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Cellulitis

Cellulitis

Cellulitis is a bacterial skin infection. Signs are acute redness of the skin, and oedema with rough borders. It usually affects lower limbs but any skin region can become infected.

The causes of cellulitis in when the skin barrier is damaged such that bacteria can cross over the skin layers and infect cells. People with pre-existent conditions such as diabetes, obesity, bite wounds or insufficient pump function of the veins are susceptible to cellulitis.

Bacteria called stapylococcus aureus is the cause in 80% of cases

The GP will differentiate between cellulitis and erysipelas. The latter is more superficial and has well marked edges or borders and usually is elevated.

The GP will want to know

  1. How long the region of the skin has been affected
  2. what happened prior to developing symptoms
  3. Recurrence of symptoms
  4. Recovering from skin disease
  5. Presence of fever or general unwell
  6. If the redness spread out
  7. if there is pain or hypersensitivity
  8. Pre-existent conditions as mentioned above

A GP will check physically for the size, thickness of the cellulitis. Also comparing the skin temperature difference beween the affected skin are and normal area can be performed. Palpating for lymph nodes is an important part of the physical examination

Blood tests may be requested by the GP if cellulitis is associated with fever, chills, general unwell appearance, lymph nodes oedema or cellulitis located near the mouth or eye.

Management of cellulitis consists of

  • Hygiene; keep the area clean and dry
  • Pain relief; cellulitis can be very painful. Take Paracetamol 500mg, 2 tablets 4 times a day
  • Bandage, elevate and immobilise the limb
  • Oral antibiotics in those with no pre-existent conditions
    • Flucloxacilline 500mg one tablet four times a day for 10 days
  • Oral antibiotics in those with pre-existent conditions
    • Amoxicilline/Clavulanic acid 625mg, one tablet 3 times a day for 7 to 10 days
    • Doxycycline 200 mg one tablet once a day for 7 to 10 days
Superficial wounds

Superficial wounds

Superficial wounds also known as abrasion or graze mostly involve the epidermis layer of your skin. There are many causes of superficial wounds and the majority are caused after a fall (during sports) on the knees, elbows and hands. Children under the age of 15 years and adults above 75 years of age are those who are frequently affected by this condition.

Abrasions typically heal quickly without any complications or scars. However co-morbidities such as diabetes mellitus, obesity, or use of medication like steroids can delay wound healing. In many cases, you will not visit your GP for an abrasion wound as it heals quickly. However, most people seek advice from a GP regarding wound management.

Your GP will ask you 4 important questions

  1. How the wound occurred: this helps to provide information on factors such as contamination of the wound
  2. When the wound occurred; wounds that are older than 6 to 8 hours need to be considered as infected wounds
  3. If you have any co-morbidities or pre-existent conditions like immune deficiency
  4. Whether you have a current vaccination status for tetanus

An abrasion is recognised by your GP as small round point bleed from the dermis. Some abrasions can bleed more profusely than others depending on the location and presence of co-morbidities. Before you get to your GP for assessment you can do the following

  • Clean the abrasion with running tap water, there is no need to add soap at this stage.

Once at your GP the following procedures will be done

  • Clean some more; if your abrasion wound is large or contaminated the GP may give you a local anaesthetic to clean the wound as this can be painful
  • Disinfect the wound with iodine which acts as an antiseptic for bacteria and fungal infection.
    • Chlorhexidine can also be used and is highly effective against bacteria (gram negative and gram positive).
  • Let the wound dry naturally without placing a bandage; one of the advantages of this method is that in time, the skin will produce a protective scab layer. This is a natural healing process and the scab will fall off by itself.
  • Bandage abrasions that are not exposed to air and that will not be able to dry naturally as explained above.
  • Occlusive bandage with an occlusive foam that protects the abrasion wound from contact with air. This provides faster healing and there is little pain or discomfort when changing the dressings
  • Local antibiotics; If the wound looks infected the GP can opt to apply an antibiotic cream
    • Fusidic acid (3 times a day for a week). The cream works better against staphylococcus aureus bacterial and is less effective for streptococcus bacteria.
  • Systemic antibiotic; in the event of general unwell, fever, regionally enlarged lymph nodes, the GP should prescribe oral antibiotics in the form of
    • flucloxacillin (500 mg 4 times daily for 10 to 14 days) or
    • clarithromycin in case of penicillin allergy (500mg 2 times a day for 10 to 14 days) or
    • clindamycine in case of penicillin allergy (600 mg 3 times a day for 10 to 14 days)

A referral to specialist care is very unlikely and depends on healing, scarring and general physical health

I have a rash but my GP refuses an allergy test.

I have a rash but my GP refuses an allergy test.

You wake up one morning and discover a small rash on your tummy, just above your belly button. It does not itch at first. In the next couple of days, the rash gradually spreads towards your chest and your upper legs. You feel otherwise well except for mild-flu like symptoms. 

The rash starts to itch more and more. You visit your local drugstore and the woman behind the counter recommends a menthol gel to rub on your rash to relieve the itch. However this does not work. It is almost 12 days since you had these symptoms and panic really starts to set in. 

You are convinced it is due to an allergic reaction you have and call your GP practice for an appointment. 

The assistant is very understanding and arranges an appointment with your GP the same day. 

At the GP, you are asked several questions like:

  1. When did it start?
  2. How does it affect your daily life?
  3. Are you taking any medication?
  4. Have you ever had this before?
  5. Did you feel generally unwell before the onset of the rash?
  6. Have you developed any fever, weight loss, changes in appetite?
  7. Any possible factors that cause this for instance changes in your diet or new hobbies?
  8. Does this type of condition occur with other family members?

You answer accordingly and note that you had taken ibuprofen a few days prior to your rash due to throat pain and general aches. Then your GP performs a focused physical examination. She then says you have a urticaria (a medical word for rash) possibly due to the Ibuprofen you took. She concludes it will go away and would like to send you home with some medication against the itch and review if things get worse.  However, you are convinced that it could be your diet or something else you are allergic to and would like to have blood tests. 

In general screening tests for dietary causes of allergies or IgE specific allergens are not needed for a rash that is persistent for less than 6 weeks without any other serious complications.

Your GP will only consider doing further tests for allergies if the following occur

  1. You develop a rash within 60 minutes of ingesting one specific food type. 
  2. You have no rash when you do not ingest that specific type of food

If symptoms persist for more than 6 weeks your GP will refer you to a dermatologist. 

Here are other reasons your GP will refer you to a specialist if you have urticaria

  • If they suspect that you are allergic to a certain type of medication for which there are no alternative treatments
  • If you suffer from a hereditary condition called C1-esterase inhibitor deficiency. This condition is when you have angio-oedema (swelling), abdominal complaints, laryngeal oedema but NO rash. 

Your GP has managed to convince you that for now you do not need further tests. 

She prescribes you antihistamines. Here are 2 antihistamine medications you will most likely receive from your GP for a rash that is itchy.

  • Levocetirizine or 
  • Desloratadine 

If you are pregnant then your GP will prescribe you

  • Loratadine or 
  • Cetirizine

Levomenthol gel is not effective in treating the rash however can be used in combination with the antihistamines for a soothing effect.

You try the medication for a few days but see no effect. You contact your GP as she suggested. This time an appointment is not made, but your GP increases the antihistamine dose to one tablet twice a day. She reassures you that this will eventually go away in 3 to 4 weeks. 

Bruises

Bruises

A bruise or hematoma is a swelling underneath the skin that is caused by damage to blood vessels that leads to a contained bleed. A bruise can occur anywhere in your body where there are blood vessels. This section describes bruises underneath the skin that is visible as a swelling with discolouration.

The blood vessels are located in the sub-cutis, underneath the dermis layer of the skin. When these blood vessels are damaged, a localised bleed occurs in the muscles or within ligaments. The result is a palpabel swelling that resolves after a few days to weeks.

Bruises can occur in two ways

  1. From the outside for instance a punch to the upper arm or chest. The size of the hematoma depends on the force and localisation of the punch.
  2. From the inside for instance a rupture of tendon such as in a sprained ankle or during high-intense sport activities.

It is important for the GP to assess the following factors

  1. Location of the bruise
  2. Nature of the bruise
  3. Any visible bleeding
  4. Size of the bruise
  5. Does the bruise displace or move due to gravity
  6. Use of medication such as anti-coagulants or platelet-inhibitors
  7. Co-morbidities such as platelet disorders or Immune thrombocytopenia purpura

If a trauma occurs (punch, fall or sprain) then the next step a GP takes is to determine the 3 following conditions

  1. Fracture
  2. Contusion
  3. Muscle rupture

Management of most bruises can be done at home under advice and involve

  1. Rest
  2. Cool packs; typically effective in the first 24 hours of the bruise.
  3. Pressure bandage
  4. Physiotherapy; a GP will consider this if there is functional limitation

Referral to surgeon will be considered in the event of internal bleeding

Bruises typically heal well and within 2 to 4 weeks. Management can be done at home and referrals are rarely indicated.

Superficial burns

Superficial burns

Superficial burns occur from accidents in and around the home mostly the kitchen. Warm fluids, gas, fire, electricity or sunlight are the major culprits. Once this makes contact with the skin, the epidermis or dermis can be affected. In the event that the epidermis is affected this is known as first-degree skin burn. The sign is redness (erythema). If some of the dermis is affected this is called non-deep second-degree skin burn and signs will be a blister and reddish/pinkish (in light coloured skin) or red/brown/purple (in dark coloured skin) appearance. If the burn crosses the dermis into the layer called the subcutis then the appearance is white/yellow or even black/brown (in light coloured skin). This is called second-degree full thickness burn and many times there is loss of pain because the nerves have also been burned.

Superficial burns usually resolve after 1 week and second-degree skin burns that are superficial will resolve within 3 weeks.

GP’s see about 5 to 10 patients each year with superficial burns and the majority are children or those aged 75 years and older.

Let the GP know about when the burn occurred, the cause and if you have applied cool/water to the burn.

Your GP can perform 2 types of tests to assess the depth of the burn.

  1. Pinprick – with a sterile needle the GP will prik the burn wound and assess for bleeding and/or pain. Superficial burns will be very painful and bleed easily whilst deeper burns (second-degree or tertiary degree) will not bleed nor be painful
  2. Capillary refill – while wearing sterile gloves, the GP will press gently on the burn wound to assess how quickly blood circulates back to this region. In superficial burns this test is normal compared to deeper burns where this test will be affected.

The GP will assess the following 3 conditions

  1. The percentage burns of your body ; this is needed to determine the risks of complications such as sepsis, shock or multiple organ failure. The GP uses a rule: This indicates 9% burn to the head or (one) arm; 18% to the front of the chest, back, (one) leg and 1% for the genitalia area.
  2. The location of burns on your body; if you are burnt near your eyes, ears, mouth, hands, genital area then complications can be very severe. These types of burns are referred to specialist care for further treatment
  3. The cause of the burn; hot water scalds can be more severe than for instance hot oil scalds.

Management of burns consist of

  • Cool, Cool and more Cool; it is important to keep the burn under flowing tap water at room temperature for a minimum of 15 minutes. This procedure not only serves as pain relief, it also stops further damage of the burn and prevents the release of toxic substance from burnt cells. Cooling the burnt area is effective for circulation of blood to the area to allow for better healing
  • Analgesia in the form of Paracetamol
  • Soothing creams in the form of vaseline or hydrogel
  • Dressing in the form of hydrocolloid to be changed once every two days. It is a semi-permeable dressing and protects from bacterial infection. The inner layer is a gelatinous membrane that protects the wound and the outer layer seals the rest of skin firmly. This type of dressing heals superficial wounds faster. Do not worry when you change the bandage you smell a pungent odour from the dressing, this is normal to allow for better results.
  • Tetanus vaccination is optional and depends on the circumstances of the burn
  • Do not use silver sulphadiazine cream; this should only be used in specialist care due to the complications of skin discolouration. Furthermore application of this cream makes it difficult to assess deeper burns that have whitened as a result.

Your GP should refer you to specialist care in case of

  • Deep second-degree or third-degree burns
  • More than 5% of your body is affected
  • Burns that are located on or near your eyes, nose, mouth, ears, hands, joints or genital region
  • Infected burn
  • Poor healing of a burn
  • Loss of function of limbs
  • Scar formation
Hair loss

Hair loss

Hair loss is defined as loss of scalp hair. It is more common in males than in females. There are various causes of hair loss

  • Fungal infection (alopecia areata)
  • Excessive plucking (tricotillomania) or pulling (tractiealopecia) of the hair
  • Scar tissue formation (alopecia atrophicans)
  • Genetic

There are about 100,000 hair follicles on the hair of which 90% are in the growth phase. The growth phase lasts about 2 to 6 years. The next three months is the rest phase and after that the hair falls off. It is normal to lose about 50 to 100 hair strands per day.

Growth phase of hair can be affected and prematurely interrupted due to the following conditions

  • Chronic disease like cancer or kidney disease
  • Folium and Iron deficiency
  • Medication use
  • Hormonal changes such as during pregnancy or thyroid gland problems
  • Diabetes mellitus

A genetic condition called alopecia androgenetica is most common in males than in females and occurs when hair follicles are highly sensitivity to androgenic hormones. These hormones cause atrophy or thinning of the hair follicles

The GP should ask for

  • How long the hair loss has been
  • If it occurs in the family
  • Any use of medication of pre-existing conditions
  • Presence of dandruff
  • if you are stressed or overworked
  • Any previous trauma or scar
  • Repetitive plucking or pulling

How to test for abnormal hair loss

  • After you shampoo and rinse your hair, take 30-40 strands between your thumb and index finger, then pull on it. If more than 6 hair strands are pulled along then this could be a reason to contact your GP

There is no effective management for alopecia androgenetica. It is important for men or women to accept this hair loss and not resort to various treatments that do not work. However the GP can consider

  • Minoxidil scalp lotion 5% twice a day for 12 months
    • In case of irritation then a 2% solution can be used
  • Finasteride 1mg tablets one day for 12 months; this has shown to have some positive effect in hair growth.
    • Stopping this medication could result in hair loss again.

In the event of alopecia areata, the GP could prescribe local injection with corticosteroids.

The GP can make a referral to specialist in the event of obsessive plucking of the hair in children or adults.

Hair loss can cause anxiety for many people. In the majority of cases alopecia areata will resolve spontaneously without any treatment in 6 months. For those with a hormonal cause of hair loss, the chance of spontaneous hair growth is low. Scar tissue that causes hair loss does not resolve.