Treatment Guidelines for Simple Skin Diseases

Before going through the manual, please note the followings:

1- Treatment options are not limited to those guidelines
2- Refer the patient to skin clinic via SHIFA referral system is advised in
case the patient
a. Presented with significant skin diseases
b. Not responding to the treatment advised in this guideline

3- In case of severe skin diseases then it is advised to contact skin clinic to

discuss the case before sending the patient directly to the clinic

4- This manual may require further updates and editions in the future.
Hence, please read the updated version of it.
Impetigo
Causes mainly staphylococcus then streptococcus

Treatment:

1- Few lesions: fusidine cream OR cetremide cream twice daily

2- extensive lesions: same as above + cloxicillin suspension/tablets (15 mg/dose QID OR 20
mg/dose TID for 7 days while adults dose is 500 mg QID for 7 days)

Ecthyma
Causes mainly streptococcus

Treatment:

1- cloxicillin/amoxicillin suspension/tablet for total of 7 days

2- fusidine OR cetremide cream twice daily
Insect bite reaction:
1- Few lesions: hydrocortisone cream mix with fusidine cream twice daily until lesions resolve
2- Many lesions: as above treatment + antihistamine syrup/tablet (Loratadine once daily OR
chlorphenarmine TID)

Herpes simplex (labialis, gingivitis, genitalis):

1- First episode: acyclovir tablet/syrup + fusidine/cetremide cream twice daily
2- If acyclovir syrup/tablet is not available then acyclovir cream and to be applied 5 times per day
and advise the patient to buy acyclovir tablet/syrup from outside
3- For herpes gingivitis, you can add chlorhexidine mouth wash TID (preferably after food) +
lignocaine oral gel (before food by 20 minutes and up to 4 times per day)

Note:

- Acyclovir pediatric dose is 10-15 mg/dose QID for 5-7 days

- Acyclovir teenage and adult dose is 200 mg/dose 5 times/day OR 400 mg TID for 5-7 days
- Valacyclovir tablet is available in Barka P/C pharmacy and it is recommended to adults and NOT
for pediatric group
- Acyclovir tablet and suspension are NOT available in Barka P/C pharmacy, hence, outside
prescription should be given to the patient to buy it from outside pharmacy
Recurrent Herpes:
1- Few lesions: acyclovir cream 5 times per day + fusidine/cetremide cream twice daily
2- Extensive lesions: acyclovir tablet/syrup + fusidine/cetremide cream twice daily
3- If the patient is having more than 6 episodes of recurrent herpes per year and he/she welling for
suppression therapy then to be referred to the skin clinic

Note:

- Acyclovir pediatric dose is 10-15 mg/dose QID for 5-7 days

- Acyclovir teenage and adult dose is 200 mg/dose 5 times/day OR 400 mg TID for 5-7 days
- Valacyclovir tablet is available in Barka P/C pharmacy and it is recommended to adults and NOT
for pediatric group
- Acyclovir tablet and suspension are NOT available in Barka P/C pharmacy, hence, outside
prescription should be given to the patient to buy it from outside pharmacy

Scabies
1- Permethrin cream/lotion to be applied over night (minimum of 6-7 hours application) from neck
and up to toes once weekly for 2 weeks
2- Mometasone mix with crotamiton and fusidine/cetremide creams and to be applied twice daily
on skin lesions (for children below 3 years then replace mometasone with hydrocortisone
cream)
3- Antihistamine syrup/tablet (Loratidine once daily and chlorphenarmine TID)
4- Treat other affected family members

Note:

- Permethrin cream/lotion is safe for pregnant ladies and for children from age of 2 months and
above
- Crotamiton is not recommended to be applied over face skin
- In case mometasone cream is not available in the pharmacy then Fluticasone cream twice daily
application is recommended and available in the outside pharmacies
- Re-infection is the major cause of treatment failure, hence, treating all family members is
recommended and all must start therapy in the same time.
- Clothes should be washed by hot water
Atopic dermatitis/nummular dermatitis/psoriasis
Can occurs from the age of 2 years old and above

1- Mometasone cream alone OR mixed with fusidine/cetremide cream (in case if

excoriated/infected lesions) twice daily on skin lesions until resolution
2- Short course of systemic antihistamine to control itching if its significant and disturbing the
patient
3- Moisturizer cream thrice daily for whole body
4- Liquid paraffin for whole body 1-2 hours before shower
5- Hygiene + cotton clothes + atoderm/aveeno soap + avoid irritant and allergic factors
6- In case the patient is no responding well after applying the above steps then its advised to refer
the patient to skin clinic

Note:

- In case mometasone cream is not available in the pharmacy then Fluticasone cream (cultivate
cream) twice daily application is recommended and available in the outside pharmacies
- In case moisturizer cream is not available in the pharmacy then outside moisturisers are
recommended (e.g., atoderm intensive moisturizer, aveeno dermexa moisturizer, trixerra
moisturizer)
- Liquid paraffin alternatives are non-perfumed natural oils like olive oil, aloe Vera oil, coconut oil
as long the patient skin can tolerate them
Infantile eczema/infantile seborrheic dermatitis
Can occurs from day 1 of live and until the age of 2 years

1- Hydrocortisone mix with miconazole cream twice daily on skin lesions until resolution
2- Moisturizer cream thrice daily for whole body
3- Liquid paraffin for whole body 1-2 hrs before shower
4- Hygiene + cotton clothes + atoderm soap + avoid irritant and allergic factors
5- Short course of systemic antihistamine to control itching

Note:

- In case moisturizer cream is not available in the pharmacy then outside moisturisers are
recommended (e.g., atoderm intensive moisturizer, aveeno dermexa moisturizer, trixerra
moisturizer)
- Liquid paraffin alternatives are non-perfumed natural oils like olive oil, aloe Vera oil, coconut oil
as long the patient skin can tolerate them
- For cradle cap over scalp (presents like thick dandruff with crustation) then its advised to apply
hydrocortisone mix with miconazole cream twice daily on skin lesions + kelual emulsion (20
minutes before shower and it is available in the outside pharmacies)
Acne grade 1 and 2
1- Clindamycin lotion twice daily minimum of 1 hour application
2- Benzoyl peroxide cream/gel 2.5% or 5% once daily (away from direct sun light) 40-60 minutes
application then to be washed off

Note:

- Acne-prone facial wash from outside pharmacies

- Skinoren (azelaic acid) 5% cream (from outside pharmacies) over acne lesions and
postinflammatory hyperpigmentations with gradual application, i.e., 1 hour then to be washed
then 3 hours then washed and finally overnight application)
- Sun screen for oily skin
- Low-fat & low-carbohydrate diet and regular exercise are recommended.

Hair fall
A. Most cases seen in the clinic are due to
1- Malnutrition and low serum ferritin
2- Traction alopecia due to hair styling (mainly seen in girls due to hair style)
3- Alopecia areata and tinea corporis
B. Investigations to be done before referring to skin clinic are : CBC, TSH, serum Ferritin
C. General Treatment of hair fall:
i. In case serum ferritin is below 60 then prescribe Ferrous sulphate tablet for adults 2-3
times per day and for children Ferrous sulphate syrup (3-5 mg/kg/day) to be given in 2
or 3 divided doses on empty stomach (i.e., 1 hour before food or 2 hours after food)
witch citrus juice and avoid taking milk dairies and tea for minimum of 30 minutes
ii. Liquid paraffin scalp application 2 hours before shower
iii. If still persistent after 3 months from treatment then refer to skin clinic
D. Alopecia areata and tinea corporis cases to be investigated and refer them to skin clinic (you
may prescribe mixture of hydrocortisone and miconazole creams and applied once daily until
appointment)
ALOPECIA AREATA TINEA CAPITIS

Allergic/Irritant hand dermatitis:

1- Avoid allergic/irritant factors (excessive water, soaps, detergents, wearing latex gloves…etc.)
2- Frequent moisturizer application (prefer lipid-based creams, e.g., atoderm intensive moisturizer,
trixerra moisturizer cream, aveeno dermexa moisturizer which are available in the outside
pharmacies)
3- For moderate-severe cases: betamethasone cream twice daily application until condition
improves and in case skin erosions present then betamethasone cream mixed with
fusidine/cetremide cream twice daily

Urticaria & Angioedema:

In adults consider food and drugs while in children consider infections (viral, bacterial and worm
infestation) then food and drugs

1- Stop/avoid possible triggers

2- In children, history, examination and investigations for possible presence of infection
(respiratory, gastrointestinal, worm, protozoal and urinary infections) are required and, if
present, then treat accordingly.
3- Treatment:
a. Antihistamine syrup/tablets (preferably long acting types, e.g., loratidine and citrizine 5
mg for patients below 40 kg weight and 10 mg for patient above 40 kg weight and to be
taken HS and if not available then chlorphenarmine tablet 4 mg 8 hourly for adults and
0.1 mg/kg/dose 8 hourly for children)
b. Antihistamine treatment should be continued until total resolution of urticaria and even
after having 48-72 hours of clearance then to be tapered gradually and MUST NOT BE
STOPPED IMMEDIATELY.
c. For severe urticaria and angioedema with no impending anaphylaxis nor difficulty in
breathing then give the following: hydrocortisone IV injection (3-5 mg/kg) + Ranitidine
IV + chlorphenarmine IM (10 mg for adults while children 0.25 mg/kg/dose) +
observation and if improve then to discharge on antihistamine syrup/tablet +/- tapered
prednisolone tablet course (started from 0.5 mg/kg OD for 4-7 days). Note that after
stopping prednisolone course, the patient must continue antihistamine syrup/tablet
until having 48-72 hours of clearance to prevent relapse.
d. For anaphylaxis or severe angioedema with difficulty in breathing then follow the same
protocols in C and add adrenaline IM/SC 0.5 mg and can be repeated every 10-15
minutes, if needed, under ECG monitor and insert endotracheal tube and the patient
must be in emergency room (preferably resuscitation room, if available).

Chicken pox:
1- Antipyretics around the clock (alternating between paracetamol and NSAIDs, like ibuprofen)
2- Calamine lotion twice daily application and once dry then to be washed away
3- Fusidine/cetremide cream twice daily application, preferably, after washing calamine lotion
4- Systemic anti-virals are recommended if the patient age is below 2 years or above 12 years or
having severe presentation (acyclovir tablet 800 mg QID for 5-7 days or valacyclovir tablet 1000
mg TID for 5-7 days), for children acyclovir suspension 20 mg/kg/dose QID for 5-7 days

Note:
- Acyclovir tablets and suspensions are not available in Barka polyclinic pharmacy. Hence, if the
patient required acyclovir, then please prescribe it and ask the patient to buy it
- Valacyclovir tablet form is available in Barka polyclinic pharmacy and it is given for adults (as it is
dose and form is suitable for adults)

Herpes Zoster:
1- If the patient is not diabetic nor immunocompromised then its recommended to do screening
HIV test
2- Acyclovir tablet 800 mg QID for 5-7 days or valacyclovir tablet 1000 mg TID for 5-7 days), for
children acyclovir suspension 20 mg/kg/dose QID for 5-7 days
3- Silver sulphadiazine cream twice daily application (if it is in the face then fusidine/cetremide
cream twice daily application).
4- Analgesics around the clock (alternating between paracetamol and NSAIDs, like ibuprofen).
5- Short course of systemic antihistamine to control itching
6- If it involves the V1 area of trigeminal nerve including the tip of nose then urgent referral to
ophthalmology clinic to rule out eye involvement.

Note:

- Acyclovir tablets and suspensions are not available in Barka polyclinic pharmacy. Hence, if the
patient required acyclovir, then please prescribe it and ask the patient to buy it
- Valacyclovir tablet form is available in Barka polyclinic pharmacy and it is given for adults (as it is
dose and form is suitable for adults)
Acute Paronychia:
1- Fusidine cream twice daily application
2- If severe then add cloxicillin capsule/suspension QID for 5-7 days

Chronic Paronychia:
1- Avoid allergic/irritant factors (excessive water, soaps, detergents, wearing latex gloves…etc.)
2- Miconazole tincture twice daily application
3- Mixture of nystatin + mometasone + fusidine creams to be applied over night

Note:

- In case mometasone cream is not available in the pharmacy then Fluticasone cream (e.g.,
cultivate cream) twice daily application is recommended and available in the outside pharmacies

Dandruff/seborrheic capitis/dermatitis:
1- Moisturizer application over affected skin areas while oils (e.g., liquid paraffin, coconut oil, aloe
Vera oil, or any other non-perffumed oils) can be applied over scalp area 2 hours before shower
2- Avoid direct sun light, humidity, swimming in the sea
3- Scalp: betamethasone scalp lotion HS is recommended until itching resolves
4- Face, neck and chest: mometasone cream (cultivate cream is an outside pharmacy good
alternative) mix with miconazole cream HS application until clearance.
5- Ketoconazole shampoo thrice weekly 15-20 minutes application then to be washed and once
improves then maintenance of once weekly application

Head lice/scalp pediculosis:

1- Anti-lice lotion to be applied over DRY scalp before shower (please follow the instruction written
in the product as its varies from one product to another) and to repeat application after 7-10
days. (over the counter products are available like Hedrin lotion, Delice lotion, Nolice lotion)
2- Anti-lice shampoo to be applied over WET scalp (please follow the instruction written in the
product as its varies from one product to another) and to repeat application after 7-10 days.
(over the counter products are available like Hedrin shampoo, Delice shampoo, Nolice shampoo)
3- It is very important to prevent re-infection:
i. Covering the hair by physical barrier like scarf or hat
ii. Treating other family members or school friends or neighbors who have scalp lice
iii. After washing antilice shampoo/lotion, then its recommended to do regular combing
using narrow-spaced tooth comb on daily basis until total clearance of lice and its eggs.