Related Therapeutic strategies

Herpes simplex virus (HSV) occurs in 2 common locations: orofacial (usually due to HSV-1) and genital (usually due to HSV-2).

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Seborrheic dermatitis can be limited to the scalp, but it also can involve the face and any hairy or intertriginous area and rarely can even progress to a generalized erythroderma.

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Chancroid

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

The diagnosis of chancroid is usually clinical, although improved culture techniques allow isolation of the causative organism H. ducreyi. The therapeutic strategy is to eliminate the pathogenic microorganism.

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Therapeutic Strategies

Creeping Eruption, Larva Migrans, and Larva Currens

Timothy Berger Bruce Wintroub

Saturday, January 01, 2011

Cutaneous Larva Migrans (CLM)

The treatment for larva currens is somewhat different so the two diseases are discussed separately.

Cutaneous larva migrans is due to animal (usually canine) hookworm. It presents as serpiginous papules on the dorsal feet and, less commonly, the other body sites contacting the sand when sunbathing on the beach. Larva migrans is usually self-limited; however, untreated cases, especially if extensive, may last for months to years. The therapeutic strategy is to eliminate the pathogenic organism.

First Steps

Oral ivermectin 12 mg as a single dose.

Alternative Steps

  1. Albendazole 400-800 mg daily for 3-7 days, depending on the severity of the disease (3 days for single lesions, 5-7 days for multifocal disease). (Albendazole is preferred over thiabendazole because of the significantly lower rates of gastrointestinal [GI] upset.)
  2. Thiabendazole 15% ointment or cream applied 3 times daily for 5-10 days. Addition of dimethyl sulfoxide (DMSO) to the vehicle may enhance efficacy.

Subsequent Steps

  1. About 90% of patients will be cured with the above regimens. Patients failing to improve after a single dose of ivermectin should have a second or third dose of 0.2 mg/kg as required every 2 weeks.
  2. Patients failing to improve with topical thiabendazole or oral albendazole should be treated with ivermectin. Patients failing to improve after 3 doses of ivermectin should be treated with oral albendazole.

Pitfalls

  1. Despite the high success rates from the above regimens, at least 5% of patients, especially those with more widespread disease, may require more prolonged or repeated courses of treatment. Relapses may occur up to 30 days following treatment.
  2. Failure of standard therapies to cure CLM may indicate underlying immunosuppression.

Larva currens

Larva currens, caused by intestinal infection with Strongyloide stercoralis, presents with serpiginous erythematous papules on the buttocks, upper thighs, and lower abdomen. In the immunosuppressed host, larva currens may appear anywhere on the body and suggests hyperinfection with hematogenous dissemination.

First Steps

Ivermectin 0.2 mg/kg daily for 1-2 days.

Subsequent Steps

Patients failing to improve on short courses of ivermectin should have longer courses or repeat courses at 10- to 14-day intervals.

Pitfalls

  1. Albendazole has a low cure rate in strongyloidiasis, and should not be used as first-line therapy.
  2. Thiabendazole 50 mg/kg twice daily (maximum 3g/day) for 2 consecutive days is effective, but GI intolerance and hepatitis may complicate treatment.

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