as scabies are more severe. Adverse drug
reactions are very common in HIV infection.

NOMA / CANCRUM ORIS

Noma is a form of infectious gangrene of the mouth. It is thought to be
caused by fusiform bacteria. It usually affects children 2 to 7 years of
age. Predisposed are malnourished children, especially those with
protein deficiency, hypovitaminosis and recurrent acute infections. The
disease generally starts as peridontitis, then ulcerative stomatitis,
always on one side of the mouth. It then progresses to gangrene with
extensive sloughing of adjacent tissue and necrosis of bone. The area is
foul-smelling and very painful. Untreated patients may die or survive with
a severe handicap.
Management of noma
- Start treatment as soon as the diagnosis is suspected!
- When only peridontitis is present, oral hygiene (e.g. chlorhexidine mouthwash) may
prevent development of noma.
- Massive doses of penicillin or in case of penicillin-allergy broad-spectrum
antibiotics for at least 2 weeks. Treat longer if necessary, until all signs of activity
have ceased.
- Intensive high-protein diet should be given, orally and parenterally, as well as
vitamin supplements.
- Early treatment may lead to great improvement of tissue defects.
Remaining deformities may need surgical repair.

BURULI ULCER

Buruli ulcer caused by Mycobacterium ulcerans is the third most common
mycobacterial disease after tuberculosis and leprosy in non-HIV-infected
patients. The disease first described in Uganda is now endemic in
swampy areas in West Africa, but may be seen elsewhere. It is
transmitted by mild injuries, the bacillus probably residing in muddy
water. Patients are usually children.
Two different forms of the disease are seen.
1. A slow form which develops in 2-3 months. A hard indurated plaque
with surrounding severely constricting oedema forms and compromises
the circulation in the affected limb, leading to ischaemia and necrosis.
2. A fast form which develops in 2-4 weeks. A painless papule or nodule
forms and ulcerates, extending rapidly. The typical ulcer has undermined
edges. The patient is not sick and there is no oedema.
Very extensive ulceration and secondary infection may occur and lead to
sepsis, tetanus and death. Besides the skin and subcutis deeper
structures may be involved. Particularly osteomyelitis may be seen.
The lesions may heal spontaneously with severe scarring and
contractures.
Management of Buruli ulcer
- Prevent secondary infections.
- There is only one effective treatment: Surgery as soon as possible, wide excision
with skin grafting. There is no effective medical treatment!

Management of leprosy complications

Treat with steroids, prednisolone 30-40 mg daily to start with, taper down to 20 mg
daily in 2 months. This daily dose should be maintained for some months (PB 1-2
months, MB 2-4 months or sometimes longer according to clinical assessments).
Thereafter the dosage can be further tapered down to zero in 2 months.
- Make sure that treatment is continued for a sufficient time!
- Check for intercurrent infections (TB, strongyloides).
Erythema Nodosum Leprosum
- Treat mild ENL, i.e. without nerve, eye or genital involvement with
acetyl salicylicum 1000 mg three times daily for 1-2 weeks.
- Treat severe ENL, i.e. a sick patient with nerve, eye, or genital
involvement, with steroids. Start prednisolone at 80 - 100 mg daily
for 2 days and taper off in 2 weeks. You may need to repeat this.
- Check for intercurrent infections!
- TB may complicate ENL!
- In countries where thalidomide is available 100 - 400 mg once daily
may be given for 1-2 weeks.
- Do not give thalidomide to pregnant women or women who do not
have 100% safe contraception!!! Thalidomide causes severe
deformities in the unborn child!
Ulceration and deformity
- Wounds should be cleaned and covered. Superficial wounds can be
covered with zinc adhesive sticking plaster which should be
renewed after 1-2 weeks. Hyperkeratotic rims should be trimmed.
- Do not use bulky bandages on the feet. These give local pressure
when walked upon and the wound will not heal!
- Use antibiotics only when there is cellulitis.
- Further deformity should be prevented by daily care by the patient: daily
inspection, soaking and oiling, trimming of cracks and softening of the skin by
applying 15% salicylic acid in vaseline. Digits should be stretched actively
and passively to prevent further contractures. For the unblinking eye protective
glasses during the day and a soft cover with vaseline during the night is necessary.
The patient has to learn to consciously blink regularly in order to moisten the eye.
Warning: Complications, reactions and further deformities
may occur for years after completion of antibacterial
WHO treatment. Patients should be informed about this and
proper treatment should be started immediately.

LEPROSY COMPLICATIONS

Complications of leprosy are the reactions which cause nerve damage
and the sequelae of this nerve damage; loss of sensation and loss of
muscle strength, with ulceration and deformity as consequence.
Reactions
Two types of reactions are recognised, the Reversal Reaction (RR) and
Erythema Nodosum Leprosum (ENL). Symptoms of a RR can be
increased swelling with erythema of previously existing lesions, the
appearance of new lesions, enlargement and tenderness of nerves which
may show increased function loss, and sometimes acral edema. The
ENL-type reaction, in its characteristic form, shows a sudden appearance
of tender erythematous nodules. The patient often feels ill. Nerves
may be tender. Sometimes arthritis occurs, or lymphadenitis, orchitis may
be encountered as well as iridocyclitis and glaucoma which can lead to
blindness. Organs may be involved separately or simultaneously.
Ulceration and deformity
Ulceration is secondary to the loss of protective sensation. The patient
feels no heat, pressure or pain. Skin trauma is not felt and easily
neglected. The risk of damage increases when there is loss of muscle
strength (claw hand, drop foot). Ulceration may lead to cellulitis or deep
infections, osteomyelitis and consequently to loss of digits.
When there is lagophtalmos, there is usually also anaesthesia of the eye
and consequently there is no blink. The eye is at risk of drying out and
ulceration with blindness may be the final result.
Deformity is the result of loss of muscle strength and ulceration
followed by osteomyelitis and shortening of digits, mostly accompanied
by stiffness and contractures.

LEPROSY

Leprosy is an infectious disease caused by Mycobacterium leprae. It is an
airborne infection (like tuberculosis) which affects skin and nerves. Leprosy
often presents with hypopigmented or slightly erythematous patches on the
skin with loss of sensation, and enlarged nerves. Loss of sensation is tested
with a whisk of cotton wool. The skin is touched, not stroked with it. The
patient is asked to close his or her eyes and to point at the spot which has
been touched. Misreference and certainly "not felt" are diagnostic for leprosy.
Nerves which should be checked for enlargement are the great auricular,
ulnar and radiocutaneous nerves. Enlarged nerves are pathognomonic
for leprosy. When there are infiltrated patches or papules and nodules skin
smears may be positive for M. leprae. Unlucky patients, those who are diagnosed
at later stages with nerve damage may show visible deformities such
as facial palsy (an eye cannot close, lagophthalmos, and that side of the
face sags) and loss of sensation of hands or feet which show dry skin with
or without ulcers. Sometimes fingers are bent or even lost, the grip is gone,
the feet drop.
For practical purposes two types of leprosy are recognised:
1. Paucibacillary (PB) leprosy or tuberculoid leprosy. These patients
do not have bacilli in their skin smears and have 5 or less skin lesions (in
some control programs 3). They are not infectious to others.
2. Multibacillary (MB) leprosy or lepromatous leprosy. These patients
have bacilli in their skin smear and more than 5 (3) lesions which may be flat
or raised patches, papules or nodules. Untreated lepromatous leprosy
patients discharge bacilli from their nose and are therefore infectious to
others.
Management of uncomplicated leprosy
1.PB-leprosy - Rifampicine 600 mg once a month under supervision plus dapsone
(DDS) 100 mg daily for 6 months unsupervised.
- When compliance is a problem, a 6 months dose taken within 9 months is
acceptable.
- Always check for complications!
2. MB-leprosy - Rifampicine 600 mg and clofazimine (Lampren) 300 mg once a month
under supervision plus dapsone (DDS) 100 mg daily plus clofazimine 50 mg daily
unsupervised for 12 or 24 months depending on the policy of the local leprosy
control programme.
- When compliance is a problem, a full treatment taken within 18 (for the 12 months
programme) resp. 36 months (for the 24 months programme) is acceptable.
- Always check for complications!

YAWS

Yaws, like syphilis, is caused by a treponema. The primary
lesion of yaws (mother yaws) is a wet, easily bleeding,
raspberry-like papule or nodule, which disappears after a few
weeks leaving an atrophic scar. When the primary infection is
not treated secondary lesions (daughter yaws) may appear as
generalised nodules, ulcerations and condylomata.
Note: Reactivity to VDRL and TPHA is the same as for syphilis.
Management of yaws
- Benzathine penicillin 2,4 million units per IM injection, repeat after two
weeks. For children benzathine penicillin 1,2 million units per IM injection,
repeat after two weeks.
- In case of penicillin-allergy: Erythromycin 500 mg 4 times daily for
2 weeks.

SECONDARY SYPHILIS

Syphilis is a sexually transmitted infection caused by the bacterium
Treponema pallidum. Ask for a history of a primary ulcer on the genital
area or elsewhere (lips) 1 to 2 months before the development of the
rash. Secondary syphilis presents with a generalised symmetric rash
which can mimic almost any other skin condition. A helpful diagnostic
symptom is the fact that secondary syphilis is not itchy. Also palms and
soles are usually affected as well as the face.
A positive RPR or VDRL screenings test is very likely based on syphilis if
confirmed by a positive TPHA (specific for Treponemal antibodies). In
yaws endemic areas positivity may however be caused by contact with
yaws. Results may be discordant in concomitant HIV-infection.
Management of secondary syphilis
- Benzathine penicillin 2,4 million units per IM injection weekly for 3 weeks.
- In case of penicillin-allergy: Erythromycin 500 mg 4 times daily for 2 weeks.
- Treat all partners!

ERYTHRASMA

Erythrasma is caused by Corynebacterium minutissimum. It presents as
dry, smooth to slightly creased or scaly, clearly demarcated reddishbrown
plaques, in the groins, armpits or under the breasts. It may easily
be mistaken for a fungal infection but direct microscopy with KOH is
negative for fungal elements. Lesions show red fluorescence when
viewed under Wood’s light.
Management of erythrasma
- An imidazole cream twice daily for 4 weeks. If not effective or recurrent infection:
- Erythromycin 250 mg 4 times daily for 2 weeks or
- Erythromycin 2% lotion twice daily for 4 weeks.

FOLLICULITIS KELOIDALIS NUCHAE

This literally means "keloid-forming folliculitis of the neck". It may start
after the neck is shaved. It is a common condition in African males. A
deep folliculitis, usually caused by staphylococci progresses to a chronic
fibrosing folliculitis and peri-folliculitis. Keloidal scars are produced in
the deeper cutaneous tissue. New papules and pustules occur at the rims
of the keloid. The course is very chronic.
Management of folliculitis keloidalis nuchae
Treatment is difficult.
- In active, pustular stages use doxycycline 100 mg twice daily for 2 weeks up to one
month followed by doxycycline 100 mg once daily for 2 weeks up to one month or
longer or other long-term antibiotics according to sensitivity tests.
- Excision of scars, with or without skin grafting. Recurrence of keloid is possible but
seems to occur less often when skin grafts are not performed and the wound is
allowed to heal per secundam, leaving an atrophic scar. Keloids may respond to
injections of steroid suspension such as triamcinolone acetonide, 10 mg diluted 1:3
to 1:5 with a local anaesthetic, every 2 to 4 weeks for several months.
- A strong steroid e.g. betamethasone ointment twice daily on lesions.
- Cryosurgery or lasersurgery may be helpful.

FOLLICULITIS

Folliculitis is an inflammation of hair follicles, usually caused by infection
with bacteria, specifically staphylococci. Common localisations are the
face, the trunk and the buttocks, but any skin area with hair follicles may
be affected. In HIV-infected patients gram negative bacteria may be
implicated or yeast infections, particularly pityrosporon.
Folliculitis may be mild and superficial or severe and deep, it may become
widespread and very refractive to treatment in immunosuppressed
patients.
Management of folliculitis
- Stop vaseline!
- For itchiness use calamine or phenol-zinc lotion as often as necessary.
- Mild forms: Dress or bathe with potassium permanganate solution or betadine
or chlorhexidine.
- Severe bacterial forms: oral
cloxacillin, erythromycin, doxycycline
or tetracycline for 7-10 days.
- Pityrosporon folliculitis: an imidazole
cream twice daily is usually
effective.
If severe add ketaconazole 200 mg
once daily for 1 to 3 weeks.
- Immunosuppressed patients may
need prolonged treatment.

IMPETIGO

This is a very common bacterial skin infection, usually caused by
staphylococci and/or streptococci. It presents with superficial pustules or
blisters which become oozing erosions with yellow crusts as it spreads.
Impetigo is contagious and may even spread through the shared use of
jars of vaseline. Vaseline application makes it worse.
Management of impetigo
- Dress or bathe affected areas with potassium permanganate, GV paint, betadine
solution or saline or wash with betadine shampoo.
- Prevent spread to others: do not share towels or ointments, change clothes, towels
and sheets frequently.
- Do not use vaseline, use aqueous cream instead.
- If severe give cloxacillin 250-500 mg 4 times daily for 7-10 days in adults,
50-100 mg/kg/24 hours divided in 4 doses for 7-10 days in children or erythromycin
250-500 mg 4 times daily for 7-10 days in adults, 25-50 mg/kg/24 hours divided in
4 doses for 7-10 days in children.

MYCETOMA / MADURA FOOT

This is a chronic localised infection which can be caused by various
species of fungi (eumycetoma) and bacteria, actinomycetes and nocardia
(actinomycetoma). These micro-organisms live in the soil and enter the
skin usually after a penetrating injury. The most common localisation is
therefore the foot or lower leg in barefoot persons but lesions may
appear anywhere on the body. A painless subcutaneous nodule or
induration is followed by more nodules which may discharge pus with
grains (small hard pinhead sized particles) through fistules, form abscesses
and ulcers and spread to underlying bones and joints. The colour and
hardness of the grain may help in deciding on the causative agent.
Management of mycetoma
- Smaller lesions which can be surgically removed without causing disability should
be radically excised.
- Decide on fungal or bacterial origin before installing drug therapy. Direct microscopy
(in 20% potassium hydroxide) of pus containing grains may help: after the grains are
crushed eumycetomas show hyphae, actinomycetomas small slender filaments.
Culture allows final identification. When in doubt, refer.
- Eumycetoma (caused by fungi) are virtually untreatable: antifungals e.g.
itraconazole, fluconazole, ketaconazole, miconazole, and griseofulvin have a success
rate of less than 30%. Actinomycetoma (caused by bacteria): dapsone or
cotrimoxazole combined with streptomycin. Streptomycin can be substituted by
amikacin, sulfonamides by rifampicin.
- Drug therapy often fails. Radical surgery / amputation is then the only option.

CANDIDIASIS

Candida is a resident yeast of the mucous membranes. It becomes
pathogenic under favourable host conditions. These are:
- When host immunity is decreased such as in HIV-infected and cancer
patients or by systemic steroids, cytotoxic drugs, and radiotherapy.
- Pregnancy and contraceptive pill use.
- Warmth and moisture (babies’ nappy area, groins, under breasts,
between toes).
- Use of broad-spectrum antibiotics which kill resident non-pathogenic
bacteria.
- Diabetes mellitus.
Candidiasis or thrush presents on the skin as red macules often with
small pustules on their periphery which break down as the lesion spreads
outwards. On the oral and vulvo-vaginal mucosa redness, superficial
erosions and white adherent plaques may be seen. These can be itchy
and painful. When oral lesions extend to the throat and oesophagus they
can cause anorexia. Infection of lips / corners of the mouth also occurs.
Severe mucosal candidiasis is seen often in HIV infection.
Management of candidiasis
- Treat large oozing lesions with potassium permanganate dressings
or baths for 10 minutes twice daily. Keep lesional skin dry.
- Paint mucosal or smaller wet lesions with Gentian Violet
solution once daily until healed. Application on normal skin
or on large areas is very unsightly.
- Nystatin ointment or cream twice daily for skin, nystatin
oral suspension (1 ml) swirled around mouth four times daily
until two days after clinical cure for oral candidiasis, nystatin
pessaries nightly for 2 weeks for vaginal candidiasis.
- An imidazole cream twice daily for skin infections,
miconazole oral gel 5 ml 4 times daily for 1 week for oral
thrush, imidazole pessaries 1-3 nights for vaginal thrush.
- Nappy rash: apply an imidazole cream and cover with
zinkoxide cream or ointment.
- In severe cases e.g. oesophageal thrush ketaconazole
200 mg twice daily for 1-2 weeks or itraconazole 100 mg
once daily for 2 weeks or fluconazole 50-200 mg once daily
for 1-2 weeks.
- Treatment duration may need to be extended in
immunocompromised patients.
- Griseofulvin is not an effective treatment
for candida infections.

PITYRIASIS VERSICOLOR

This is a common, chronic, superficial fungal infection which is caused by
the yeast pityrosporum. It is usually asymptomatic, causing only cosmetic
complaints. Pityrosporum is a normal skin resident predominantly of
seborrhoeic areas which becomes pathogenic under favourable circumstances:
warmth and humidity, pregnancy, serious underlying disease or
a genetic predisposition. On the scalp the infection presents as dandruff,
from there the neck and upper trunk become infected. Recurrences are
common, especially after inadequate treatment or re-infection.
Management of pityriasis versicolor
- Scrubbing the skin with a brush takes away a lot of the infected scales.
- Do not use vaseline, olive oil or palm oil.
- An imidazole cream twice daily on affected areas for 4 weeks. Add selenium
sulphide shampoo or ketaconazole 2% shampoo (expensive) twice weekly for the
scalp if lesions are widespread or if they are recurrences or
- Selenium sulphide suspension (e.g. Selsun shampoo) to affected areas overnight as a lotion or
- Selenium sulphide suspension (e.g. Selsun shampoo) to affected areas and the scalp
for 10 minutes daily for 2-4 weeks or
- Sodiumthiosulphate 20% solution overnight for
2-4 weeks or
- Propylene glycol 50% in water applied twice daily to
affected areas + scalp for 2-4 weeks or
- Salicylic acid 5% + sulphur 5% ointment
overnight for 2-4 weeks or
- Salicylic acid 5% gel or lotion overnight for
2-4 weeks.
- Recurrences can be prevented by 2 weekly or
once monthly preventiive treatment with any
of the above.
- In severe recurrent cases: ketaconazole 400 mg
stat or ketaconazole 200 mg once daily for 5 days
or itraconazole 200 mg once daily for 1 week.
- Treatment is complete when all the scales have
disappeared. You can test this by stretching
affected skin between two fingers; if scales
appear the infection is still active. After treatment
hypopigmentation may persist for some time and
wil re-pigment faster when exposed to the sun.

ATHLETE’S FOOT

Itchy, often macerated whitish scaling lesions and inflammation of the
skin in the interdigital spaces of the foot. Most common between the 4th
and 5th toe. The condition is not always caused by fungi but can be
caused by bacteria as well. For this reason oral antifungals are often
ineffective. The condition is often seen in people wearing rubber boots or
rubber / plastic sandshoes.
Management of Athlete’s foot
- Keep the space in-between the toes DRY. This may be achieved by drying the
skin thoroughly after washing, exposing to air, using betadine scrub, GV paint,
wearing cotton socks and not wearing shoes that are too tight or hot. Changing
socks daily will help prevent re-infection.
- An imidazole cream or Whitfield’s ointment twice daily until a week after symptoms
have cleared. This usually takes a minimum of 4 weeks.

TINEA UNGUIUM

Fungal infection of the nails is common, especially of the toenails in the
elderly, where it generally does not require treatment. There may be a
mixed fungal and yeast infection of toenails and /or fingernails.
Chronic paronychia is a chronic inflammation of the skin around the nail
caused by mixed or yeast infections. It often occurs in people who frequently
wet their hands such as domestic workers, cleaners, kitchen and
laundry staff.
Management of tinea unguium
Infection of the toenails:
- Usually this does not require any treatment. Thickened toenails may be softened using
Whitfield’s ointment or urea 10 to 40% ointment, and then thinned with a stone or a file.
- Systemic treatment of infected toenails is sometimes indicated e.g. when there is
pain or when the patient is young; griseofulvin 500 mg once daily until the affected
nails have grown out completely, this may take a year or longer. Recurrences are
common, take this into account when deciding whether to use one of the more
expensive drugs as listed below for infection of the fingernails.
Infection of the fingernails:
- Griseofulvin 500 mg once daily in adults or griseofulvin 10 mg/kg once daily in
children. Continue treatment until the affected nails have grown out completely,
this may take 4-9 months.
- If there is no improvement after 2-4
months, there may be a mixed infection
(griseofulvin treats only fungal infections,
not yeast infections) or resistance to
griseofulvin. One of the systemic azoles
should be given, e.g. ketaconazole 200 mg
once daily until symptoms clear or
itraconazole 200 mg once daily for
3 months or itraconazole 200 mg twice
daily for 1 week per month during
3 months. Alternative: terbinafine 250 mg
once daily for 6-16 weeks.
Chronic paronychia: Keep dry! Work
conditions may need adapting. Bathe in
betadine or potassium permanganate
solution followed by application of an
imidazole cream or GV paint twice daily.
Massaging the nailfold with a mild steroid
helps decrease swelling.
Fig. 24. Fungal infection
of the hand and nails.

TINEA CAPITIS

Scalp ringworm is common in children. The fungus has grown into the
hair follicle and will not be removed by topical treatment only. Severe
pustular forms exist with follicular pustules and nodules and often massive
purulent secretion. Lymph nodes in the neck swell and the patient
may have a fever and headache. There may be bacterial superinfection.
Systemic treatment is necessary to prevent scarring leading to permanent
bald patches.
Management of tinea capitis
- Griseofulvin 500 mg once daily for 8-12 weeks in adults.
- Griseofulvin 10-15 mg/kg once daily for 8-12 weeks in children.
- Add Whitfield’s ointment or miconazole twice daily topically for 4 weeks.
- Continue treatment after 12 weeks if the infection has not cleared completely.
- Alternative: Ketaconazole 200 mg twice daily or terbinafine 250 mg once daily or
itraconazole 200 mg (2 tabs) once daily for 4-8 weeks in adults.
- Ask for signs of infection in siblings or friends of affected children or in pets or
farm animals (bald patches, rash) and have these treated.
- In case of bacterial superinfection: antiseptics and / or antibiotics.

TINEA CORPORIS

Fungal infection of the skin, most common on the exposed surfaces of the
body, namely the face, arms and shoulders. Tinea or ringworm presents
in typical round lesions, which show scaling at the periphery, or in concentric
rings. Usually one or a few lesions are seen and only topical treatment
is necessary. Multiple, large or widespread lesions may be seen
if a patient delays seeking treatment for a long time or is malnourished
or immunosuppressed.
Management of tinea corporis
- An imidazole cream or Whitfield’s ointment twice
daily for a minimum of 4 weeks.
- Continue treatment until one week after symptoms
have cleared.
Multiple, widespread lesions may be treated
systemically:
- Griseofulvin 500 mg once daily for 2 to 6 weeks in
adults or griseofulvin 10 –15 mg/kg once daily for
2 to 6 weeks in children or
- Ketaconazole 200 mg once or twice daily or
itraconazole 200 mg (2 tabs) once daily for 2 to 4
weeks in adults.
- When there is severe itching a mild steroid may be added.

FUNGAL / YEAST INFECTIONS

Fungal infections may occur at any age. Children may easily infect each
other or get infected by animals / pets. The most common fungal infection
is "athlete’s foot" = infection of the interdigital spaces of the toes.
Skin, nails and / or hair may be infected. When a fungal infection is treated
incompletely or too short it will almost certainly recur. In
immunosuppressed patients fungal infections may be more widespread
and take longer to treat than normal. Always ask your patient to come for
review when his or her treatment is about to be completed, If you then
see any remaining sign of infection continue the treatment, as it is likely
to recur if you do not.
MYCIDS
A hyperergic reaction to the fungus may occur in the course of fungal
infections. These are usually itchy eruptions of small blisters at a site distant
from the fungal infection, often the hands and fingers (pompholyx). No fungi
are found within these "mycids". They disappear when the causative fungal
infection is treated. Sometimes the itching is so severe that treatment is
advisable: a strong steroid cream under wet dressings for a couple of days.

Management of contact eczema

- Avoid contact with the relevant irritant or allergen!
- Avoid soap and vaseline, use aqueous cream/emulsifying ointment
instead.
- Vaseline dermatitis: use calamine or phenol-zinc lotion, betadine scrub or shampoo,
use no vaseline for months or rather years.
Severe infection: cloxacillin or erythromycin for 1 week.
- Acute contact eczema: Wet dressings with saline or potassium permanganate
solution twice daily. For itch calamine lotion or phenol-zinc lotion. When dry a
topical steroid cream e.g. hydrocortisone 1% twice daily. Antihistamines orally e.g.
promethazine 25 mg nightly for 5 days.
- Chronic contact eczema: Hydrocortisone 1% ointment, if necessary stronger topical
steroid. Coal tar ointment for itch nightly. Aqueous cream, emulsifying ointment. If
lichenified: urea 10% ointment or salicylic acid 2-5% ointment twice daily.
- If photo-allergic: sunprotection (sunhat, long sleeves, high collar).

CONTACT ECZEMA

Contact eczema is caused by contact of the skin with an irritant or an
allergen.
Chronic irritant contact eczema is caused by excessive, repeated
contact of an irritant with the skin. Vaseline commonly causes "vaseline
dermatitis", which presents with papules and pustules on the lower legs,
often of schoolgirls. Common causes of irritant contact eczema on hands,
arms and legs are excessive use of water, soap (especially if not washed
off properly after use) and detergents, and many types of chemicals (e.g.
alkaline and acid solutions, organic solvents such as alcohol, benzene,
toluene, gasoline). Saliva may cause "lip-licking disease" through
repeated wetting of the skin around the lips.
Acute and chronic allergic contact eczema develop after sensitisation
to an allergen through previous contacts with the same allergen.
In acute allergic contact eczema the contact site shows redness,
small or large blisters which on bursting become oozing red erosive
areas, and finally crusting and scaling. When the allergic reaction is set
off by exposure to sunlight it is a photo-allergic contact eczema. Some
soaps contain photo-allergens which cause these reactions. The history
(e.g. "I have applied betadine dressings on that site") and the usually
sharp margins of the eczema help define the causative allergen.
Chronic allergic contact eczema usually shows a symmetrical
distribution and blurred borders. The skin is usually dry, scaly and shows
lichenification (thickening), often cracks. It can spread to sites distant
from the original contact making it difficult to determine the cause.
Some examples of contact allergens are: occupational (dyes,
preservatives, rubber, bleach, soap, floor wax, nickel, oils, diesel,
fertilisers, pesticides, cement), environmental (plants, spices), medical
(betadine, lanolin, local anaesthetics, menthol, camphor), cosmetic
(perfumes, nail polish, hair-chemicals), clothes or jewellery (chromate,
nickel, rubber, dyes). This list is not complete. Allergy testing may be
done by a dermatologist or allergologist.

INFECTIVE ECZEMA

This is an eczema which occurs as a response to an oozing skin infection.
The most common localisation is the foot/ankle region, especially around
the instep. Causative organisms are usually staphylococci or
streptococci. The use of vaseline often aggravates the condition.
Management of infective eczema
- Stop the use of vaseline.
- Treat the infection with antibiotics (cloxacillin, erythromycin) and/or antiseptics
(betadine solution/scrub, GV paint, potassium permanganate baths).
- When dry, add a topical steroid, starting with hydrocortisone cream twice daily.
- Prevent recurrences by preventing irritation (no vaseline, sweating), habitual
scratching (instruct the patient, use aqueous cream, calamine lotion, keep
fingernails short, cover at night) and infection (use betadine scrub as a soap for
4 weeks).

LICHEN SIMPLEX

In lichen simplex there is one (sometimes more) well-circumscribed patch
of lichenified skin which is very itchy. Lichenification means thickening of
the skin with exaggerated skin lines and this is usually caused by continuous
scratching, rubbing with a stone or stick and the likes. Patches are
commonly seen in the neck, in the genital area and on the lower legs.
Management of lichen simplex
- The vicious circle of -itch-scratch-lichenification-itch- needs to be broken.
The patient must therefore make a conscious effort to stop scratching!
- Coal tar ointment or coal tar in zinc paste applied nightly to reduce itching.
- Application of simple zinc-adhesive tape may prevent scratching and help to break
the vicious cycle.
- A strong topical steroid, especially if applied at night under plastic occlusion (e.g.
twice weekly) is usually very effective. To do this cover the lesion with plastic after
applying the steroid, then tape the sides of the plastic to surrounding skin. Do not
apply plastic occlusion in the genital area.

SEBORRHOIC ECZEMA

This is an eczema with classically greasy scales on seborrhoic areas of
the skin; scalp, border of forehead/scalp, behind ears, above and in
between eyebrows, in nasolabial folds, chin, the sternum, the middle of
the upper back in between the shoulder blades, in axilla, groin and
perianal area. Constitutional and stress factors play a role as well as a
yeast, pityrosporum ovale, which is found in sebaceous glands. Patients
often complain of oily skin as a result of their pronounced sebum production.
The eczema comes and goes.
In mild cases only the face, scalp and chest are affected. Sometimes, and
commonly in case of immunosuppression such as in HIV-infected persons
the eczema can become very widespread and easily superinfected. It
occurs in armpits and groin and is conspicuous behind the ears. It may
generalise to cover the entire skin. Usually you will still find the typical
greasy scales in e.g. the nasolabial folds. The entire skin is inflamed, red
to a darker shade than normal.
Management of seborrhoic eczema
- Stop vaseline, use a non-greasy or no moisturiser.
For minor lesions e.g. only on seborrhoic areas in the face and on the scalp:
- An imidazole cream twice daily (suppresses pityrosporon) with or without
hydrocortisone, sulphur 3-5% cream with or without hydrocortisone, or
hydrocortisone cream twice daily. For chronic scaling salicylic acid 2-5% ointment or
sulphur 2-5% ointment. Warn the patient that the eczema will probably recur.
For acute and severe, widespread lesions (usually infected):
- Hydrocortisone cream once or twice daily.
- An imidazole cream twice daily.
- Ketaconazole 200 mg once daily or 200 mg on alternate days orally
1-3 weeks.
- Antibiotics and betadine scrub/potassium permanganate solution
as required.
For chronic recurrent widespread lesions:
- At night: Coal tar 2-6% in zinc paste or coal tar ointment or coal
tar + sulphur 5-10% ointment (not on wet lesions).
- Daytime: Hydrocortisone cream or betamethasone cream once
daily and / or an imidazole cream twice daily.
- Salicylic acid 2% or 5% ointment twice daily for dry scaling lesions.
- Systemic ketaconazole in low doses as above may be added
when severe.
- Antibiotics and antiseptics as required.