Sandra Leipheimer MSN APRN BCPNP Heidelberg High School

Continually renewed Stores fat and water Provides protection Gets rid of waste Regulates

Bed Bugs: Cimex lectularius (Cimidieae) Harmful? Do not transmit any infectious agents Only stay on skin to feed on a few drops of blood Treatment Aimed at itch- AH and corticosteroids Treat secondary infections from scratching Copyright 2013 S Leipheimer 3

Lice Pediculosis (place) Facts Not “medically necessary” to remove NITS Most are non-viable

Lice feed on human blood Not a sign of poor hygeine Transmitted by

What to put on school fact sheet? Not a major health issue Nuisance factor RX: Least intrusive to Most intrusive treatment Mechanically remove lice (risk reduction) OTC treatment ( oovacidal) Rx Examine all family members for live (crawling) lice If infested –treat If not – need not be treated Myths and Treatment folklore ARE THEY ACTUALLY INFESTED? Copyright 2013 S Leipheimer 6

History When started? What else going on? Other S & S? Rx = better or worse? Exposure? Associated Signs & Symptoms Fever URI Previous illness or treatment Exam Skin + other symptoms Copyright 2013 S Leipheimer 9

Superficial Infections Bacterial Fungal Viral Tattoos Copyright 2013 S Leipheimer 10

� Caused by S. aureus a normal skin colonizer in up to 50% of people � Yellow, oozing, crusty sore, often starts in nose Itch is common � Requires antibiotic � Excluded for 24 hrs and keep covered at school (contagious) � 1 -3 days incubation Copyright 2013 S Leipheimer 11

Bullous Staph. aureus- fluid filled blisters Non-Bullous S. aureus & streptococcus – crusted

Skin lesions usually caused by different strain than those causing “strep throat” Can cause glomerulonephritis if strain is Gr. A B-hemolytic Blood or brown sugar (maple sugar; coke) urine May culture lesions to be sure what is infectious agent Copyright 2013 S Leipheimer 13

� Caused by inflammation to the hair follicles �shaving/friction from tight clothes; ingrown � Typically infected with S. aureus � Avoid trigger � Antibiotics if infection suspected Copyright 2013 S Leipheimer 14

� Usually caused by S. aureus � Increased frequency with MRSA and other antibiotic

� Methicillin Resistant Staphylococcus Areas Copyright 2013 S Leipheimer 16

� Exclusion Policy for Schools? Copyright 2013 S Leipheimer 17

Spread Skin to Skin Touching contaminated objects (drainage) Regular Cleaning and Disinfecting No evidence that spraying or fogging rooms or surfaces with disinfectant works better than focusing on frequently touched surfaces Wash hands: soap and water alcohol-based sanitizers Take showers: immediately after exercise; don’t share items Use barriers: cover cuts; towels on items Wash uniform: dry completely in dryer; wash after each use Copyright 2013 S Leipheimer 20

Culture suspicious lesions Not return to play until: Appropriate antibiotic taken for at least 72 hours Drainage from wound has stopped No new lesions in past 48 hours CDC: do not exclude unless MD directed… Sport-specific guidance should be in place Excluded if wounds cannot be properly covered “properly covered” = securely attached bandage/dressing containing all drainage and remain intact during activity No water; whirl pools; therapy pools Copyright 2013 S Leipheimer 21

Nontuberculous mycobacteria (NTM) “various types” M. chelonae exists in tap water MRSA and “others”… Persistent inflammatory reaction Located within margins of recent intradermal tattoo Cause- ? using tap water or distilled water for ink Many believe distilled or reverse-osmosis water is sterile Many other reasons… Cartilage piercings >> delay healing “Allergies” >>> contact dermatitis Copyright 2013 S Leipheimer 22

What do you think? ? Copyright 2013 S Leipheimer 23

“THINK BEFORE YOU INK” www. fda. gov Tattoos & Permanent Makeup NOV 00

Tinea – sounds like a bug, but really a fungus (trichophyton, microsporum) Name of group of diseases caused by fungus Named for location of infection Acquired by touching infected person, damp surfaces, pets Copyright 2013 S Leipheimer 25

Generally a circular lesion (hence the name “ring worm” Raised (can be blistery)

Tinea in the scalp Patchy areas of hair loss or breakage and scale

Non scarring Noninflammatory alopecia Twist or pull hair Deny behavior Done in private 7 X > kids than adults 2 X Girls > Boys Scalp most common Eyelashes and eyebrows Psychosocial issues Copyright 2013 S Leipheimer 28

Moist area between toes Itchy, red, blisters, cracking, peeling Nails can also become

Itching in groin, thigh folds, anus Red, raised, scaly patches that blister and ooze Patches have sharply-defined edges Redder around outside with normal skin tone in center Usually starts in creases of upper thigh and does not involve scrotum/penis but may spread to anus causing itching and discomfort Usually less severe than other tinea infections but lasts longer Copyright 2013 S Leipheimer 30

Also known as eczema: “the itch that rashes” Hypersensitivity reaction similar to allergy Long-term swelling and redness (inflammation of skin) May lack certain proteins in the skin which leads to greater sensitivity Often accompanies asthma Eczema = compromised skin barrier @ critical point in development Strong link with food allergies Copyright 2013 S Leipheimer 31

Eczema + Food Allergies + Asthma ANAPHYLAXIS Copyright 2013 S Leipheimer 32

Very, very itchy Red/salmon colored patches Can look like pustules Likes the antecubetal

Subgroup of disorders results from hypersensitivity to physical or mechanical factors Cold urticaria Pressure -induced urticaria and angioedema Aquagenic urticaria Solar urticaria Exercised- induced urticaria History and distribution Confirmed by challenge Cold Challenge ( immediate … 4 hours later) Copyright 2013 S Leipheimer 36

Trauma –induced pressure urticaria Initial white line = reflexive vasoconstriction followed by pruritic, erythematous swelling Wheal or Flare Reaction Chronic ? Cause Interferes with skin testing = false + Copyright 2013 S Leipheimer 37

Eye “rashes” or Conjunctivitis Bacterial Viral Allergic Vernal Chemical Irritant Drugs Copyright 2013

Bacterial etiology Very contagious Red conjunctiva, itchy not painful, purulent drainage Should not

Chlamydia Gonoccocal Herpes Copyright 2013 S Leipheimer 40

Typically associated with an upper respiratory infection Watery, red, irritated Doesn’t usually have any discharge Refer anyone who wears contacts and has a red eye to a doctor Copyright 2013 S Leipheimer 41

Typically occurs in someone with seasonal allergies (hay fever) Itchy/bumpy/puffy and red Improves

Symptoms URI & Cough Red, Watery Eyes Tired Koplik’s spots (2 -3 days after above) Blotchy Rash (3 -5 days after symptoms) Starts on face at hairline Spreads downward to neck, trunk, arms, legs, feet Fever spike with rash (~ 104 F 40 C) Copyright 2013 S Leipheimer 43

Caused by infection of human papilloma virus Common – fingers and toenails Subungual (under) periungual ( around) nails Plantar- soles of feet (painful) Genital – STI (condyloma) Flat – appear wear shaving ( most common in children however) Trends: Children- warts tend to go away Adults- tend to stay Copyright 2013 S Leipheimer 45

Viral etiology Difficult to treat Can occur anywhere Most therapies aimed at triggering

Also viral (poxvirus) Difficult to treat Contagious Center has viral load Most advocate leaving them alone, though can currette or treat with topical irritant If many lesions- may be immune system concern Copyright 2013 S Leipheimer 48

Non-specific reactions Irritants Infections Immune System Disease Allergies Cold & Heat Chemicals Wind

Typically associated with an allergic reaction Can be seen as a response to viral infection, foods, medications or ? ? = idiopathic Refer if S&S of other system: cough/wheeze or swelling of lips/tongue; N & V Copyright 2013 S Leipheimer 50

Acute hypersensitivity reaction Can be seen in response to drugs, illness (viruses, bacteria) foods and immunizations May look similar to hives, but typically not pruritic, look like targets, can be painful, and unlike hives, persist (are fixed) No treatment Copyright 2013 S Leipheimer 52

Drugs Barbiturates PCNs Phenytoin Sulfonamides EM Minor – better in 2 -6 weeks; can recur Herpes simplex Mycoplasma EM Major = SJS Reaction to medication Infections; radiation Rx; UV light Epidermal necrolysis – morality risk high Copyright 2013 S Leipheimer 53

Drug reaction- Medical Emergency Atypical antipsychotics Antibiotics Sulpha Penicillins Other as listed Skin and mucous membranes reaction Widespread pain Facial swelling Tongue swelling Top layer of skin>> necrosis & sloughing Blistering & Erosion Copyright 2013 S Leipheimer 54

Starts with a herald patch (~ 1 -3 weeks) Confused Fine scaling oval

Very itchy in 50 % Can be concentrated in groin, forearms, shin Some report

Herpes Simplex Oral = “cold sores” Type 1 Genital = Type 2 But

Most infections with Type I are asymptomatic Most commonly presents as gingivostomatitis Characterized

Digital Herpes Painful Contagious Virus enters break in skin (torn cuticle) – from

Chickenpox – many are vaccinated Can be fatal for the neonate Fever, painful

Reactivation of varicella Very painful Occurs in dermatomal distribution Can be treated if

Zoster infects nerve on head Facial nerve near inner ear Painful rash on TM, canal, earlobe, tongue, roof of mouth, on same side as weakness or face Eye closing; motor movements - Hearing loss on side Vertigo Urgent referral Prompt RX Steroids Antivirals Copyright 2013 S Leipheimer 63

Streptococcal infections (Group A strep or strep pyogenes) Copyright 2013 S Leipheimer 64

Fever, sore throat, malaise, stomach s/s Contagious Treat with 10 days of penicillin

Strept Throat with rash S/T; Fever; H/A Abd pain; N/V + lymph nodes

Can also cause glomerulonephritis (coke colored urine), rheumatic fever, impetigo Also associated with severe invasive infections – pneumonia, arthritis, sepsis, toxic shock syndrome, etc Rheumatic Fever Appears 2 -4 or 1 -5 weeks following Strep infection Inflammation is the cause of symptoms: Inflammation of the heart - chest pain, fatigue, SOB Inflammation of the joints - arthritis symptoms Inflammation of the skin - skin rashes and nodules Inflammation of the CNS (central nervous system) - chorea (jerking), personality changes Increased risk of fulminant bacteremia from strep pneumo in kids with asplenia Vaccine in US Copyright 2013 S Leipheimer 67

Mumps and Measles Must always keep in mind based upon local immunization policies World travel – one small planet Immunization: concern with waning immunity over time WHO Travel Advice Copyright 2013 S Leipheimer 68

Viral infection that causes systemic disease and swelling of the salivary glands More

Characterized by fever, cough, rash, conjunctivitis Encephalitis with permanent brain damage 1: 1000

Petechiae, Purpura and Vasculitis Copyright 2013 S Leipheimer 71

Red blood cells outside the vessel walls – don’t blanch Seen with low

Never forget about abuse – bruising or petechiae, or other signs of trauma – in multiple stages of healing, unusual places, in strange shapes Obligated to report !!!!!!!!!!!! Copyright 2013 S Leipheimer 73

Large areas of cutaneous hemorrhage Refer to doctor Usually bad, may be life

Tetrad: Purpura Arthritis Usually Self-Limiting Usually children Small minority of cases can cause severe kidney and bowel disease Follows URI ~ 10 days following Mean age 5. 9 years Purpura is due to vasculitis not low platelets (Ig. A in walls of blood vessels) Steroids ease symptoms and may disrupt abnormal immune response Copyright 2013 S Leipheimer & Arthralgia Swelling around joints Kidney inflammation Abdominal pain 75

Erythema Induration Temperature Lesion Papule Pustule Macule Vesicles Hyper / Hypo pigmentation Linear

Size of each or all lesions Color Description of shape/distribution of lesion(s) Location What Trend or Changes over time Mark areas are spared? areas Aggravating or Alleviating Factors Associated Signs or Symptoms Copyright 2013 S Leipheimer 78

1+1+1=3 History 2 Associated S&S Exam Copyright 2013 S Leipheimer Potential Assessment &

https: //identitfy. us. com School. Nurse. com CD Head Louse Infestations: Evidence-Based Strategies & Best Practices for Tackling Head Lic NASN S. C. R. A. T. C. H. http: //www. cdc. gov/mrsa/groups/ http: //www 2. aap. org/new/idphotos. htm Medline. Plus www. cdc. gov www. fda. gov Copyright 2013 S Leipheimer 81