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ECZEMA
ECZEMA
Eczema, also known as atopic dermatitis, or atopic eczema, is a dermatologic problem where patches of skin become inflamed, itchy, red, cracked, and rough. Blisters may sometimes occur.
It is commonly seen in children. It is a relapsing skin problem that is manifested as pruritus, accompanied with swelling, redness, and dryness of the skin. Flaking, cracking, oozing, blistering or bleeding may occur as a result of excessive scratching of the skin.
Several factors are linked with this disease such as genetic mutation, and family history. Eczema cannot be cured, but it is not contagious. This is usually associated with allergy.
Causes of Eczema
The specific cause of eczema remains unknown, but it is believed to develop due to a combination of genetic and environmental factors.
Genetic Factors:
- Family History: Children with relatives affected by eczema or other atopic diseases, such as asthma or hay fever, have a higher likelihood of developing the condition.
- Inherited Gene Mutations: Genetic mutations can disrupt the skin’s natural barrier function, increasing vulnerability to irritants and allergens.
Environmental Factors:
- Irritants: Exposure to harsh soaps, detergents, shampoos, disinfectants, and even juices from fresh fruits, meats, or vegetables can trigger eczema. Certain fabrics like wool or synthetic materials may also contribute to irritation.
- Allergens: Eczema can be aggravated by exposure to common allergens, including dust mites, pet dander, pollen, mold, and dandruff.
- Microbes: Presence of microbes like bacteria (e.g., Staphylococcus aureus), viruses, and fungi can play a role in eczema development.
- Environmental Conditions: Extreme temperatures, whether hot or cold, and fluctuations in humidity levels can impact eczema.
Dietary Factors:
- Common Food Triggers: Consumption of certain foods, including dairy products, eggs, nuts, seeds, soy products, and wheat, can be associated with eczema development.
Other Factors:
- Stress: Psychological stress can exacerbate eczema symptoms.
- Hormonal Changes: Hormonal fluctuations, such as those occurring during pregnancy or the menstrual cycle, may influence the severity of eczema symptoms.
- Age: Eczema is more common in children and infants, although it can affect individuals of all ages.
- Skin Dryness: Dry skin can worsen eczema symptoms, emphasizing the importance of maintaining proper skin hydration.
Classification of Eczema
The National Eczema Association has categorized eczema into various types.
Table 1. More Common Types of Eczema.
Table 2. Lesser Common Types of Eczema.
Symptoms of atopic eczema vary across different age groups:
Infants (Under 2 Years Old):
- Rashes commonly appear on the scalp and cheeks.
- Rashes typically bubble up before leaking fluid.
- Extreme itchiness may interfere with sleep, and continuous rubbing can lead to skin infections.
Children (2 Years Until Puberty):
- Rashes commonly appear behind the creases of elbows or knees, as well as on the neck, wrists, ankles, and buttock- leg creases.
- Over time, rashes can become bumpy, change in color, thicken (lichenification), develop knots, and lead to permanent itching.
Adults:
- Rashes commonly appear in creases
- of the elbows or knees, the nape of the neck, and cover much of the body.
- Prominent rashes on the neck, face, and around the eyes may occur.
- Skin can become very dry, and rashes can be perma
- nently itchy.
- Rashes in adults may be more scaly than those in children.
- Skin infections can result from scratching.
- Adults who had atopic dermatitis as children may still experience dry or easily-irritated skin, hand eczema, and eye problems, even if the condition has resolved.
Diagnosis of Eczema.
Assessment:
- Eczema is a skin condition and the main characteristic of this disease is itching.
- Acute refers to the initial stage, where the skin may have crusted, oozing, eroded vesicles (small blisters), erythematous plaques (red, raised areas of skin), or papules (small, raised bumps).
- Subacute is the stage that comes after the acute stage, where the skin may have erythematous scaly plaques (red, flaky areas of skin) or papules.
- Chronic is the stage that comes after the subacute stage, where the skin may have slightly pigmented (discolored), lichenified (thickened and hardened) plaques or excoriations (areas where the skin has been scraped or scratched).
Skin Allergy Test:
- Conducting a skin allergy test helps identify specific allergens that may be contributing to eczema flare-ups.
- Skin Prick Testing: Involves introducing small amounts of allergens into the skin to identify specific triggers.
- Patch Testing: Identifies delayed hypersensitivity reactions by applying small amounts of potential allergens to the skin and observing reactions over time.
- Food Allergy Testing: Helps identify food triggers contributing to eczema symptoms.
Skin Biopsy:
- In some cases, a skin biopsy may be recommended, involving the collection of a small skin sample for laboratory examination. This procedure helps in confirming the diagnosis and ruling out other skin disorders.
Blood Tests – IgE Level:
- An elevated IgE level can be associated with eczema and may be measured through blood tests.
Treatment and Management of Eczema
There is no cure for eczema. Treatment for the condition aims to heal the affected skin and prevent flare-ups of symptoms.
Treatment based on an individual’s age, symptoms, and current state of health.
For some people, eczema goes away over time. For others, it remains a lifelong condition.
Home Care
- Lukewarm baths: Avoid hot water, which can dry out the skin.
- Moisturizing: Apply moisturizer within 3 minutes of bathing to “lock in” moisture. Moisturize daily, especially after bathing.
- Clothing: Wear loose-fitting, soft fabrics like cotton. Avoid rough, scratchy fibers and tight clothing.
- Cleansing: Use a mild soap or non-soap cleanser when washing.
- Drying: Air dry or gently pat skin dry with a towel. Avoid rubbing.
- Temperature control: Avoid rapid temperature changes and activities that cause sweating.
- Trigger avoidance: Identify and avoid individual eczema triggers.
- Humidifiers: Use a humidifier in dry or cold weather.
- Nail care: Keep fingernails short to prevent scratching.
Medications
- Topical corticosteroids: Anti-inflammatory creams or ointments applied directly to the skin to reduce inflammation and itching.
- Systemic corticosteroids: Injected or oral corticosteroids for severe cases. Used for short periods only.
- Antibiotics: Prescribed if eczema is accompanied by a bacterial skin infection.
- Antiviral and antifungal medications: Treat fungal and viral infections.
- Antihistamines: Reduce nighttime scratching by causing drowsiness.
- Topical calcineurin inhibitors: Suppress immune system activity, reducing inflammation and preventing flare-ups.Calcineurin works by suppressing the activity of the immune system, specifically by inhibiting the production of certain inflammatory chemicals called cytokines.
- Barrier repair moisturizers: Reduce water loss and repair the skin’s barrier.
Other Therapies
- Phototherapy: Exposure to ultraviolet light to treat moderate eczema. Skin is monitored closely.
Ongoing Care
- Even after skin has healed, it is important to continue caring for it to prevent irritation. Regular moisturizing and trigger avoidance are helpful for long term care.
ATOPIC DERMATITIS
ATOPIC DERMATITIS.
Atopic dermatitis (AD) also known as atopic eczema is a common type of eczema that causes the skin to become itchy, dry, and cracked.
It results in itchy, red, swollen, and cracked skin. Clear fluid may come from the affected areas, which often thicken over time.
Other names include “infantile eczema“, “flexural eczema“, “prurigo Besnier“, “allergic eczema“, and “neurodermatitis“.
While the condition may occur at any age, it commonly starts in childhood with changing severity over the years. In children under one year of age much of the body may be affected.
As children get older , the back of the knees and front of the elbows are the most common areas affected.
In adults the hands and feet are the most commonly affected areas.
Scratching worsens symptoms and affected people have an increased risk of skin infections.
Many people with atopic dermatitis develop hay fever or asthma.
Causes and Predisposing Factors of Atopic Dermatitis
The exact cause of atopic dermatitis (AD) is unknown, but several factors are believed to contribute to its development, including genetics, immune system dysfunction, environmental exposures, and difficulties with the permeability of the skin.
- Genetics: AD is strongly influenced by genetics. If one identical twin has AD, there is an 85% chance that the other twin will also have the condition. Many people with AD have a family history of atopy. Atopy is an immediate-onset allergic reaction (type 1 hypersensitivity reaction) that manifests as asthma, food allergies, AD or hay fever.
- Immune system dysfunction: People with AD have an overactive immune system that reacts to allergens and irritants in the environment. This leads to the production of inflammatory chemicals that cause the skin to become red, itchy, and inflamed.
- Environmental exposures: Exposure to certain environmental factors can trigger or worsen AD symptoms. These factors include: Dust mites, Pollen, Pet dander, Smoke, Chemicals, Dry air, Stress. Exposure to certain chemicals or frequent hand washing makes symptoms worse. Those who live in cities and dry climates are more commonly affected.
- Skin barrier defects: People with AD have a defective skin barrier that allows allergens and irritants to penetrate the skin more easily. This leads to inflammation and the development of AD symptoms. Studies have found that abnormalities in the skin barrier of persons with AD are exploited by S. aureus to trigger cytokine expression, thus aggravating the condition.
- Staphylococcus aureus (S. aureus) colonization: S. aureus is a type of bacteria that is commonly found on the skin. In people with AD, S. aureus can colonize the skin and produce toxins that worsen the inflammation and symptoms of AD.
- Calcium carbonate in household water: Studies have found that children who live in areas with high levels of calcium carbonate in their household water are more likely to develop AD. Atopic dermatitis in children may be linked to the level of calcium carbonate or “hardness” of household water.
- Hygiene Hypothesis: According to the hygiene hypothesis , when children are brought up exposed to allergens in the environment at a young age, their immune system is more likely to tolerate them, while children brought up in a modern “sanitary” environment are less likely to be exposed to those allergens at a young age, and, when they are finally exposed, develop allergies. There is some support for this hypothesis with respect to AD.
Triggers of Atopic Dermatitis:
There are several factors that can trigger or worsen symptoms, including:
- Food allergies
- Stress
- Heat and humidity
- Certain fabrics, such as wool and synthetic fibers
- Harsh soaps and detergents
- Perfumes and other fragrances
Pathophysiology of Atopic Dermatitis
The disorder is not contagious. The pathophysiology may involve a mixture of type I and type IV -like hypersensitivity reactions.
After a Genetic Predisposition or any other predisposing factor, it leads to Skin Barrier Dysfunction hence a compromised skin barrier allowing irritants to penetrate more easily.
The immune system, especially the T-cells, responds exaggeratedly to these triggers leading to the release of inflammatory chemicals like histamines.
Inflammation occurs in the skin layers, causing redness, swelling, and itching. Scratching the itchy skin worsens the inflammation, leading to a cycle of itching and scratching leading to an imbalance of the skin’s normal flora like Staphylococcus aureus (S. aureus) with an overgrowth of S. aureus, further contributing to inflammation.
Chronic inflammation and persistent scratching can lead to a thinning of the skin layers which makes the skin more susceptible to infections and environmental damage.
Immune cells release cytokines like Interleukins, in particular, leading to even more inflammation. The combined effects of inflammation, scratching, and immune response result in characteristic eczematous lesions. These include red, dry, and scaly patches of skin. Triggers like allergens, stress, and environmental factors can exacerbate symptoms, leading to flare ups.
Signs and symptoms of Atopic Dermatitis
- Dry and scaly skin that spans the entire body, except perhaps the diaper area: Atopic dermatitis can cause dry, scaly skin that affects most of the body, except for areas that are usually covered by a diaper.
- Intensely itchy red, splotchy, raised lesions in the bends of the arms or legs, face, and neck: These lesions are a hallmark symptom of atopic dermatitis and can be extremely itchy. They often appear in the creases of the elbows, knees, and neck.
- Dennie-Morgan infraorbital fold, infra-auricular fissure, and periorbital pigmentation on the eyelids: These are subtle signs of atopic dermatitis that can appear on the eyelids. The Dennie-Morgan infraorbital fold is a crease below the lower eyelid, the infra-auricular fissure is a groove in front of the ear, and periorbital pigmentation is darkening of the skin around the eyes.
- Post-inflammatory hyperpigmentation on the neck, giving it a classic ‘dirty neck’ appearance: This is a darkening of the skin on the neck that can occur after inflammation from atopic dermatitis.
- Lichenification, excoriation, erosion, or crusting on the trunk, indicating secondary infection: Lichenification is a thickening and hardening of the skin, excoriation is scratching of the skin, erosion is a loss of the top layer of skin, and crusting is a buildup of dried fluid on the skin. These signs can indicate that a secondary infection has developed on the skin.
- Flexural distribution with ill-defined edges with or without hyperlinearity on the wrist, finger knuckles, ankle, feet, and hand: Flexural distribution means that the rash appears in the creases of the body, such as the elbows, knees, and wrists. Ill-defined edges means that the rash does not have a clear border. Hyperlinearity is an increase in the lines on the palms of the hands and soles of the feet.
Additionally;
- Dry, itchy skin: Intense itching is a hallmark symptom.
- Redness and inflammation: Skin appears red and inflamed, often with small bumps or blisters.
- Eczema: Dry, scaly patches of skin that can become crusty or oozing.
- Oozing or crusting: Blisters or lesions may break open and release fluid that crusts over.
- Lichenification: Thickening and hardening of the skin due to chronic scratching.
- Skin infections: Due to compromised skin barrier, infections such as staph or yeast can occur.
- Allergic reactions: Atopic dermatitis can be triggered by allergens, leading to flare-ups with symptoms such as hives, swelling, and itching.
Diagnosis of Atopic Dermatitis
Atopic dermatitis is diagnosed clinically, meaning that it is diagnosed based on signs and symptoms alone, without special testing. However, several different forms of criteria developed for research have also been validated to aid in diagnosis.
Assessment: This involves a physical examination and a review of the patient’s medical history. The physical examination will focus on the skin, and the doctor will look for signs of atopic dermatitis, such as:
- Dry, itchy skin
- Redness and swelling
- Scaling and crusting
- Lichenification (thickening and leathery appearance of the skin)
They will also ask about the patient’s family history of atopic dermatitis and other allergic conditions. A diagnostic criteria such as the UK Diagnostic Criteria can be used.
UK Diagnostic Criteria
The UK diagnostic criteria for atopic dermatitis are as follows:
- People must have itchy skin, or evidence of rubbing or scratching, plus 3 or more of the following:
- Skin creases are involved.
- Flexural dermatitis of fronts of ankles, antecubital fossae, popliteal fossae, skin around eyes, or neck, (or cheeks for children under 10 years old).
- History of asthma or allergic rhinitis (or family history of these conditions if patient is a child ≤4 years old).
- Symptoms began before age 2 (can only be applied to patients ≥4 years old).
- History of dry skin (within the past year).
- Dermatitis is visible on flexural surfaces (patients ≥age 4) or on the cheeks, forehead, and extensor surfaces (patients<age 4).
Explanation of the Criteria:
- Itchy skin or evidence of rubbing or scratching: This is a hallmark symptom of atopic dermatitis.
- Skin creases are involved: Atopic dermatitis often affects the creases of the body, such as the elbows, knees, and neck.
- Flexural dermatitis: This refers to a rash that appears in the creases of the body.
- History of asthma or allergic rhinitis: Atopic dermatitis is often associated with other allergic conditions, such as asthma and allergic rhinitis.
- Symptoms began before age 2: Atopic dermatitis typically begins in childhood.
- History of dry skin: Dry skin is a common symptom of atopic dermatitis.
- Dermatitis is visible on flexural surfaces or on the cheeks, forehead, and extensor surfaces: The location of the rash can help to distinguish atopic dermatitis from other skin conditions.
Other Investigations
In some cases, the doctor may order other investigations to help confirm the diagnosis of atopic dermatitis. These investigations may include:
- Allergy testing: Allergy testing can be used to identify the allergens that are triggering the atopic dermatitis. This testing can be done through skin prick tests or blood tests.
- Patch testing: Patch testing is a type of allergy test that is used to identify the allergens that are causing contact dermatitis. This test involves applying small amounts of different allergens to the skin and then observing the skin for signs of a reaction.
Differential Diagnosis
Atopic dermatitis can sometimes be confused with other skin conditions, such as:
- Contact dermatitis
- Seborrheic dermatitis
- Psoriasis
- Eczema
Treatment of Atopic Dermatitis
There is no known cure for atopic dermatitis (AD), but treatments can help to reduce the severity and frequency of flares. Treatment involves both preventive measures and medications.
Preventive Measures
- Avoiding triggers: Identifying and avoiding triggers that make the condition worse is an important part of managing AD. Common triggers include wool clothing, soaps, perfumes, chlorine, dust, and cigarette smoke.
- Daily bathing and moisturizing: Bathing daily with lukewarm water and applying a fragrance-free, hypoallergenic moisturizer afterwards can help to keep the skin hydrated and reduce the need for other medications.
- Using mild soaps and detergents: Harsh soaps and detergents can irritate the skin and worsen AD. It is important to use mild, fragrance-free soaps and detergents that are designed for sensitive skin.
- Wearing loose, cotton clothing: Loose, cotton clothing allows the skin to breathe and helps to prevent irritation.
- Managing stress: Stress can trigger AD flares. Finding healthy ways to manage stress, such as exercise, music, or meditation, can help to reduce the frequency and severity of flares.
Medications
- Topical corticosteroids: Topical corticosteroids, such as hydrocortisone, are effective in reducing inflammation and itching. They are typically applied to the affected areas of skin once or twice daily.
- Topical calcineurin inhibitors: Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, are non-steroidal medications that can be used to treat AD. They are typically used for short periods of time, as they can cause side effects such as skin irritation and burning.
- Systemic immunosuppressants: Systemic immunosuppressants, such as cyclosporine, methotrexate, and azathioprine, are used to suppress the immune system and reduce inflammation. They are typically used for severe AD that does not respond to other treatments.
- Antidepressants and naltrexone: Antidepressants and naltrexone can be used to control pruritus (itchiness).
- Antibiotics: Antibiotics may be used to treat bacterial infections that can develop on the skin of people with AD.
- Phototherapy: Phototherapy involves exposing the skin to ultraviolet (UV) light. This can help to reduce inflammation and improve the skin’s appearance.
Other Treatments
- Moisturizers: Applying moisturizers regularly can help to keep the skin hydrated and reduce the need for other medications.
- Salt water baths: Bathing in salt water can help to soothe the skin and reduce inflammation.
- Dilute bleach baths: Dilute bleach baths have been shown to be effective in managing AD.
- Vitamin D supplementation: There is some evidence that vitamin D supplementation may improve AD symptoms.
- Dietary changes: This is only effective if allergens have been identified in certain foods hence avoiding them.
Complications of Atopic Dermatitis
- Skin infections: People with AD are more likely to develop skin infections, such as eczema herpeticum (a viral infection) and impetigo (a bacterial infection).
- Allergic contact dermatitis: AD can increase the risk of developing allergic contact dermatitis, which is a type of skin irritation caused by contact with an allergen.
- Hand eczema: AD can lead to hand eczema, which is a type of eczema that affects the hands. Hand eczema can be difficult to treat and can interfere with daily activities.
- Sleep problems: The itching and discomfort of AD can make it difficult to sleep.
- Psychological problems: AD can lead to psychological problems, such as anxiety, depression, and low self-esteem.
- Increased risk of asthma and hay fever: People with AD are more likely to develop asthma and hay fever.
- Poor quality of life: AD can have a significant impact on quality of life, affecting work, school, and social activities.
- Erythroderma: Erythroderma is a rare but serious complication of AD that causes the skin to become red, swollen, and itchy. Erythroderma can be life-threatening if not treated promptly.
- Lymphoma: People with severe AD are at an increased risk of developing lymphoma, a type of cancer that affects the lymph nodes.
Inguinal Buboes Syndrome
Inguinal Buboes Syndrome
Inguinal buboes refer to localized swellings or enlarged lymph glands in the groin and femoral area.
They are often locally described as “grenades.”
Case Definition:
Inguinal Buboes Syndrome is characterized by the clinical manifestation of localized swellings or enlarged lymph glands in the groin and femoral area.
Aetiology
It is crucial to differentiate sexually transmitted causes, specifically LGV and chancroid, from non-sexually transmitted local and systemic infections, such as lower limb or gluteal region infections. Exclusion of these non-STI causes is essential for accurate diagnosis. Other causes inclide;
- Chlamydia strains: lymphogranuloma venereum (LGV).
- Haemophilus ducreyi: chancroid.
- Treponema pallidum: syphilis.
Clinical features
These swellings may present with pain and fluctuation and are commonly associated with Lymphogranuloma venereum (LGV) and chancroid. In the case of chancroid, an observable ulcer may accompany the buboes.
- Excessively swollen inguinal glands.
- Pain, tenderness.
- Swellings may become fluctuant if pus forms.
Treatment Protocol: Inguinal Buboes Syndrome
Examination and Differential Diagnosis to rule out Non-STI Causes:
- Thorough clinical examination to rule out non-sexually transmitted infections causing inguinal swellings.
- Rule out infections in the foot, leg, or buttock.
- Exclude the possibility of an inguinal hernia.
- Differential diagnosis to consider both STI-related and non-STI-related etiologies.
Follow the Management Flow Chart:
- Adhere to the syndromic management flow chart for inguinal buboes.
- Treatment options may include antibiotics and other therapeutic measures based on the underlying cause.
- If a genital ulcer is present, initiate treatment following the established protocol.
- Administer doxycycline 100 mg orally every 12 hours for a duration of 14 days.
- Ensure treatment for both the patient and their partner.
Pregnant Partner Consideration:
- In cases involving a pregnant partner, substitute doxycycline with erythromycin.
- Administer erythromycin 500 mg orally every 6 hours for a period of 14 days.
Aspiration of Fluctuant Swellings:
- Fluctuant swellings, indicative of fluid accumulation, should be aspirated daily.
- Do not incise the bubo; instead, aspirate through normal skin using a large bore needle (gauge <20) every 2 days until resolution.
- As an alternative to doxycycline, azithromycin 1 g as a single dose can be considered.
- Caution: Never incise fluctuant swellings, as this may lead to sinus formation.
Address Underlying STI:
- If LGV or chancroid is diagnosed, initiate appropriate antibiotic therapy as per established guidelines.
- Consider partner notification and treatment to prevent further transmission.
Monitoring and Follow-up:
- Regular monitoring of the swelling’s progression and response to treatment.
- Follow-up examinations to assess resolution and ensure the absence of complications.
Persistent Bubo Treatment:
- If the inguinal bubo persists and the partner was not treated, continue the prescribed treatment for an additional 14 days.
Referral for Specialist Management:
- In cases where the condition does not show improvement, consider referral for specialist management.
Lower Abdominal Pain Syndrome
Lower abdominal pain syndrome stands out as one of the most prevalent and serious STI syndromes among women, bearing significant reproductive health and socio-economic consequences.
Its presentation can be acute or chronic, posing diagnostic challenges due to numerous potential differential diagnoses.
Patients usually present with
- abdominal pain,
- Bleeding,
- dyspareunia,
- meno-metrorrhagia,
- fever, and occasional vomiting.
Comprehensive evaluation involves assessing
- abdominal tenderness,
- cervical motion,
- adnexal tenderness,
- uterine tube enlargement, and pelvic masses.
- Elevated temperature may be indicative, requiring thorough bimanual vaginal examination.
Case Definition:
Symptoms of lower abdominal pain and pain during sexual intercourse, coupled with examination findings such as vaginal discharge, lower abdominal tenderness on palpation, or a temperature > 38 degrees Celsius.
Aetiology:
This syndrome strongly suggests pelvic inflammatory disease (PID), encompassing salpingitis and/or endometritis. Causative agents may include gonococcal, chlamydial, or anaerobic infections.
Management:
Referral for Surgical Emergencies:
- Patients presenting with symptoms of other surgical emergencies resembling lower abdominal pain syndrome should be promptly referred for inpatient admission and management.
Syndromic Antibiotic Treatment:
- Ciprofloxacin, metronidazole, and ceftriaxone are prescribed, targeting the likely causative agents due to the challenge of specific diagnosis.
- Outpatient treatment is extended due to the chronic nature of the condition.
Intrauterine Contraceptive Devices (IUCD):
- Patients with IUCDs, predisposing factors for PID, should have the device removed after initiating treatment for at least 2 days.
- Contraceptive counseling is essential for these patients.
Comprehensive STI Case Management:
- Include other components such as partner notification and treatment, education on treatment compliance, and promotion of preventive measures.
- Continuous monitoring and evaluation to address potential complications and ensure treatment effectiveness.
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Genital Ulcer Syndrome
Genital Ulcer Syndrome
Genital ulcer disease is a common syndrome affecting both men and women, characterized by single or multiple ulcers with different clinical manifestations.
Genital ulcer disease refers to breaks in the skin or mucosa and may present as ulcers, sores or vesicles.
Case Definition:
Non-vesicular Genital Ulcer: Ulcer on the penis, scrotum, or rectum in men, and on the labia, vagina, or rectum in women, with or without inguinal adenopathy. Vesicular ulcers involve the presence or history of vesicles.
Causes:
The aetiology of this syndrome varies across geographical regions and can evolve over time, often presenting challenges due to mixed infections and the influence of HIV.
- Non-vesicular Ulcers: Commonly caused by syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, or atypical cases of genital herpes (HSV infection).
- Vesicular Ulcers: Primarily caused by Herpes genitalis, syphilis, and Chancroid in Uganda.
Multiple organisms can cause genital sores, commonly:
- Treponema pallidum bacteria: syphilis
- Herpes simplex virus: genital herpes
- Haemophilus ducreyi: Chancroid
- Donovania granulomatis: Granuloma inguinale
- Chlamydia strains: lymphogranuloma venereum (LGV)
Clinical Presentation:
In men, genital ulcer disease occurring under the prepuce may present with a discharge in uncircumcised male patients, therefore, prepuce should be retracted and examined for ulcer lesions.
Female patients should have the labia separated and inspected, with speculum examination if necessary.
Mixed infections are common
- Primary syphilis: the ulcer is at first painless and may be between or on the labia or on the penis.
- Secondary syphilis: multiple, painless ulcers on the penis or vulva.
- Genital Herpes: small, multiple, usually painful blisters, vesicles, or ulcers. Often recurrent.
- Granuloma inguinale: an irregular ulcer which increases in size and may cover a large area.
- Chancroid: multiple, large, irregular ulcers with enlarged painful suppurating lymph nodes.
Management:
Prompt treatment is important due to the increased risk of HIV transmission associated with genital ulcers.
Treatment strategies for both genders should align with the local epidemiology. In Uganda, the following approach is recommended:
- Non-vesicular Ulcers: Treatment according to the provided flow chart, distinguishing between specific etiologies.
- Vesicular Ulcers: Given the increased risk of HIV transmission, treatment for genital herpes is strongly recommended.
Management Protocol for Genital Ulcer Syndrome:
Multiple Painful Blisters or Vesicles (Likely Herpes):
- Administer Aciclovir 400 mg every 6 hours for 7 days.
- If RPR (Rapid Plasma Reagin) positive, add Benzathine penicillin 2.4 MU IM single dose (half in each buttock).
- In case of persistent lesions, repeat Acyclovir for an additional 7 days.
All Other Cases:
- Prescribe Ciprofloxacin 500 mg every 12 hours for 3 days.
- Add Benzathine penicillin 2.4 MU IM single dose (half in each buttock).
- For individuals with penicillin allergy, substitute with Erythromycin 500 mg every 6 hours for 14 days.
If Ulcer Persists Beyond 10 Days and Partner Was Treated:
- Add Erythromycin 500 mg every 6 hours for 7 days.
If Ulcer Still Persists:
- Refer the individual for specialist management.
Important Notes:
- A negative RPR does not exclude early syphilis.
- Genital ulcers may appear with enlarged and
- fluctuating inguinal lymph nodes (buboes). Do not incise buboes.
Other Components of STI Case Management:
In addition to antimicrobial therapy, comprehensive STI case management includes:
- Partner Notification and Treatment: Partners should be notified and treated, irrespective of symptoms.
- Preventive Measures: Emphasize preventive measures, including safe sexual practices and condom use.
- Health Education: Counsel and educate all clients on:
- The importance of treatment compliance and regular follow-ups.
- Condom use and provide condoms.
- Partner management.
- Offer or refer for HIV VCT services if necessary.
- Schedule a return visit if feasible.
- Abstaining from sex symptoms resolve.
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Abnormal Vaginal Discharge Syndrome
Abnormal Vaginal Discharge Syndrome
Abnormal vaginal discharge is defined as discharge that is different from usual with respect to colour/odour/consistency (e.g. discoloured or purulent or malodorous).
While all women experience physiological vaginal discharge, concerns arise when it is perceived as abnormal. This syndrome is primarily attributed to endogenous vaginal infections, such as bacterial vaginosis and vaginal candidiasis, which are not exclusively sexually transmitted.
Candida vaginitis and bacterial vaginosis are NOT sexually transmitted diseases, even though sexual activity is a risk factor.
Case Definition:
Abnormal vaginal discharge (indicated by amount, colour, and odour) with or without lower abdominal pain or specific risk factors.
Aetiology:
- Vaginitis and Vaginosis: Commonly caused by bacterial vaginosis(by Gardnerella vaginalis, Mycoplasma hominis), vulvovaginal candidiasis, and trichomoniasis.
- Cervicitis: Gonococcal and chlamydial infections contribute to cervicitis, which is often asymptomatic, and rarely a cause of abnormal vaginal discharge.
Clinical Presentation:
All women with vaginal discharge are treated for trichomoniasis, bacterial vaginosis, and candidiasis.
Increased Quantity of Discharge, Abnormal Color, and Odor:
- Lower abdominal pain, itching, and discomfort during sexual intercourse may be reported.
- Candida Albicans Vaginitis: Characterized by a very itchy, thick, or lumpy white discharge and red, inflamed vulva.
- Trichomonas Vaginalis: Presents with an itchy, greenish-yellow, frothy discharge accompanied by an offensive smell.
- Bacterial Vaginosis: Manifests as a thin discharge with a distinct fishy odour.
Specific Discharge Characteristics for Different Infections:
- Gonorrhoea-Induced Cervicitis: Rarely causes vaginitis. Presents with purulent, thin, mucoid, slightly yellow pus discharge devoid of smell and non-itchy.
- Chlamydia-Induced Cervicitis: May present with a non-itchy, thin, colourless discharge.
Note: Microscopy and speculum examination are recommended to rule out early lesions of cervical carcinoma.
Management:
Women with vaginal discharge should be managed according to the flow chart. The flow chart differentiates between candidiasis and other vaginal discharges.
However, all women with abnormal vaginal discharge are treated for bacterial vaginosis and trichomoniasis and candidiasis. At the moment, it is not possible in this country to identify women with cervicitis, and all women with a non- curd like discharge should be treated for cervicitis.
Management Protocol for Abnormal Vaginal Discharge Syndrome:
Initial Assessment:
- Conduct a thorough history and examine for genital ulcers and abdominal tenderness.
- Perform speculum examination to check for cervical lesions.
- Assess the risk for sexually transmitted diseases.
Lower Abdominal Tenderness with Sexual Activity:
- If lower abdominal tenderness is present and the individual is sexually active, treat as per Pelvic Inflammatory Disease (PID) guidelines.
Thick, Lumpy Discharge with Itching and Erythema/Excoriations (Likely Candida):
- Administer Clotrimazole pessaries 100 mg: Insert high in the vagina once daily before bedtime for 6 days or twice daily for 3 days.
- Alternatively, prescribe Fluconazole 200 mg tablets as a single oral dose.
- Consider Metronidazole 2 g stat dose if indicated.
Abundant/Smelly Discharge (Possible Trichomonas or Vaginosis):
- Prescribe Metronidazole 2 g stat dose.
Purulent Discharge, High STD Risk, or Previous Ineffective Treatment:
Treat for Gonorrhea, Chlamydia, and Trichomonas:
- Cefixime 400 mg stat or Ceftriaxone 1g IV stat.
- Doxycycline 100 mg 12 hourly for 7 days.
- Metronidazole 2 g stat dose.
- If pregnant, replace Doxycycline with Erythromycin 500 mg every 6 hours for 7 days or Azithromycin 1 g stat.
- Ensure partner treatment.
Persistent Discharge or Dysuria Despite Partner Treatment:
- Refer the individual for further management.
Key management points include:
Treatment for Vaginal Infections:
- All women are treated for bacterial vaginosis, trichomoniasis, and candidiasis.
- Identification of cervicitis is challenging; hence, all women with non-curd-like discharge are treated for cervicitis.
Promotion of Syndromic Management Package:
- Encourage adherence to comprehensive STI management, including partner treatment, preventive measures, and health education.
Communication:
- Explain the endogenous and recurrent nature of vaginitis to patients to prevent marital discord.
- Partners with urethral discharge should be treated for cervicitis.
Evaluation and Referral:
- Persistent abnormal vaginal discharge warrants evaluation to exclude cervical cancer.
- Speculum examination and referral for specialist management may be necessary.
Counsel and educate all clients on:
- Treatment compliance.
- Condom use and provide condoms.
- Partner management.
- Offer or refer for HIV VCT services if necessary.
- Schedule a return visit.
- Abstaining from sex till symptoms resolve.
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Urethral Discharge Syndrome
Urethral Discharge Syndrome
Urethral discharge syndrome is a prevalent sexually transmitted infection (STI) among men, marked by purulent urethral discharge, with or without dysuria.
The amount of discharge varies depending on the causative pathogens as well as prior antibiotic treatment.
Clinical Presentation:
- Chief Complaint: Patients with this syndrome often complain of a discharge from the urethra. Mucus or pus at the tip of the penis; staining underwear
- Symptoms: They may have symptoms of burning sensation while passing urine and frequency of micturition.
Physical Examination:
- Visual Inspection: Examination might reveal a purulent discharge from the urethra. If the discharge is not readily seen, it may be necessary to milk the penis and massage it forwards before the discharge becomes visible. If the discharge is copious, do not milk or squeeze the penis.
- Prepuce Examination: If the patient is not circumcised, you should examine with the foreskin retracted so that you ascertain whether the discharge is from the urethra or from beneath the prepuce.
- Discharge Characteristics: The discharge may range from frank pus to mucopurulent.
Case Definition: Urethral discharge in men with or without dysuria.
Causes (Common and Uncommon):
- Neisseria Gonorrhoeae and Chlamydia Trachomatis: This syndrome is commonly caused by Neisseria gonorrhoeae and Chlamydia trachomatis in over 98% of cases.
- Other Infectious Agents: Trichomonas vaginalis, Ureaplasma urealyticum, and Mycoplasma spp.
- Mixed Infections: Mixed infections especially of Neisseria gonorrhoeae and Chlamydia trachomatis occur
Management:
All male patients with urethral discharge should be managed according to the syndromic chart.
Medicines
- Ceftriaxone 250 mg IM or Cefixime 400 mg single dose plus Doxycycline 100 mg every 12 hours for 7 days
If partner is pregnant
- Substitute doxycycline with erythromycin 500 mg every 6 hours for 7 days or Azithromycin 1 g stat if available
Treatment Procedure:
Clinical Assessment:
- Obtain a comprehensive medical history and conduct a thorough examination of the client.
- If urethral discharge is not evident, perform urethral milking.
- Retract the prepuce (if applicable) and examine for ulcers.
Comprehensive Treatment:
- Treat both the patient and their sexual partners simultaneously.
- Provide counselling on abstinence or emphasize condom use to prevent further transmission.
Medication:
- Administer Ceftriaxone 250 mg intramuscularly (IM) or Cefixime 400 mg as a single dose.
- Prescribe Doxycycline 100 mg every 12 hours for a duration of 7 days.
For Pregnant Partners:
- If the partner is pregnant, substitute Doxycycline with Erythromycin 500 mg every 6 hours for 7 days.
- Alternatively, administer Azithromycin 1 g as a single stat dose if available.
Persistent Symptoms Despite Partner Treatment:
- Investigate for the presence of ulcers under the prepuce.
- If discharge or dysuria persists, repeat Doxycycline 100 mg every 12 hours for 7 days.
- Administer Metronidazole 2 g as a single dose.
If Partners Were Not Treated Initially:
- Restart the initial treatment regimen and ensure partners are treated simultaneously.
Comprehensive STD Case Management Package:
- Education: Emphasis on treatment compliance.
- Condom Promotion: Provision and demonstration of correct usage.
- Partner Notification: Treatment for partners, whether symptomatic or not.
- HIV VCT Services: Offer or refer when necessary.
Continued Persistence of Discharge:
- Administer Ceftriaxone 1 g IM.
- If symptoms persist, consider referral for specialist management.
Counsel and educate all clients on:
- Treatment compliance.
- Condom use and provide condoms.
- Partner management.
- Offer or refer for HIV VCT services if necessary.
- Schedule a return visit.
- Abstinence from sex till all symptoms have resolved.
Urethral Discharge Syndrome Read More »
Syndromic management of STI
Syndromic Approach
Syndromic approach to STI management is a method of diagnosing and treating sexually transmitted infections (STIs) based on the patient’s clinical signs and symptoms, rather than laboratory confirmation.
Instead of targeting a specific pathogen, healthcare providers address the symptoms and syndromes associated with various STIs.
It is very useful in settings where laboratory testing is limited or unavailable.
Advantages of using Syndromic Approach.
Improved Clinical Diagnosis:
- The syndromic approach can help to improve clinical diagnosis of STIs, as it allows healthcare providers to identify and treat STIs based on the patient’s symptoms and signs, even if laboratory testing is not available. This can help to reduce the number of misdiagnoses and ineffective treatments.
Ease of Learning for Primary Health Care Workers:
- The syndromic approach is easy for primary healthcare workers to learn, as it does not require specialized equipment or training. This makes it a feasible approach for use in resource-limited settings where laboratory testing may not be available.
Rapid diagnosis and treatment:
- The syndromic approach allows for rapid diagnosis and treatment of STIs, as it does not require waiting for laboratory results. This can help to prevent complications and reduce transmission of STIs.
Same-Visit Treatment for Symptomatic Patients:
- Symptomatic patients can receive immediate treatment during a single visit, eliminating the need for multiple visits for laboratory tests. This accelerates care and minimizes patient inconvenience.
Cost-effectiveness:
- The syndromic approach is more cost-effective than laboratory-based testing, as it does not require expensive equipment or reagents. This makes it a more sustainable approach for use in resource-limited settings.
Accessibility at Lower Health Units:
- Treatment is available at the initial point of contact with the healthcare system, extending STI management even to lower health units. Referrals are reserved for complex cases.
Preventive Partner Treatment:
- The syndromic approach includes the treatment of sexual partners, contributing to preventing reinfection and interrupting the transmission cycle.
Resource Efficiency:
- Resource utilization is optimized as the approach minimizes the demand for laboratory testing, making it suitable for resource-limited settings.
Increased access to treatment:
- The syndromic approach can help to increase access to treatment for STIs, as it allows healthcare providers to treat patients without having to wait for laboratory results. This is particularly important in settings where patients may have difficulty accessing laboratory services.
Disadvantages of using Syndromic Approach
Inadequate Care for Asymptomatic Individuals:
- The syndromic approach may overlook individuals with STDs who exhibit no symptoms, particularly asymptomatic women. This limitation hinders the identification and treatment of silent infections.
Overuse/Wastage of Medications:
- The syndromic approach can lead to wasting of drugs, as patients may be treated for STIs that they do not actually have. This can be a particular problem in settings where resources are limited.
Poor Predictive Value for Some Infections:
- Symptoms and signs, especially in women, may have limited predictive value for certain STIs, such as gonococcal and chlamydial infections. This can result in missed diagnoses and delayed appropriate treatment.
Risk of Antibiotic Resistance:
- Over reliance on syndromic treatment may contribute to antibiotic resistance, as broad-spectrum antibiotics are often used without targeting the specific pathogens causing the infection.
Challenges in Addressing Co-Infections:
- Co-infections with multiple pathogens may pose challenges as the syndromic approach focuses on a single syndrome, potentially missing the concurrent presence of different STIs such as Chlamydia or Gonorrhea, in individuals with genital ulcers who are also infected with genital herpes or syphilis. This can lead to inadequate treatment and potential complications.
Inefficacy for Viral Infections:
- The approach may be less effective for viral STIs, as antiviral medications may require specific identification of the viral agent, which the syndromic approach does not provide.
Potential for misdiagnosis:
- The syndromic approach may lead to misdiagnosis of STIs, as it is not always possible to accurately identify the specific STI causing the symptoms based on clinical signs and symptoms alone. This can lead to incorrect treatment and potential complications.
Inadequate care for asymptomatic patients:
- The syndromic approach does not adequately care for people with STIs who have no symptoms, especially women with STIs, as they are often asymptomatic. This can lead to untreated infections and potential complications.
NOTE:
RATIONALE OF SYNDROMIC APPROACH
Limited laboratory facilities:
- In many healthcare settings, particularly in resource-limited areas, laboratory facilities for STI testing may be limited or unavailable.
- The syndromic approach allows for the diagnosis and treatment of STIs based on clinical symptoms and signs, without the need for laboratory confirmation.
Multiple organisms causing STI syndromes:
- Most STI syndromes can be caused by more than one organism.
- For example, urethral discharge in men can be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis.
- The syndromic approach uses broad-spectrum antibiotics that are effective against a wide range of organisms, ensuring effective treatment even when the specific causative agent is unknown.
Delayed laboratory results:
- Even where laboratory facilities exist, test results may not be immediately available.
- Patients may be unlikely to return for their results and treatment, leading to delays in diagnosis and treatment and increased risk of transmission.
- The syndromic approach allows for immediate treatment, reducing the risk of complications and transmission.
Common occurrence of mixed infections:
- Mixed infections, where a patient is infected with more than one STI, are common.
- The syndromic approach uses broad-spectrum antibiotics that are effective against a range of organisms, increasing the likelihood of treating all infections.
Influence of self-medication and immunity on clinical picture:
- Self-medication and immunity can alter the clinical presentation of STIs, making it difficult to make a specific diagnosis based on symptoms alone.
- The syndromic approach provides a standardized treatment approach that is effective regardless of the specific causative organism or the influence of self-medication and immunity.
STD Syndromic Treatment Flow Charts (Algorithms)
Diagnosis and treatment flow charts formalizing the Syndromic approach have been developed. They provide health workers with step by step instructions to diagnose and treat STDs with recommended drugs.
STD syndromic treatment flow charts, also known as algorithms, offer several advantages in the diagnosis and management of sexually transmitted infections (STIs):
- Problem-oriented and improved clinical diagnosis: Algorithms are designed to focus on the specific symptoms and signs of STIs, guiding healthcare providers in making accurate diagnoses.
- Training tool for primary care providers: Algorithms serve as valuable training tools for primary care providers, including those with limited experience in STI management.
- Standardization of treatment: Algorithms promote the standardization of STI treatment across different healthcare settings and providers. This consistency ensures that patients receive appropriate and evidence-based treatment, reducing variations in care.
- Disease surveillance: Algorithms facilitate the collection of standard data on STI diagnoses and treatments. This information is important for disease surveillance, monitoring trends, and evaluating the effectiveness of STI control programs.
- Evaluation of training: Algorithms can be used to assess the effectiveness of STI training programs for healthcare providers. By comparing the diagnostic and treatment practices of providers before and after training, the impact of training interventions can be evaluated.
- Treatment in one visit: Algorithms enable the diagnosis and treatment of STIs in a single visit, improving patient convenience and reducing the risk of transmission. This is particularly important in settings where patients may have limited access to healthcare services or may be reluctant to return for multiple visits.
STI SYNDROMES
Commonest:
- Urethral discharge
- Abnormal vaginal/cervical discharge
- Genital ulcers
- Lower abdominal pain
- Enlarged groin lymph nodes (Bubo)
Others:
- Painful scrotal swelling
- Bartholin’s abscess
- Conjunctivitis with pus in newborn (ophthalmia neonatorum)
- Genital growth
- Inflammation of glans penis and prepuce (Balanitis)
- Acquired immunodeficiency syndrome
Syndromic management of STI Read More »
CHANCROID, BALANITIS & SYPHILIS
Chancroid(Soft Chancre)
Chancroid is a sexually transmitted infection that causes painful open sores, or chancroids, to develop in the genital area. It can also often cause the lymph nodes in the groin to swell and become painful.
Incubation period: 2-5 days.
Cause
Chancroid is a sexually transmitted infection (STI) caused by the bacteria Haemophilus ducreyi.
Risk Factors:
Contracting chancroid primarily occurs through direct contact with the open sores of an infected individual. Additional risk factors include:
- Unprotected sexual contact
- Multiple sexual partners
- Sexual engagement with sex workers
- Substance abuse
- Anal intercourse
- General sexual activity
- Residence in specific developing nations
- Rough intercourse
Signs and symptoms:
- A small, painful ulcer appears on the genital parts, known as a soft chancre.
- Enlargement and inflammation of the inguinal area with pus.
- Headache.
- Fever.
- Generalized malaise.
Treatment:
Timely medical intervention is crucial, usually involving a prescribed course of antibiotics. Recommended antibiotic therapies include:
- Azithromycin: 1 g orally once daily.
- Ceftriaxone: 250 mg intramuscular once daily.
- Ciprofloxacin: 500 mg orally twice daily for 3 days.
- Erythromycin base: 500 mg orally three times a day for 7 days.
- Completing the full antibiotic course is imperative to prevent chronic or untreated infections, which are more challenging to address. Follow-up assessments after 3 to 7 days may involve reevaluation, medication adherence checks, testing for other STIs, and consideration of antibiotic resistance in H. ducreyi strains.
Balanitis
Balanitis refers to the inflammation of the glans penis, a condition that can be influenced by various factors, with Candida being a common causative agent, and Trichomonas, though rare, also implicated.
Aetiology:
The primary causative agents for balanitis are fungal, with Candida being the commonest. In rare cases, Trichomonas may contribute to the inflammation.
Clinical Features:
- Discharge: Patients often present with noticeable discharge, indicating the presence of infection.
- Erythema: Redness and inflammation of the glans penis are common clinical features.
- Erosions: The presence of erosions on the glans further characterizes the inflammatory condition.
- Retractable Prepuce: The prepuce is retractable..
Management:
Effective management of balanitis involves an approach aimed at addressing the underlying infection and promoting genital hygiene.
- Fluconazole 200 mg Stat: A single, stat dose of Fluconazole is recommended to combat fungal infections effectively.
- Metronidazole 400 mg Every 12 Hours for 7 Days: The addition of Metronidazole, administered every 12 hours over a week, provides broad-spectrum coverage, particularly against certain anaerobic microorganisms.
- Hygiene Counselling: Patients are advised on proper genital hygiene practices to mitigate the risk of recurrent infections.
- Circumcision: Circumcision is suggested as part of the management plan, potentially reducing the risk of future episodes.
Follow-Up Measures:
In cases where the condition persists despite initial management:
- Partner Treatment: Ensuring the partner receives appropriate treatment to prevent potential reinfection and establish comprehensive care.
Syphilis:
Syphilis is an STI caused by the spirochete known as Treponema Pallidum, with an incubation period of 9-90 days.
Modes of transmission:
- Vertical transmission through mother to child during intrauterine life (transplacental).
- Direct contact with infected discharges.
- Sexually (unprotected sex) with infected persons.
Signs and symptoms:
Primary stage:
- Identified by the presence of painless sores or lesions, known as chancre, which disappears at the site of contact from the 10th to 90th day after initial exposure.
- The sore/chancre is firm, painless, superficial, ulcerated, and may persist for 4-6 weeks, healing spontaneously.
- Painless regional Lymphadenopathy may develop within 1-2 weeks after the appearance of the chancre. This stage may be missed since the sore is usually painless.
Secondary stage:
- Occurs about 1-6 months after the primary infection.
- Characterized by flu-like syndrome (mild pyrexia, headache, anorexia, and sometimes weight loss).
- Lymphadenopathy and the appearance of systemic reddish-pink rashes on the trunk, extremities, palms, soles of the feet, anus, and vagina.
- Flat-broad whitish lesions develop from the rash, known as Condylomata Lata.
- Grey-white patches on the tongue, soft palate, and throat, known as Snail Tracks.
- Loss of hair (alopecia) may occur.
- Serological tests are positive.
- This stage may last up to 9 months and is followed by a latent period where no clinical signs are present.
Latent period:
- A period of natural cure with no clinical presentations. Lesions disappear, and the patient feels perfectly well.
Tertiary stage:
- Affects the cardiovascular and nervous systems 1-10 years after initial infection.
- Without treatment, complications may include:
Swelling (gumma) on the skin, mucous membrane, and bones.
Ulceration of skin swellings resulting in chronic ulcers.
Spread to the cardiovascular system may lead to aortic aneurysm, aortic insufficiency, or coronary arteriosclerosis.
Spread to the nervous system may result in memory loss, confusion, mental disability, and general paralysis of the insane.
Joint degeneration, failing sight, and deafness may occur.
Diagnosis:
- VDRL (venereal disease research laboratory) test.
- RPR (rapid plasma reagent) test, which confirms the presence of the disease.
- Rahm test and Wasserman are some of the tests for syphilis.
Treatment:
- No penicillin resistance exhibited
- Benzyl benzathine penicillin 2.4 mu weekly 3-4 doses/Benzathine benzyl penicillin 2.4 mu once weekly for 3 weeks.
- Allergic patients will be treated with erythromycin 500mg orally 6 hourly for 2 weeks.
- All exposed sexual partners should be treated
- Treated patients need blood tests at 3-month intervals to ensure freedom from the bacterium
- To prevent birth defects and fetal death, all pregnant women are recommended to be tested for syphilis at the first prenatal visit
- Babies of mothers diagnosed with or showing signs of syphilis are given Benzathine penicillin 50,000 IU as a single dose into the lateral aspect of the thigh.
Education of clients:
- Drug compliance to ensure care and prevent resistance.
- Explanation of the risk of vertical transmission.
- Mandatory patient treatment.
- Partner counselling and testing for HIV.
- Abstinence during treatment or correct and consistent use of condoms.
Effects of untreated syphilis in pregnancy and childbirth:
- Mid-trimester abortion, usually after 20 weeks.
- Premature labour.
- Intrauterine foetal death.
- IUGR (Intrauterine Growth Restriction).
- Stillbirth, usually macerated.
- Congenital syphilis.
- Aortic aneurysm and insufficiency from spread to the cardiovascular system.
- Loss of memory, confusion, mental disability, and general paralysis of the insane.
- Coronary artery stenosis.
- Joint degeneration, failing sight, and deafness.
Basic Facts About STIs:
Sexually transmitted diseases (STDs) are infectious conditions caused by one or more microorganisms primarily transmitted from one infected person to another during unprotected sexual intercourse.
The following table provides a summary of the most common STDs, categorizing them based on their etiological grouping and highlighting their main clinical features.
Risk Factors for STI/STDs:
Risk factors contributing to the prevalence of STDs in Uganda encompass a range of influential elements. These include:
- Multiple Sexual Partners: Engaging with numerous sexual partners increases the risk of contracting and spreading STDs.
- Lack of and Inconsistent Condom Use: Inadequate or irregular use of condoms exposes individuals to heightened susceptibility to sexually transmitted infections.
- Lack of Circumcision in Men: Non-circumcision in men has been identified as a potential risk factor for the transmission of STDs.
- Alcohol/Drug Use: Alcohol consumption and drug use significantly impact sexual health. Regular alcohol use, especially in social contexts, may lead to less discerning choices in sexual partners, lower inhibitions, and hinder the negotiation and correct usage of condoms during sexual activities.
- Early Sexual Involvement by Younger Age Group: Premature engagement in sexual activities among younger age groups contributes to the prevalence of STDs.
- Socio-Cultural Factors, such as Early Marriage: Societal and cultural norms, including early marriage practices, can contribute to the spread of STDs.
- Economic Factors, Particularly Poverty: Economic challenges, notably poverty, can limit access to preventive measures and healthcare services, increasing vulnerability to STDs.
- Gender-Related Factors, Including Limited Negotiation Powers for Women: Gender dynamics, where women may have restricted negotiation powers concerning sexual matters, contribute to the risk of STD transmission.
- Legal and Human Rights Constraints, Stigma, and Discrimination: Legal prohibitions, human rights limitations, and the stigma associated with certain populations, such as sex workers, can affect interventions aimed at preventing and controlling STDs.
- Inequality in Access to Social and Health Services: Differences in accessing social and health services further increases the risk of STDs, creating a scenario where certain populations face increased vulnerability.
CHANCROID, BALANITIS & SYPHILIS Read More »
GONORRHOEA
GONORRHOEA
Gonorrhoea is a sexually transmitted infection caused by the Neisseria gonorrhoeae bacterium, which targets the mucous membranes of the reproductive tract.
In women, this includes the cervix, uterus, and fallopian tubes, while in both men and women, it affects the urethra. Additionally, Gonorrhea can impact other areas such as the mouth, throat, eyes, and rectum. Perinatal transmission from an infected mother to her child during delivery through the birth canal is also possible.
Incubation Period: 2 to 7 days
Signs and Symptoms:
In Men:
- Dysuria (painful urination).
- Genital sores.
- White, yellow, or green urethral discharge (usually appearing 1-4 days after infection).
- Testicular or scrotal pain.
- Burning sensation in the throat.
In Women:
- Dysuria.
- Yellowish-white (pus) vaginal discharge.
- Rectal discharge.
- Genital sores.
- Anal itching, soreness, or pain during oral sex.
- Painful bowel movements.
- Pharyngeal infection may cause a sore throat but is usually asymptomatic.
Complications:
Untreated gonorrhoea can lead to severe permanent problems in both men and women, increasing the risk of acquiring HIV, hepatitis B and C.
In Women:
- Pelvic inflammatory diseases (PIDs)
- Internal abscess and chronic pain
- Blockage of fallopian tubes
- Increased risk of ectopic pregnancy
- Infertility
- Urinary tract infections (UTI)
- Bartholin’s abscess
- Puerperal sepsis
- Ophthalmia neonatorum
In Men:
- Infertility
- Orchitis
- Spread to the blood causing disseminated gonococcal infections (DGI), usually characterized by arthritis and dermatitis
In Neonates:
- Ophthalmia neonatorum.
Note: In both sexes, the bacteria can enter the bloodstream, spreading throughout the body in approximately 2% of cases, causing fever, loss of appetite, arthritic pain, and potentially invading vital organs such as the heart, liver, and CNS.
Treatment:
- Ceftriaxone 250 mg in a single intramuscular dose.
- Azithromycin 1 g orally in a single dose.
- Doxycycline 100 mg orally twice a day.
- Erythromycin (500mg qid) in pregnancy
Alternative Treatment:
- Cefixime 400 mg in a single oral dose.
- Doxycycline 100 mg orally twice a day.
CHLAMYDIA
Chlamydia is a common sexually transmitted infection caused by Chlamydia trachomatis, a gram-negative bacterium.
It stands as the most frequently reported sexually transmitted disease. Most people with chlamydia do not show symptoms.
Mode of Transmission:
It is spread through unprotected sexual intercourse, whether vaginal or oral, with an infected person.
Signs and Symptoms:
In Women:
- Increased vaginal discharge.
- Vaginal bleeding.
- Bleeding between periods.
- Bleeding during and after sex.
- Lower abdominal pain (LAP).
- Burning pain during urination.
In Men:
- Watery discharge from the penis.
- Burning/itching around the penile tip.
- Frequent urination.
- Testicular pain.
Investigations:
- Vaginal swabs.
- Urethral swabs.
- Urinalysis.
Treatment:
- Azithromycin (Azithromax) 1g single dose.
- Erythromycin 500mg every 6 hours for 7 days.
- Levofloxacin (Levaquin) 500mg once daily for 7 days.
Complications:
- Pelvic inflammatory diseases (PIDs).
- Infertility.
- Ectopic pregnancy.
- Cervicitis.
- Arthritis.
- Bartholin’s abscess.
- Ophthalmia neonatorum.
PROTOZOA-TRICHOMONIASIS
Caused by Trichomonas vaginalis
- Incubation Period: Months to years
Symptoms:
- Yellowish froth and offensive vaginal discharge
- Dyspareunia
- Reddened erythematous mucosa
Diagnosis:
- Profuse, purulent malodorous discharge
- May be accompanied by vulvar pruritis
- Secretions may exudate from the vagina
- Severe cases → patchy vaginal edema and strawberry cervix
- pH >5
- Microscopy: motile trichomonads and increased leukocytes
- Clue cells may be present if bacterial vaginosis (BV) is present
- Whiff test may be positive
Treatment:
- Metronidazole 500mg TDS for 5/7
- Tinidazole, secnidazole, ornidazole pessaries can be used
- Nystatin and clotrimazole cream
- Drez V gel
- Flagyl gel is not effective
- The partner should be treated
Bacterial Vaginosis (BV)
Bacterial vaginosis, also known as vaginal bacteriosis, is the most common cause of vaginal infection for women of childbearing age.
It frequently develops after sexual intercourse with a new partner, and it is rare for a woman to have it if she has never had sexual intercourse.
Bacterial vaginosis (BV) also increases the risk of developing a sexually transmitted infection (STI). However, BV is not considered an STI.
Diagnosis:
- Fishy odour (especially after intercourse)
- Grey secretions
- Presence of clue cells
- pH >4.5
- Positive whiff test (adding KOH to the vaginal secretions will give a fishy odour)
Treatment:
- Flagyl 500 mg Po Bid for one week (95% cure)
- Flagyl 2g PO x1 (84% cure)
- Flagyl gel PV
- Clindamycin cream PV
- Clindamycin PO
- Treatment of the partner is not recommended.
Transmission:
- Penile-vaginal, oral-genital, oral-anal, or genital-anal contact
- Condoms provide some protection but don’t prevent transmission of viral infections on vulva, base of penis, scrotus, and other genital areas not covered by condoms
- HPV is most commonly transmitted by people who are asymptomatic
Genital Warts (Condylomata Accuminata):
Genital warts are a viral infection that develops in the genitals, perineum, and anus. In females, it rarely occurs in the vagina. They grow rapidly during pregnancy and regress in the puerperium. The infection may result in an offensive odour.
Diagnosis:
Based on the clinical findings of a soft chancre, a small painful ulcer that is irregular in shape.
Treatment:
- Application of 10% Podophyllin to the wart 2-3 times a week. Note: Podophyllin burns; therefore, the skin around it must be protected with the application of Vaseline.
- The medicine is washed after 4 hours of application.
- Cauterization is another alternative treatment in case of severe genital warts.
- The patient must be investigated for syphilis to rule out the Condylomata of the infection.
- Podophyllin is contraindicated in pregnancy, so treatment is usually delayed until after birth.
Genital Herpes (Herpes Simplex):
Genital herpes presents as small, painful blisters on the vulva, perineum, vagina, and/or the penis or perineum in males, caused by the herpes simplex virus.
Incubation period: 2-21 days.
Signs and symptoms:
- Small painful blisters that burst and leave small red painful wounds.
- Dysuria from irritation of urine.
- Pyrexia.
- Purulent vaginal discharge.
- Muscle pain and headache with the initial attack.
- Enlarged inguinal nodes that may be tender on touch.
Treatment:
- 5% Acyclovir cream application five times daily for 5 days or
- Acyclovir 200 mg orally five times daily for 5 days.
- Warm saline bath to relieve pain and prevent secondary infection.
- Treatment of the partner is important to prevent re-infection. Note: Pregnant women with active genital herpes at term usually undergo elective caesarean section to prevent the risk of infections to the baby.
Pelvic Inflammatory Diseases (PID):
PID is an infection of the upper genital tract (uterus, fallopian tubes, ovaries, and peritoneum), commonly resulting from STDs (gonorrhoea, Chlamydia).
Signs and symptoms:
- Fever.
- Abdominal pain and tenderness.
- Extreme excitation (tenderness of the vaginal fornices on moving the cervix).
Treatment:
- Metronidazole 400 mg-500 mg orally twice a day for 10 days, plus
- Azithromycin.
- Erythromycin or Cotrimoxazole given in sensitivity reaction.
Complications:
- Salpingitis.
- Infertility.
- Chronic abdominal and pelvic pain.
- Menstrual disorders.
- Dyspareunia.
Prevention:
- Safer sex practices.
- Fidelity in marriage.
- Avoiding promiscuity.
- Health education on STIs.
- Adequate detection and treatment of infected persons.
- Investigations and serological tests of pregnant mothers for adequate prompt treatment.
Basic Facts About STIs:
Sexually transmitted diseases (STDs) are infectious conditions caused by one or more microorganisms primarily transmitted from one infected person to another during unprotected sexual intercourse.
The following table provides a summary of the most common STDs, categorizing them based on their etiological grouping and highlighting their main clinical features.
Risk Factors for STI/STDs:
Risk factors contributing to the prevalence of STDs in Uganda encompass a range of influential elements. These include:
- Multiple Sexual Partners: Engaging with numerous sexual partners increases the risk of contracting and spreading STDs.
- Lack of and Inconsistent Condom Use: Inadequate or irregular use of condoms exposes individuals to heightened susceptibility to sexually transmitted infections.
- Lack of Circumcision in Men: Non-circumcision in men has been identified as a potential risk factor for the transmission of STDs.
- Alcohol/Drug Use: Alcohol consumption and drug use significantly impact sexual health. Regular alcohol use, especially in social contexts, may lead to less discerning choices in sexual partners, lower inhibitions, and hinder the negotiation and correct usage of condoms during sexual activities.
- Early Sexual Involvement by Younger Age Group: Premature engagement in sexual activities among younger age groups contributes to the prevalence of STDs.
- Socio-Cultural Factors, such as Early Marriage: Societal and cultural norms, including early marriage practices, can contribute to the spread of STDs.
- Economic Factors, Particularly Poverty: Economic challenges, notably poverty, can limit access to preventive measures and healthcare services, increasing vulnerability to STDs.
- Gender-Related Factors, Including Limited Negotiation Powers for Women: Gender dynamics, where women may have restricted negotiation powers concerning sexual matters, contribute to the risk of STD transmission.
- Legal and Human Rights Constraints, Stigma, and Discrimination: Legal prohibitions, human rights limitations, and the stigma associated with certain populations, such as sex workers, can affect interventions aimed at preventing and controlling STDs.
- Inequality in Access to Social and Health Services: Differences in accessing social and health services further increases the risk of STDs, creating a scenario where certain populations face increased vulnerability.