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.