Monkeypox: Everything Nurse’s need to know when Caring for Monkeypox patients

Monkeypox

A nurse’s guide to monkeypox

William Kelly, MSN, FNP-C

Author | Nurse Practitioner

Published: September 19, 2022

Unless you’ve buried your head under a rock, you probably have heard about the recent outbreak of Monkeypox.

Just like any infectious disease, nurses are on the front lines and we need to be educated about how to care for these patients, as well as how to minimize the risk of spread to our patients or families.

What is Monkeypox?

Monkeypox is a virus that is similar to smallpox because they are part of the same genus – the orthopoxvirus genus. It is a zoonotic disease, which means its natural hosts are animals – in this case primates and rodents. This virus causes a syndrome of fevers, body aches, malaise, and a pustular rash that is similar to smallpox, although less deadly and less contagious.

This is not a new virus, and normally tends to occur primarily in the tropical forests of West and central Africa. However, this does occasionally cause small outbreaks outside of these areas.

In 2003 there was a brief outbreak in the US, which included only 71 confirmed cases. Out of these, there was no spread to any healthcare staff or other patients within the hospital, and no associated deaths. 

Since May 2022, there is another outbreak in the US that is current and continues to spread, this time much more prevalent with over 21,000 cases confirmed in Septemeber, and over 50,000 cases globally.

Check out CDC for updated statistics.

Transmission of Monkeypox

There are multiple ways in which viruses can be transmitted to other people.

Monkeypox has a few different routes of transmission, some more common than others. These routes of transmission include:

Skin-to-skin contact

Skin-to-skin contact with an infected lesion is the most common route of transmission for monkeypox. This. ismost contagious when the lesions are present on the skin. This is why it is commonly transmitted via sex, even though it is not a sexually transmitted infection.

An enlarged prostate and urinary retention

Is Monkeypox an STI?

Despite what you may have heard on some news outlets, monkeypox is NOT a sexually transmitted infection and you cannot only get it through gay sex.

Most cases that are occurring are currently within the gay community of men who are having sex with men. This is sometimes how viruses work – they will spread in a certain community, and then make their way to other communities.

Respiratory Droplets

As with many viruses such as COVID, respiratory droplets can transmit infection. So if you cough sneeze or even speak, this can sometimes infect others depending on how close you are to them. Prolonged face-to-face contact may be required for this to occur with monkeypox.

Fomites

Fomite transmission is when the virus lives on a surface and another person picks up that object or touches that surface and then infects themselves. This can commonly be bed linens, clothing, or surfaces. This is different for every virus, and monkeypox has been known to be able to live on surfaces for up to 15 days!

An enlarged prostate and urinary retention

Not Contagious Anymore?

A person is considered infectious from the onset of clinical symptoms until all lesions have scabbed over and re-epithelization has occurred.

What to do if Exposed?

The CDC recommends that if a patient is exposed to monkeypox in the community, they should:

  • Monitor for symptoms for up to 21 days
  • If any symptoms develop, should isolate for at least 5 days to watch for the development of a rash
  • If the rash develops, isolate until evaluated by a healthcare professional (likely isolate until lesions resolve)

How dangerous is Monkeypox?

It’s difficult to predict how dangerous monkeypox is for those in the US, as most of our data comes from Africa. In Africa, they have less access to quality healthcare, and the predominant strain (called a “clade”) is more deadly there. 

From the data regarding Monkeypox in Africa, up to  3-6% of cases die.

So far. in the US, there have been one confirmed death from Monkeypox in LA. 

Remember that most of the current monkeypox infections are circulating among younger, generally healthy men.

We have not yet seen monkeypox in large amounts in older patients with significant comorbidities and immunocompromised patients, and they’re expected to have higher rates of complications and death.

Even if monkeypox does not cause death, it can last for weeks and lead to very painful and sometimes scarring lesions.

Prevention

Prevention is the most important aspect of infection control. If we can prevent spreading the virus, we can’t control the virus. This leads to better patient outcomes overall.

With monkeypox, there are ways to prevent the spread within and outside of the hospital. Monkeypox prevention includes:

Universal Precautions

Universal precaution should ALWAYS be used on all patients in every setting, and includes proper hand hygiene, and the use of clean gloves when dealing with or anticipating contact with a patient’s body fluids. This is one of the most important things we can do in healthcare to prevent the spread of infection.

Isolation Precautions

Patients who have suspected or confirmed monkeypox should be placed into isolation as per your facility protocol. As we discussed, monkeypox is spread primarily through physical contact as well as through respiratory droplets. This means that you should be using contact and droplet precautions, so typically that involves the use of a gown, gloves, N95 facemask, and protective eyewear.

N95 Mask

The CDC currently recommends N95 masks when entering a patient’s room with Monkeypox.

Vaccination

Smallpox, a similar but more contagious and deadly virus than monkeypox, was essentially eradicated in 1977 thanks to vaccinations. Because of this, routine vaccination was discontinued in 1980.

Because smallpox and monkeypox are so similars and comes from the same family of viruses, the smallpox vaccine is effective against monkeypox. However, it is in short supply and is being given to patients who meet high-risk criteria.

Currently, vaccination is recommended for patients who:

  • Have had close contact with Monkeypox for extended periods of time
  • A recent sex partner (the last 2 weeks) has been diagnosed with Monkeypox
  • A man or transgender/non-binary who has sex with men and in the last 2 weeks has:
    • Had multiple sex partners or group sex
    • Had sex at a commercial venue (bathhouse, sex club, etc)
    • Had sex in an area where monkeypox transmission is occurring

Assessment

Symptoms

Prodromal Symptoms

Patience with monkeypox will often present with a Prodromal period of symptoms, followed by the characteristic rash. During the prodrome, these symptoms will usually last up to 5 days and include:

Fever

A temperature above 100.4 F

graphic of a brain

Headache

Patients often complain of a severe headache

Back & Body Aches

Myalgias and pain are common with monkeypox, as with many other viruses

Fatigue

Patients are often very fatigued and tired

Lymphadenopathy

Patients often have swollen lymph nodes, which can be localized toa specific area, or generalized throughout their body

The Monkeypox Rash

The characteristic rash of monkeypox will typically develop 1-4 days after the prodromal symptoms start.

The Rash

Monkeypox will cause a characteristic vesicular/pustular rash that progresses through different stages (See more on the stages below). These lesions are often in the same stage as each other, but not always.

Other history

Recent Travel

Recent travel to an area where Monkeypox is Endmic, such as western Africa or the Congo Basin

Recent Exposures

Any recent contact with someone who may have had monkeypox

Sexual History

Any recent sexual contact or history that would place them at risk of getting monkeypox?

Physical Assessment

The physical inspection will primarily involve inspecting the skin for the monkeypox lesions, noting their quality, amount, number, and locations.

  • Generalized: May be febrile, sweaty, pale
  • HEENT: May have enlarged and tender anterior cervical lymph nodes, throat may be erythematous
  • Cardio: May have tachycardia, especially if fever present
  • Respiratory: may have increased respiratory rate, sometimes could have cough
  • Skin: Monkeypox lesions as described in detail below
  • Extremities: Lymphadenopathy may be present in axillae or groin

Vitals:

  • Temp: Often have fever >100.4
  • BP: Often normal
  • HR: May have mild tachycardia d/t fever, dehydration, etc
  • RR: May by mildly tachypneic
  • SPO2%: Often normal

THE RASH

The characteristic monkeypox rash begins approximately 1-4 days after the start off the other symptoms, although some people get the rash first. This begins as a macule, then slowly develops into vesicles, pustules, and then scabs over.

The rash will typically last 2-3 weeks. Patients are considered infectious until the scabs fall off and a new layer of skin forms.

1. Enanthem Stage

In some cases, lesions will first form in the mouth and/or on the tongue.

2. Macular Stage

Macular lesions will first appear, which are basically just rounded red spots that are flat. 

This stage lasts 1-2 days

3. Papular Stage

The macular lesions will then turn into papules, which are raised red bumps.

This stage also lasts 1-2 days

4. Vesicular Stage

The papular lesions will then turn into vesicles, which are raised bumps filled with clear fluid

This stage also lasts 1-2 days

5. Pustular Stage

The vesicular lesions will then turn into pustules, which are raised bumps that are filled with pus (suppurative fluid).

Initially, these are deep-seated, meaning firm and hard. Eventually, they develop an umbilication in the center.

This stage lasts 5-7 days

6. Scab Stage

Finally the pustules crust over and become scabs. These fall off after about 1 week.

This stage lasts 7-14 days

Nursing interventions

There are some nursing inventions that you can do right off the bat with these patients he suspected to have a monkeypox:

Isolate

Patients with suspected monkeypox or even chickenpox should be placed in contact and droplet precautions. The difference with chickenpox is that that tends to be airborne, whereas monkeypox is not, so a negative air pressure room is not required, although may be prudent just in case of chickenpox or other airborne viruses.

Follow proper isolation precautions to minimize the acquisition and spread of the virus. Always refer to your facility’s protocols.

Place the IV

Place at least one IV, preferably 20 gauge or larger, in order to infuse normal saline once it’s ordered. These patients are usually tachycardic and have fevers, and fluids will help rehydrate them, improve their vitals, and help them feel better overall.

Prime your Fluids

Prime at least 1 L of NSS spiked and ready to infuse. Verify a verbal or electronic order being administering (as always 😉).

Bedside Monitor

If these patients are significantly ill and tachycardic, it would be a good idea to hook them up to a cardiac monitor. While doing so, a full set of vitals should be taken if not done already in triage.

Administer Meds

Ask for and verify any medication that the patient may need, including antipyretics like Tylenol, an analgesic like morphine or Toradol, and/or an antiemetic like Zofran.

Diagnosis of Monkeypox

Diagnosis of monkeypox is largely clinical – so based on their history and the rash. However, it is recommended to confirm this in a lab due to the current outbreak.

There are a few ways monkeypox can be confirmed in the lab:

PCR Swab

A swab of the lesions can be obtained and sent to the lab, they should be obtained with a dry synthetic swab. For more information on how to collect the swab – see here.

2 swabs should be obtained from at least 2 different lesions. Vigorously swabbing back and forth is fine, and you do not need to “unroof” the lesions.

Antibody Testing

Some facilities can check for IgG and IgM antibodies to monkeypox. IgM is typically detected 5 days after onset of rash, and IgG is detected 8 days after onset of the rash.

Electron microscopy

Monkeypox can be identified under a microscope as well, where the pathologist visualizes brick-shaped poxvirus virions (indistinguishable from smallpox).

Other Lab abnormalities

There are other lab abnormalities that can present in patients with monkeypox, although these are NOT specific to monkeypox. these include:

  • Leukocytosis (increased WBC)
  • Transaminitis (Elevated liver enzymes)
  • Thrombocytopenia (Low platelets)
  • Hypoalbuminemia (low albumin levels)

Prognosis & Treatment

With the current US outbreak, patients who get Monkeypox generally have a good recovery, and most can fully recover at home without hospitalization. So far only one death has been specifically attributed to monkeypox in the US during this current outbreak.

However, patients can present with more severe symptoms and complications, which can lead to worse outcomes and even death. These patients are kept in the hospital and given more extensive treatment.

For most people who get Monkeypox, treatment is going to be symptomatic, just like with most viruses. Symptomatic or supportive care includes:

Supportive Care

Antipyretics

Antipyretics like Tylenol or Ibuprofen can be used to control fever and symptoms of pain.

Fluids

Encouraging oral hydration is important with any virus, and will help the body recover quicker, and prevent complications such as acute kidney injury. If the patient is admitted, these fluids can be given IV as well.

A vector graphic of a bed

Rest

Resting while the body recovers from infection is important for any virus, and will help the body heal as quickly as it can.

Antivirals

TPOXX

TPOXX is the abbreviation for Tecovirimat – an antiviral used for severe monkeypox infections. This is reserved for patients who are admitted to the hospital and have severe disease. Although we don’t have much data in humans, this antiviral has been shown to decrease mortality rates in animals with monkeypox when started early in the course of the illness.

  • Rx: 600mg IV or PO Q12h x 14 days (depending on weight).
  • Side Effects: include headaches, nausea, and abdominal pain.

Tecovirimat

Antiviral


Mechanism of Action

Potently inhibits the orthopoxvirus protein required for the formation of virus particles

DOSING

600mg IV/PO Q12H x 14days (for 40-120kg)

SIDE EFFECTS

Headache, Nausea, abdominal pain

Cidofovir/brincidofovir

Cidofovir has been shown to be effective in killing monkeypox in animal studies. Brincidofovir is a prodrug of cidofovir and was also approved for the treatment of monkeypox, however, did show some elevated liver enzymes in animal studies.

Complications & Monitoring

As discussed, most patients recover well at home, but there are certain complications and monitoring that you should watch for.

Patients at increased risk of developing more severe complications include:

  • Immunocompromised: People with HIV/AIDS, leukemia, chronic steroid use or other immunosuppressants
  • Age < 8
  • Pregnant or breastfeeding women
  • People with active skin diseases like severe eczema, impetigo, burns, etc

Secondary bacterial infections can occur with viral infections, and this is no different than with monkeypox. Bacteria like to strike while the immune system is busy fighting the virus. This can lead to infections like pneumonia or sepsis.

Common secondary infections include:

sepsis

Bacterial infections in any location can cause sepsis. This often happens from UTIs, lung infections, or skin infections.

Bronchopneumonia

Pneumonia should be suspected with productive cough, shortness of breath, adventitious breath sounds, and respiratory distress. This is evaluated with a CXR.

graphic of a brain

Encephalitis

Encephalitis can occur with various infections and cause confusion, migraines, seizures, and overall altered mental status. This may be diagnosed by brain imaging (CT or MRI), EEG, and a lumbar puncture.

18 Acute Skin Rashes for Nurses to Know (with pictures)

18 Acute Skin Rashes for Nurses to Know (with pictures)

William J. Kelly, MSN, FNP-C
William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

Skin rashes are a common reason why patients and parents seek medical care. Skin rashes can look gross and are often uncomfortable – whether they itch, burn, or cause pain.

Many causes of skin rashes are temporary, but some are chronic and can be ongoing.

Understanding the most common types of skin rashes and their treatment will be important, as you will run into skin-related problems in any setting of healthcare.

Oxygen delivery devices and flow rates FB

Skin Rashes: Taking the History

In order to successfully diagnose a skin rash, you need to know which questions to ask.

Timing is an important factor to consider. How long has the rash been there, does it come and go? Did the rash look different when it first occurred, and how has it changed? If it occurred before, what was it and what treatment worked?

Associated symptoms can be key in making the right diagnosis. Does it itch, burn, or is it painful? Are there any fevers, chills, pain anywhere else in their body?

Related activities that may have caused or worsen the rash should be investigated. This includes things like sunlight exposure, being out in the woods, using a new skin product like shampoos or lotions, or new medications or foods.

Treatments that the patient has already tried should be evaluated, which usually includes OTC creams and sometimes prescribed medications from a previous diagnosis or from another recent healthcare visit. This may be Benadryl cream, steroid cream (like hydrocortisone), moisturizers, etc.

A detailed past medical history and current medications should be evaluated as well.

Meds that are more likely to cause a rash include:

  • Antibiotics
  • Anti-epilepsy medications
  • allopurinol

The Skin Rash Physical Exam

When looking at skin rashes, they are described using various describers which have different meanings and significance.

A lesion is a general umbrella term that essentially means any non-normal “spot” or region.

Macules are lesions that are flat, <1 cm in diameter, and have different pigmentation from the base skin color. These are called patches when they are >1cm.

  • Macules: Café au Lait, freckles
  • Patches: Vitiligo

Papules are like macules, except they are raised and palpable, also <1cm, and have different coloring from the base skin color. Lesions >1cm are termed plaques. Pustules are papules with purulent fluid inside.

  • Papules: Acne, moles, warts
  • Pustule: Cystic Acne, Folliculitis
  • Plaque: Psoriasis

Purpura are red-purple discolored lesions that do not blanch. Blanching is when you press on an area of skin and it turns white from capillary compression. Purpura occurs due to leakage of blood into the extra-capillary space.

Vesicles are small papules <1cm that contains clear or bloody fluid. Bullae are bigger than 1cm.

  • Vesicles: Shingles
  • Bullae: Bullous pemphigoid

Wheals are elevated irregular-shaped areas of edema that are pale or erythematous. An example of this is urticaria like with an allergic reaction.

These lesions and skin rashes can present in certain patterns and distributions, which can also help you successfully identify the rash.

Skin rashes can be clustered in small groups, grouped together in some fashion, linear (in a line), following the dermatome (termed zosteriform), and even coalescing together. Various rashes have certain patterns which can make the diagnosis easier.

IMPORTANT DISCLAIMER!

The following images are examples of how these rashes present on white and light-skinned individuals. For examples of how these rashes may present in darker-skinned individuals, please check out @brownskinmatters on Instagram.

20 COMMON SKIN RASHES

TABLE OF CONTENTS

Allergy-Related Rashes

CONTACT DERMATITIS

Contact dermatitis is when the skin has a reaction to something that it has come into contact with. 80% of cases are caused by an irritant, and 20% are caused by allergens. Contact dermatitis is the most common dermatologic diagnosis.

Irritant contact dermatitis is very common and often occurs from exposures to heavy metals, strong acids, rubbing alcohol, and certain ingredients in soaps and lotions. Patients often complain of pain or burning with some itching.

The skin will typically look erythematous, dry, and irritated. There may be pustules present as well.

In Allergic contact dermatitis, common causes include nickel, black hair dye, topical medications, latex, and various cosmetics and environmental exposures (like poison ivy or poison oak). Allergic dermatitis tends to be itchier with less pain or burning. There may be vesicles present as well.

Treatment for these includes steroids for the reaction, and benadryl for the itching. If the lesion is smaller, a topical steroid like Triamcinolone 0.5% once daily for 2-4 weeks can be effective. If the lesion is more widespread, systemic steroids can be used like prednisone.

ALLERGIC URTICARIA

Urticaria or hives are itchy raised wheals that are often erythematous or pale. They are often a response to an allergy such as in anaphylaxis, but many cases of urticaria are non-allergic and some are idiopathic (aka we don’t know why).

Allergic urticaria occur after contact with an allergen. These allergens can be in the environment (like dust or pollen), in food (like nuts or dyes), and in medications like with antibiotics. Urticaria can also occur after bug bites and stings.

Treatment for urticaria skin rashes depends on the underlying cause, but in cases of allergic cause includes anthistamines like benadryl, and sometimes steroids like prednisone.

ECZEMA

Eczema, also termed atopic dermatitis, is a chronic allergic-related chronic skin condition which is very itchy.

Ecezema involves very dry skin that is erythematous with oozing and crusting, excoriation from scratching, and eventual lichenification (when the skin becomes thick and leathery).

In adults, eczema skin rashes often occurs on skin flexures like the elbows and behind the knees, on the face, neck, and hands, but can occur anywhere.

All patients with eczema should liberally use a water-based emollient moisturizer like Cetaphil, Aquafor, or CeraVe.

Since eczema is a chronic condition, it cannot be taken away completely, but there are treatments that can help. Depending on the severity of the eczema, lower or higher strength steroid creams can be used once or twice daily for 2-4 weeks.

  • Low Potency: Hydrocortisone 2.5%
  • Mid Potency: Triamcinolone 0.1%
  • High Potency: Usually not prescribed for eczema

Clinical Note: Higher potency steroids on the face or thinner areas of skin have a higher risk for atrophy and permanent discoloration, so use cautiously and for limited amounts of time.

For more severe eczema, topical calcineurin inhibitors can be used as well or even monoclonal antibodies. A dermatologist should be the ones to prescribe these advanced medications.

AUTOIMMUNE-RELATED RASHES

PSORIASIS

Psoriasis is a type of chronic autoimmune skin rash condition. This is characterized by erythematous flaking thick patches of skin. They can be itchy and even burn.

Treatment for psoriasis depends on the severity of the disease, but can range from topical steroids, retinoids, tacrolimus, or at times systemic steroids and immunomodulators.

VIRAL-RELATED RASHES

SHINGLES

Shingles, also called Herpes zoster, occurs from reactivation of inactive varicella virus within the body (the chicken pox virus). Shingles almost always occurs in adults and usually >50 years old.

Shingles begins as an erythematous maculopapular rash that develops fluid-filled vesicles that scab over in 7-10 days and clear up by 2-4 weeks. The rash will follow 1-2 dermatomes (termed zosteriform), and should not cross the midline. Shingles is often very painful and can itch, which may even precede the rash.

Treatment involves pain control. Antivirals like acyclovir can be started within 72 hours that the lesion develops, otherwise they are unlikely to be beneficial.

Shingles is very contagious, especially if any vesicles pop open until the lesion scab over.

PITYRIASIS ROSEA

Pityriasis rosea is a self-limiting rash thought to be secondary to viral infections. Skin rashes and reactions secondary to viruses are termed viral exanthems. This is often preceded by a viral prodrome including headache, malaise, arthralgias, and/or chills.

Pityriasis rosea starts as a herald patch which is a single oval-shaped erythematous macule or patch on the trunk with central clearing. 1-2 weeks later, a christmas tree pattern will appear on trunk with similar smaller lesions.

There is no specific treatment for pityriasis rosea, and only time will cause the rash to resolve. Pityriasis can be itchy so benadryl can help. This is not contagious.

HAND-FOOT-MOUTH

Hand Foot and Mouth disease is a viral rash that occurs due to the Coxsackie Virus A16 and some other enteroviruses.

HFM typically occurs in outbreaks every few years in the summer months. 

While HFM usually affects children, it can easily spread to parents and family members via droplets. Adults and teenagers will often have systematic symptoms including fevers, body aches, and flu-like symptoms. HFM may be preceded by upper respiratory symptoms by a few days. 

The HFM rash appears on the palms, soles, buttock, and mouth of patients. The oral lesions have football shaped vesicles that are very painful and are on the soft palate, buccal mucosa, gums, and tongue. The posterior pharynx is unaffected. 

Skin lesions are red papules with a red halo, then become gray vesicles, then ulcers after the vesicles rupture, then heal 7-10 days later. 

Like all viruses, treatment is symptomatic. Antipyretics and NSAIDs for pain and fevers and topical lidocaine for painful oral lesions. Keeping the patient well-hydrated is very important. 

In severe cases, the patient can have altered mental status from encephalitis or myocarditis.

MEASLES

Measles, once nearly eradicated, has begun to make a comeback, largely due to the growing Anti-Vax movement. However, since COVID cases have dropped again. The measles, caused by the morbillivirus, causes 150,000 deaths per year worldwide, usually in those less than 5 years old.

The rash itself is an red-brown maculopapular rash that starts 3-5 days after systemic symptoms of severe cough, nasal congestion, red eyes, high fevers, and photophobia. 

The rash starts on the forehead and spreads to the face, neck, trunk, extremities. It spreads to the palms and soles in 50% of patients. 

Koplik spots are small white spots with red halos in the mouth on the inside of the cheeks that occur early in measles, which is very specific to measles.

Treatment is largely supportive with antipyretics, analgesics, vitamin A, and hydration. More severe cases will need hospitalization and sometimes the antiviral medication Ribavirin.

FUNGAL RASHES

INTERTRIGO

Intertrigo is inflammation and infection of the skin folds, usually in obese individuals with diabetes. This is often a fungal infection, but can have a bacterial component as well.

Candida is the most common fungus, with erythema, scaling, satellite lesions, and foul odor.

Common sites include the groin, axillae, underneath the breasts, and inbetween fat rolls.

These places will often be itchy, burning, and may smell bad.

When in the groin region, this is often called tinea cruris

Prevention and treatment includes measures to reduce friction, reduce moisture (talcom powder), use of barrier cream or ointment, and wearing breathable fabric.

The fungal infections can be treated with topical antifungals including clotrimazole cream or nystatin powder 2-3x per day.

TINEA CORPORIS

Tinea corporis, also known as ringworm, is a fungal infection of the trunk or extremities. This is spread via skin-to-skin contact with an infected individual or animal, but can also be picked up by fomites. This is also common in athletes like wrestlers and in warm-moist locker rooms where fungus likes to live.

Tinea corporis is a pruritic, round, erythematous or hyperpigmented, scaly patch or plaque with a raised border. They can coalesce together as well. Pustules can appear as well, although not as common.

Treatment inovlves the use of topical antifungals 1-2x/day for 1-3 weeks. An example includes Clotrimazole 1% BID. More severe infections may need oral antifungals.

BACTERIAL RASHES

CELLULITIS

Cellulitis is a local bacterial skin infection. This starts as some sort of breach to the skin barrier (small cut or puncture), and subsequent infection of the skin and surrounding soft tissue.

Cellulitis presents as localized erythema, edema, pain, and warmth to touch. This often presents in a unilateral leg, but can present anywhere on the body.

Cellulitis may be associated with systemic symptoms such as fevers, chills, and generalized malaise. Sometimes abscesses can form.

Cellulitis is treated with PO antibiotics, but if significant systemic symptoms, high risk, or severe disease – IV antibiotics may be necessary.

  • PO: keflex 500mg QID x 7 days
  • IV: Ancef 1gm q8h

MRSA is resistant to certain antibiotics such as those above. Risk factors for MRSA include a personal history of MRSA, recent hospitalization, surgery, or nursing home stay; recent antibiotic use, immunocompromised, open wounds, etc.

The following antbiotics should cover MRSA:

  • PO: Bactrim, Clindamycin, or Doxycycline
  • IV: Vancomycin, Linezolid, or Daptomycin

FOLLICULITIS

Folliculitis is a bacterial infection of the hair follicle, usually caused by staph aureus.

This causes a tender, red, elevated papule/pustule. These skin rashes can occur anywhere where hair follicles are. This is common after hot tub use in young healthy individuals.

If mild, folliculitis is self-limiting and may not need any specific treatment. A topical antibiotic like Mupirocin ointment TID x 7 days can be used.

More significant folliculitis can be treated with PO antibiotics like dicloxacillin, keflex, or another antibiotic with good gram positive coverage.

FURUNCLE & CARBUNCLE

A furuncle is a larger painful infection of a hair follicle which is deeper than folliculitis. Another term for furuncle is a boil.

A furuncle is a well-circumscribed painful erythematous lesion which is full of purulent fluid. This can extend into the dermis and soft tissue, leading to skin abscess. These often occur in areas of friction such as the buttock, axillae, extremities, breasts, etc.

Multiple furuncles can coalesce together to form a carbuncle.

Smaller lesions can be successfully treated with warm compresses, but larger more significant lesions will need treated with Incision & Drainage.

PO antibiotics are often given, however may not be necessary if I&D is performed. They should be given if there is cellulitis present, significant comorbidities like diabetes, with systemic symptoms, or unreliable follow-up. 

PO antibiotic choices are the same for cellulitis, except MRSA should probably be covered regardless.

Personal hygeine should be encouraged as this can help prevent skin abscesses from occurring.

 BITE-RELATED SKIN RASHES

There are plenty of bugs that can bite, sting, and infest our skin, leaving skin rashes behind.

BED BUGS

Bed bugs inhabit typically houses and beds that are somewhat unclean (very common in group homes and homeless shelters). They feed on blood which causes a local reaction in the skin.

While not everyone reacts the same to these bites, they will typically present as itchy papules or wheals, macules, or bullae. They have a habit of appearing in a linear pattern, indicating the bed bug’s trajectory. These can show up when the patient wakes up but can take a few days.

Treatment includes benadryl for itching, and if there is significant itching, a low to medium potency topical steroid can be used.

Maintaining good hygiene is essential, and a pest service will need to be used to clear out an infestation.

FLEA BITES

Flea bites occur when fleas are transmitted from animals to humans. This is usually due to infested domesticated cats or dogs who transmit the fleas to their owners.

When a flea bites, it will cause pruritic papules, most common on the ankles.

An antihistamine like benadryl or zyrtec can be given for itching. Ice packs and calamine lotion can also help with the itching. Topical steroids are usually not necessar but can help.

SPIDER BITES

Spider bites are actually pretty rare, as many spiders do not have fangs strong enough to pierce human skin. They also usually do not bite unless they are provoked or about to be squished.

Most cases of “spider bites” are something else (i.e. furuncle, abscess, MRSA, etc).

When there is a real spider bite – a papule, pustule, or wheal will appear. Two small central fang marks can often be visualized in the center. The most common areas are in the axillae, the waist, and the ankles/feet.

Most spider venoms are benign and only cause a local reaction. Black widows, funnel web, and phoneutria spiders are more poisonous and the patient may have systemic symptoms including body aches, hypertension, tachycardia, abdominal pain, etc.

Brown recluse spiders can cause systemic symptoms, but often causes a more significant local reaction with potential necrosis.

Treatment for simple spider bites involves cleaning the area, and they will spontaneously resolve in 7-10 days. If there is associated cellulitis, appropriate antibiotics should be given as above. More severe reactions may need more supportive care and hospitalization.

SCABIES

Scabies is more common in children but can happen in adults as well. It is also associated with poor hygiene and crowded living conditions similar to bed bugs.

Scabies is not exactly a bite, but rather an infestation of the scabies mite into the patient’s skin where they burrow and lay eggs, leaving behind nasty skin rashes.

Scabies rash appears initially as tiny to small erythematous papules, and will often form vesicles or pustules. They will often present in lines as the mites burrow through the epidermis. This can be easily noticeable in the web spaces of the fingers, wrists, and elbows.

Scabies is very itchy as well, and itching may persist 2-6 weeks after treatment.

Benadryl can help with the itching, but scabies will need treated with Permethrin 5% cream applied to the entire body, left on overnight (8-14 hours), and washed off in the morning. This should be reapplied in one week.

Everything else in the house that could be infested should be cleaned. Bedding and clothing within the last 48 hours should be washed in hot water and heat-dried. Non-washable items should be placed in plastic bags for at least 1 week (stuffed animals, etc).

ERYTHEMA MIGRANS

Erythema migrans is the “bulls eye rash” of early lymes disease.

This rash occurs in about 90% of lymes cases, and occurs 3-30 days after getting bit by a deer tick that carries lymes.

The initial rash will be a small red painless papule, which will expand over a few days and turn into a circular erythematous rash with central clearing and induration. This resolves in weeks if left untreated.

Treatment for this rash is treatment of the underlying Lymes disease. Lymes should be treated with doxycycline 100mg BID x 21 days.

Be sure to have your patient EAT with and directly after doxycycline, as it can cause significant GI upset and pill esophagitis.