Where you are:
You are F2 working in General Practice.Who the patient is:
Sandra Peters, the mother of Samuel aged 2, has come to you with a complaint.Special Note:
Samuel had gone for a pit walk with his father, he is not in the room.What you must do:
Take focused history, address patient’s concerns, and discuss management plan with the mother.
P1
D: How can I help you?
P: Samuel is scratching all over.
D: How did it start? Onset
P: Suddenly doctor and it’s getting worse (Course)
D: Since when? Duration
P: 1 week.
D: Does anything make it better or worse?
P: I haven’t notice doctor OR maybe worse at night.
D: Where is he scratching exactly? Site
P: It started between his fingers and now it’s all over his body.
D: Any other symptoms? Open Qs
P: Like what?
D: Is there any rash? Meningitis
P: Yes.
D: Have you placed a glass over the rash to see if it disappears? Meningitis
P: Yes, I have checked it and it does disappear.
D: Any Fever?
P: No.
D: Any Discharge?
P: No.
P2+ MAFTOSA
D: Has he been diagnosed with any medical condition in the past?
P: No.
D: Is he taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Has he come into contact with anybody having the same itching? CONTACT very important
P: No.
D: Is Samuel an only child? CONTACT
P: Yes.
D: Have you recently travelled abroad? Travel
P: Yes.
BIRDDD
D: How was Samuel’s birth?
P: It was a normal vaginal delivery.
D: Are you happy with his red book?
P: Yes.
D: Is he up to date with all his jabs?
P: Yes.
D: Has he received any recent jab?
P: No.
D: Is he feeding well?
P: Yes. he is feeding very well.
D: Does he have any problems with his wee?
P: No.
D: Is Samuel an active and playful child?
P: Yes.
D: Is Samuel playing well with other children? If he is coming into contact with others
P: He does not go out to play much.
On examination
Observation and examine the lesion.
We may use a magnifying glass to examine the rash (for any burrows). We may also do an ink burrow test where ink is rubbed over the rash and then wiped out with an
alcohol swab to outline the burrow track.
Tiny mites lay eggs in the skin, leaving lines with a dot at one end The rash can appear anywhere, but it often starts between the fingers.
The rash may then spread and turn into tiny spots. This may look red on lighter skin; The rash may leave dark spots on the skin. This may look brown or black on darker skin.
Management:
Diagnosis:
From what you have told me and the rash that you have shown me, it appears that your son has a skin infection caused by mites which is known as scabies. These bugs actually burrow into the skin and can cause terrible itching and rashes.
Senior.
Symptomatic:
- Anti-Scabies creams:
− Permethrin cream (Main TTT) that kills the mites, applied to cool dry skin (not wet) overnight to the whole body from head to toe, including the scalp and face specially between the fingers, the front of the wrists and elbows, beneath the breasts, the armpits and around the nipples in women.
− Malathion liquid. (If allergic to permethrin.).
− The cream or lotion should be left on for the full recommended time. Permethrin
cream should be left on for 8-12 hours. Malathion lotion should be left on for 24
hours.
– Children should stay off school until the first application of treatment has been
completed.
– Breast-feeding mothers should wash off the lotion or cream from the nipples before
breast-feeding, and re-apply treatment after the feed.
– Permethrin cream is not usually used for babies under the age of 2 months, and
malathion is not usually used under the age of 6 months. - Antibiotics: for a secondary skin infection may also be prescribed.
- For Itching: Topical treatments that you apply to the skin:
− Emollients
− Antihistamine medicine that makes you drowsy, such as chlorphenamine if itching is a problem at night (particularly for children).
− Hydrocortisone cream. This is a mild steroid cream that may ease any inflammation and help to ease itch. It can be applied once or twice per day, for up to a week.
General advice:
- You’ll need to repeat the treatment 1 week later to make sure all mites are killed.
- Scabies is very infectious, but it can take up to 8 weeks for the rash to appear.
- Everyone in your home and all close contacts need to be treated at the same
time, even if they do not have symptoms. - Anyone you have had sexual contact with in the past 8 weeks should also be
treated. - You or your child can go back to work or school 24 hours after the first treatment.
DO
− Wash all bedding and clothing in the house at 50C or higher on the first day of
treatment.
− Put clothing that cannot be washed in a sealed bag for 3 days until the mites die.
− Stop babies and children sucking treatment from their hands by putting socks or
mittens on them.
− Alternative options to kill any mites on clothes and linen are ironing the item with a hot iron, dry cleaning, or putting items in a dryer on the hot cycle for 10-30 minutes.
DON’T
− Do not have sex or close physical contact until you have completed the full course
of treatment.
− Do not share bedding, clothing or towels with someone with scabies.
Specialist:
Seek specialist advice for children under 2 months old - scabies is rare in this age group.
Notify Public Health in case of outbreaks.
Safety netting
− If the itch persists longer than 2-3 weeks after treatment. Sometimes the first treatment does not work, and a different one is then needed.
− If the rash becomes sore, painful or you experience fever, come to us immediately as it might be complicated by a secondary bacterial infection.
Follow up
Concerns:
P: How many days will it take to go away? 2 -3 weeks
P: What will you do for her? Management plus advice
P: What happens if it gets worse? Specialist, repeat treatment, try another treatment.
5 POINTS RECAP:
- SEVERE ITCHING WORSE AT NIGHT
- CONTACT
- MAGNIFYING LENS AND INK BURROW TEST
- TREAT ALL HOUSE MEMBERS
- ADVICE