management of common skin infection - rcpt.org · management of common skin infection natta...
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Management of common skin infection
Natta Rajatanavin,MD.Div. of Derm, Dep. Of Medicine
Ramathibodi hospital,Mahidol university8th July 2010
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Skin VS. EnvironmentSkin VS. Environment
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Photosensitivity and 1 year after Tx
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Skin is theSkin is the only organ that can itch. only organ that can itch. Pruritus =itch =scratchPruritus =itch =scratch
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Overview
• Infestation insect, parasite.• Infection fungus
bacteria virus
• Management
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Insect bite reactionInsect bite reaction
•• Itch and inflammationItch and inflammation•• ManagementManagement•• Cold Cold •• AntihistamineAntihistamine•• Topical steroidTopical steroid
moderatemoderateto high potencyto high potency
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Insect bite in cover areaInsect bite in cover area
linear pruritic papules. linear pruritic papules.
‘‘breakfast, lunch and breakfast, lunch and dinner signdinner sign’’ ––
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Dz presented with itchDz presented with itch
•• Flea Flea หมัดหมัด bite bite
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Bite Bite
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Tick bite (rickettsia, lyme Dz.)Tick bite (rickettsia, lyme Dz.)
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Management of Tick biteManagement of Tick bite((เห็บเห็บ))
•• Lyme dz.Lyme dz.•• Doxycyclin 200 mg/d Doxycyclin 200 mg/d
21 day.21 day.•• Amoxicillin 500x3/d Amoxicillin 500x3/d
21 day.21 day.
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Dz presented with itchDz presented with itch
•• Insect bite reactionInsect bite reaction•• FleaFlea•• Tick;systemic dzTick;systemic dz
•• Mite Mite
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burrowburrow
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scabiesscabies
•• Scabies mites burrow, Scabies mites burrow, or tunnel, under the or tunnel, under the outer layer of skinouter layer of skin. . This produces pimpleThis produces pimple--like irritations known like irritations known as the scabies rashas the scabies rash. . These mites lay eggs These mites lay eggs under the skin and under the skin and feed on bloodfeed on blood. .
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scybala
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Common sitesCommon sites
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Norwegian scabiesNorwegian scabies
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Diagnostic TestsDiagnostic Tests::Skin scrapings after application of Skin scrapings after application of
mineral oil to look for eggs under the mineral oil to look for eggs under the microscopemicroscope. . Deep scraping.Deep scraping.
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TreatmentTreatment
•• Eradicate mitesEradicate mites•• Control rash and itch.Control rash and itch.•• Prevent spreading. Prevent spreading.
•• Topical/oralTopical/oral
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Topical Scabies Rx
• Permethrin 5% 8-12hrs• 2-10% sulphur ointment safest
applied to all body surfaces for 2-3 nights
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Topical Scabies Rx
• Benzyl benzoate 10-25%applied 3 consecutive times below neck
for 24 hrs, age>2 yrs.• Gamma benzene hexachloride 1%
>50 kg , CNS toxic
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Oral Scabies Rx
• Ivermectin(6 mg/tab)• Children >15 kg• 200 mcg/kg as a single dose, may repeat at 10-
14 days.• Pediculosis days1,2 and 10• Wt 15-24kg 3 mg single dose• 25-35 6• 36-50 9• 51-65 12
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TreatmentTreatment
•• Eradicate mitesEradicate mites•• Control rash and itch.Control rash and itch.•• Prevent spreading. Prevent spreading.
•• Topical/oralTopical/oral•• Topical steroid and Topical steroid and
antihistamine.antihistamine.•• All contact cases.All contact cases.
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Head /Body louseHead /Body lousePubic louse (crab)Pubic louse (crab)
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Rx
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Dz presented with itchDz presented with itch
•• Insect bite reactionInsect bite reaction•• FleaFlea•• TickTick
•• Mite Mite •• ScabiesScabies•• Head /Body louseHead /Body louse•• Pubic lousePubic louse
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ดวงกนกระดก (Rove beetle:Paederus fuscipes)
• kissing lesion
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Acute irritant contact; kissing lesion
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Rx
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Overview
• Infestation insect, parasite.
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Larva migran
• Humans are accidental hosts, and the larvae are believed to lack the collagenase enzymesrequired to penetrate the basement membrane to invade the dermis.
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Larva migran
• Thiabendazole; topical 10-15% suspunder occlusive *4x7d
• 25-50 mg/kg/d PO divided q12h for 2-5 dnot to exceed 3 g/dalbendazole, mebendazole, and ivermectin
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Overview
• Infestation insect, parasite.• Infection fungus
bacteria virus
• Management
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Tinea corporis กลาก
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Fungal infectionFungal infectionTinea facei/corporis Tinea facei/corporis
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KOH;dermatophyteKOH;dermatophyte
• Clotrimazole• Miconazole• Gently massage into
affected area and surrounding skinareas bid for 4 wk
• Ketoconazole 2-4 wk• Terbinafine
qd for 1-4 wk
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Tinea versicolor เกลื้อน
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KOH KOH เกลื้อน
• Selenium sulfide lotion is liberally applied to affected areas of the skin daily for 2 weeks; at least 10 minutes prior to being washed off.
• Ketoconazole shampoo
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Tinea versicolor เกลื้อน
• Ketoconazole; single-dose 400-mg fluconazole, single150-300 mg/wk 2-4 wk itraconazole
200 mg/d x 7days
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Recurrences
• 1 tablet a month of ketoconazole, fluconazole, and itraconazole has been used successfully to prophylactically prevent recurrences
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Candidiasis ;immune status
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Management
• Cause• Topical or oral azole• Not terbinafine• 10-mg troches: Hold
in mouth and allow to dissolve over a single 15- to 30-min period 5 times/d
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Fungal infection
• Exogenous Tinea;dermatophyte(กลาก)• Endogenous Tinea versicolor(เกลื้อน)
Candidiasis-immune status
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Antifungal topical
• imidazoles (eg, clotrimazole, miconazole, econazole, ketoconazole)
• Terbinafine กลาก
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Antifungal oral
• triazoles (eg, fluconazole, itraconazole) • Diazoles (eg, ketoconazole) have more
effect on mammalian cytochromes than do triazoles and tend to have more severe adverse effects.
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• Widespread Tinea corporis and Tinea crurismay need systemic antifungal therapy
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Drugs Dosage (tab/day)
Duration (days)
Rx Cost (baht)
efficacy
Griseofulvin (500mg)*
2 21-28 130 ~70%
Ketoconazole (200mg)*
1 14 252 79%
Itraconazole (100mg)
1 14 616 88%
Terbinafine (250mg)
1 14 1162 87%
Systemic antifungal therapy
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Original vs local madeDrugs Dosage
(tab/wk)Duration (weeks)
Rx Cost (Baht)
Efficacy(%)
Diflucan (150mg)
1 4 813 88
Fluconazole (200mg)*
1 6 24 ?
Once weekly oral doses of Generic Fluconazole 200mg in the treatment of Tinea corporis and Tinea cruris
Oraparn Techaritpitak ,Natta Rajatanavin 2007
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7079
88 87 88
0102030405060708090100
Griseofluvin Ketoconazole Itraconazole Terbinafine Diflucan Fluconazole
Percent
Efficacy comparison
85 %
(our study)
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130252
616
1162
813
240
200
400
600
800
1000
1200
1400
Griseofluvin Ketoconazole Itraconazole Terbinafine Diflucan Fluconazole
Baht
Price comparison
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Conclusion
Fluconazole 200mg (local made)once weekly for 6 weeks is cost-effective and safe regimen in the treatment of Tinea corporis and Tinea cruris.
Efficacy 85%,cost 24 bathKetoconazole has higher risk of hepatitis.
* Ramathibodi Phototherapy Research Fund
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onychomycosis
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Paronychia
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onychomycosis /Paronychia
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onychomycosis
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White superficial onychomycosis swo
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Proximal subungual onychomycosis
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Proximal white onychomycosis
• is a fungal infection which occurs by inversion into the proximal nailfold and growth under the nailplate. It is strongly associated with HIV infection.
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Leuconychia striata
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Mee’s line
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psoriasis
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Trachyonychia (Twenty-nail dystrophy)
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Lichen Planus (pterygium)
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Onychomycosis Dx
KOH +Nail clipping for PAS +
Culture +
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Nail clipping picture
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Sensitivity of different methods
Wilsmann-Theis etal. JEADV 2010
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Onychomycosis Dx and Rx
2-12 months RxWhich medication?
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Antifungal drug for onychomycosis
• Topical ineffective• Nail lacquer• Oral grisiofulvin ineffective
ketoconazol hepatotoxicitraconazole expensive
(1,960-3,920 baht)terbinafine very expensive
(3,360-6,720 baht)
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J Am Acad Dermatol 1998;38:S77-86
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diagram
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Paronychia
• Chronic irritation avoid wet work and topical steroid +/-antifungal
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T. capitis ;Hair loss + itch
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T. capitis
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• A discrete patch of alopecia in the scalp of a child where the skin is covered with scale, pustules and/or black dots is typical of tinea capitis
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Tinea capitis
• Children• Grisiofulvin
• Kerion ชันต ุ;antibiotic
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Moth-eaten alopecia of secondary syphilis
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secondary syphilis
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alopecia areata
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Trichotillomamia
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Antifungal
• imidazoles (eg, clotrimazole, miconazole, econazole, ketoconazole)
• triazoles (eg, fluconazole, itraconazole) • Diazoles (eg, ketoconazole) have more
effect on mammalian cytochromes than do triazoles and tend to have more severe adverse effects.
• Oral Rx ;nail,hair;grisiofulvin
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Overview
• Infestation insect, parasite.• Infection fungus
bacteria virus
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Impetigo
Impetigo is a superficial skin infection with honey-colored crusting caused by streptococci, staphylococci, or both.
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Impetigo
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• The face is a common location for impetigo. The area below the nose is particularly prone, presumably because staphylococci often colonize the nose. Any nasal drainage promotes infection.
• Mupirocin topically =3 times /day for 7 days.
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Impetigo แตไดacyclovir
•• Ass. Prof. Amornsri Ass. Prof. Amornsri ChunharajChunharaj
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Impetigo
• Mupirocin topically three times a day for 7days.
• S. aureus nasal carriage
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Impetigo
• widespread involvement, an oral antibiotic (e.g.cephalexin,dicloxacillin, or erythromycin.
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Bullous impetigo,4S,scarlet
• Systemic antibiotic.
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4S
Ass. Prof. Amornsri Ass. Prof. Amornsri ChunharajChunharaj
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Scarlet feverSand paper rashStrawberry tongue
desquamation
Ass. Prof. Amornsri ChunharajAss. Prof. Amornsri Chunharaj
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Folliculitis(hairy area,bacterial)
Hot Tub Folliculitis
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Folliculitis/abcess
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Precipitating causes
• Trauma • Chronic friction • Occlusive clothing • Occlusive chemicals • Excessive sweating • Exposure to water
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Folliculitis
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Pityrosporum folliculitis
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Lab, gram stain
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• Furuncle diagram
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Furuncle(boil)/Carbuncle
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• Carbuncle on the nape of a diabetic man. This is a staphylococcal infection of several contiguous hair follicles.
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• Mild cases of folliculitis and small furuncles may heal on their own with good hygiene and wound care. More extensive furuncles and all carbuncles need to be treated with antibiotics such as dicloxacillinor cephalexin.
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Erysipelas
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Mycobacteria
Tuberculosis & leprosyAtypical mycobacterium
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Tuberculosis
continuous propagation
of infection from an underlying
structure, most commonly
lymph node or bone.
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Tuberculosisverrucosa cutis (wart like)
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โรคเรื้อนประเภทเชื้อนอย (Paucibacillary Leprosy - PB)
• ผื่นเปนวง สีจางหรือเขมกวา ผิวหนังปกติ ผิวแหงมีอาการชา
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Sensory loss is a typical feature of leprosy.
• ประชาชนสวนใหญจะมีภูมิตานทานตอโรคเรื้อน เมื่อไดรับเชื้อโรคเรื้อน โอกาสที่จะปวยเปนโรคมีเพียงประมาณรอยละ 5 เทานั้น
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Transmission
• The principal means of transmission is by aerosol spread from infected nasal secretions to exposed nasal and oral mucosa. Leprosy is not generally spread by means of direct contact through intact skin
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ผูปวยโรคเรื้อนประเภทเชื้อนอย(PB)
• กินยา Rifampicin 600 มิลิกรัม กินตอหนาหรือตามคําแนะนําของเจาหนาที่ เดือนละครั้ง และยา Dapsone 100 มิลิกรัม ทุกวัน ระยะเวลากินยานาน 6 เดือน
• การหยุดยาและจําหนายจากทะเบยีนการรักษา ระยะเฝาระวัง(การติดตามหลังจากหยุดยา)ตรวจรางกายปละครั้งเปนเวลา 3 ป ในผูปวยชนิดเชื้อนอย
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โรคเรื้อนประเภทเชื้อมาก (Multibacillary Leprosy - MB)
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โรคเรื้อนประเภทเชื้อมาก (Multibacillary Leprosy - MB)
ผื่นนูนแดงหนาหรือตุม มีจํานวน มาก กระจายตามสวนตาง ๆของรางกาย พบเชื้อ
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ผูปวยโรคเรื้อนประเภทเชื้อมาก
• กินยา Rifampicin 600 มิลิกรัม และ Clofazimine(Lamprene) 300 มลิิกรัม กินตอหนาหรือตามคําแนะนําของเจาหนาที่ เดือนละครั้ง และยา Dapsone 100 มลิิกรัม และ Clofazimine(Lamprene) 50 มิลิกรัม ทุกวัน ระยะเวลากินยานาน 2 ป
• การหยุดยาและจําหนายจากทะเบียนการรักษา ตรวจรางกายและตรวจเชื้อปละครั้งเปนเวลา 5 ปในผูปวยชนิดเชื้อมาก แลวจึงจําหนายจากการเฝาระวัง
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Atypical mycobacterium
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Atypical mycobacterium Sweet syndrome
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Overview of lecture
• Infestation insect, parasite.• Infection fungus
bacteriavirus
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HZV
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H.simplex
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Herpes
vesicle
Erosive ulcer
crust
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Recurrent
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Herpes zoster
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Management
• Acyclovir 1,000 -4,000 mg/d*7days• Herbal medicine , phrayayor cream• None prevent recurrent
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Verrucae vulgaris / warts
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Genital wart
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Management
• Topical; cold water,occlusion • salicylic cream 5-10%• wart solution irritation• imiquimod activates immune cells through
the toll-like receptor 7 ;penetration, irritation and price.
• Surgical;cryo,electro,laser- surgery,
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Molluscum contagiosumหูดขาวสุก
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Rx ;currettage + EMLA
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Conclusion
• Infestation insect, parasite.• Infection fungus
bacteria,mycobactrium virus
• Management
• Thank you
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AcknowledgementAcknowledgementAss. Prof. Amornsri ChunharajAss. Prof. Amornsri ChunharajAll dermatology staffs and residentsAll dermatology staffs and residents
Div. Of DermatologyRamathibodi Hospital
Question&AnswerQuestion&Answer
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Adverse drug reaction ADR
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Recurrent dusky red patches
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• Dx Acneiform drug eruptionStriae due to steroid
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Staphylococcal scalded skin syndrome
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Nikolsky sign
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Impetigo
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Scarlet fever