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Scabies

++ Clinical features
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  • Intense itching (worse with warmth and at night)

  • Erythematous papular rash

  • Usually on hands and wrists

  • Common on male genitalia

  • Also occurs on elbows, axillae, feet and ankles, nipples of females

  • Diagnosis by microscopic examination of skin scrapings

++ Treatment: for all types of scabies
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  • Permethrin 5% cream (adults and children >6 months) or

  • Benzyl benzoate 25% emulsion (dilute 50:50 with water if under 10 yrs; if <2 yrs dilute 1:3)

++ Method for application
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  • Apply to clean, dry cool skin of whole body from jawline down (preferably at night time). Include under nails, flexures and genitalia. Apply to face and hair if involved.

  • Leave permethrin overnight (min 8 hrs) and benzyl benzoate 24 h and wash off.

  • Repeat in 1 wk.

  • Complete change of clothes and bed linen: wash in hot water after treatment and hang in sun. Wash any soft toys.

  • Treat all family members and contacts even if free of symptoms.

  • A topical antipruritic (e.g. crotamiton cream) can be used for persistent itch (usu. up to 3 wks).

  • Can use sulphur 5% cream or crotamiton 10% cream daily for 3 days in children <2 yrs.

    Note: Lindane 1% lotion is an alternative, esp. for genital scabies.

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Norwegian scabies (profuse infestation with crusting)

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  • Add ivermectin 200 mcg/kg (o) as single dose. Consult dermatologist.

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Scrotal pain

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Serious problems include testicular torsion, strangulation of an inguinoscrotal hernia, a testicular tumour and a haematocele, all of which require surgical intervention. A varicocele can cause discomfort—examine in standing position.

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Scrotal pain/discomfort: diagnostic strategy model
++ Probability diagnosis
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  • Trauma including haematoma, haematocele

  • Torsion of a testicular appendage

  • Varicocele

++ Serious disorders not to be missed
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  • Vascular:

    • testicular torsion

  • Infection:

    • acute epididymo-orchitis/orchitis

    • fulminating necrotising cellulitis

    • psoas abscess

    • tuberculosis

  • Cancer:

    • testicular neoplasm

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Other:

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  • strangulated inguinoscrotal hernia

  • acute hydrocele

++ Pitfalls (often missed)
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  • Referred pain (e.g. spine, ureteric colic, abdominal aorta)

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Rarities:

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  • idiopathic scrotal oedema

  • filariasis

++ Key investigations
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Useful investigations include:

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  • FBE

  • urine analysis, microscopy and culture

  • Chlamydia detection test

  • ultrasound

  • technetium-99m scan.

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Torsion of the testis versus epididymo-orchitis
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With torsion of the testicle there is pain of sudden onset, described as severe aching sickening pain in the groin that may be accompanied by nausea and vomiting. With epididymo-orchitis the attack usually begins with malaise and fever. The testicle soon becomes swollen and acutely tender; however, elevation of the scrotum usually relieves pain in this condition while tending to increase it with a torsion.

++ Key facts about torsion of ...

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