1. Healthy skin and Skin infections

3. Objectives  Introduction and background  Toi Te Ora goals and analysis  Serious skin infections  Key prevention messages and resources

4. Functions of skin  Skin is an amazing organ:  Covers and protects  Helps to maintain correct temperature  Sense of touch  Skin also protects against infections  However, the skin may become infected leading to serious health problems

5. Serious skin infections  Serious skin infections (SSI) are a significant cause of avoidable hospitalisations in NZ  SSI includes cellulitis, impetigo and abscesses  Can affect the blood, kidneys, bones, joints, lymph nodes and brain

6. Toi Te Ora – Public Health Service Goals

8. Reducing skin infections 3 key strategies: 1. Increasing community awareness 2. Increasing skills, capacity and responsiveness of health professionals 3. Improving responsiveness and effectiveness of primary and community health services

9. Area served by Toi Te Ora

10. Defining Serious Skin Infection “A child aged 0-14 years, admitted to hospital with a principal or additional diagnosis of serious skin infection, with a diagnosis code either within the ICD skin infection sub-chapter, or within the categories of skin infection of an atypical site or skin infection following primary skin disease or external trauma.” (O’Sullivan & Baker, 2010, p181)

11. Category A – Skin infections of typical sites L01.0, L01.1Impetigo L02.0 to L02.9 inclusiveCutaneous abscess, furuncle and carbuncle L03.01 to L03.9 inclusiveCellulitis L04.0 to L04.9 inclusiveAcute lymphadenitis L05.0Pilonidal cyst with abscess L08.0Pyoderma L08.1, L08.8, L08.9Other infections of skin and subcutaneous tissue Category B – Skin infections of atypical sites A46Erysipelas H00.0Hordeolum/cellulitis/abscess eyelid H60.0 to H60.3 inclusive, H62.0, H62.4Abscess/cellulitis external ear and infective otitis externa J34.0Abscess/cellulitis nose K61.0 Anal abscess/cellulitis (excludes rectal, ischiorectal or intersphincteric regions) H05.0Acute inflammation/cellulitis/abscess of orbit N48.2, N49.2, N49.9 Other inflammatory disorders of penis, scrotum and unspecified male genital organ(excludes deeper tissues) N76.4Abscess/cellulitis of vulva Category C – Skin infections secondary to primary disease of the skin B01.8Varicella with other complications B86Scabies L30.8,L30.9,L30.30 Dermatitis unspecified and other specified (eczema) and infective eczema Category D – Skin infections secondary to trauma S10.13, S10.83, S10.93, S20.13, S20.33, S20.43, S20.83, S30.83, S30.93, S40.83, S50.83, S60.83, S70.83, S80.83, S90.83, T00.9, T09.03, T11.08, T13.03, T14.03, T63.3, T63.4 Insect/spider bites T79.3Post-traumatic wound infection not elsewhere classified T89.01,T89.02Open wound infection with foreign body (+ infection) and open wound with infection

12. Data Analysis  Hospital discharge data were obtained from the Ministry of Health  The data included all children in New Zealand aged 0-14  The same filters that O’Sullivan and Baker (2011) used were applied to the data:  Day cases were removed – (discharge that had a length of stay of less than 1 day)  Transfers – any discharge data that was classified as a transfer was removed  Readmissions – discharges within 30 days of previous discharge with the same principle diagnosis were removed  Overseas visitors – Data for non-residents were removed from the dataset

13. Incidence of Serious Skin Infection

18. Incidence by Age

21. Incidence by Ethnicity

24. Incidence by Category

28. Incident Cases by CAU Census Area UnitDistrictPercentage Kawerau 6.6 Te Puke Community EastWestern BOP5.1 Whakatane NorthWhakatane4.5 Opotiki 4.3 Yatton ParkTauranga3.8 Whakatane WestWhakatane3.3 HairiniTauranga3.0 Gate PaTauranga2.8 TridentWhakatane2.8 Tauranga CentralTauranga2.7 MuruparaWhakatane2.3 GreertonTauranga2.1

29. Tip of the Iceberg  In Tairawhiti DHB it is estimated that for each incident case of serious skin there are a further 14 cases of skin infection seen in primary care (O’Sullivan, 2011)  It is likely to be a similar situation in Bay of Plenty DHB

30. Summary  Incidence of serious skin infection in Bay of Plenty DHB is higher than the incidence of New Zealand  Younger children are more likely to have a serious skin infection  There is a large inequality between Maori and Non-Maori  We can identify the census area units where a disproportionate number of the cases come from  Serious skin infection represents the tip of the iceberg

31. Common SSIs

32. Cellulitis  Cellulitis is an acute bacterial infection of the soft tissues of the skin. The infection spreads causing the skin and layers underneath to become red, swollen and tender

33. Cellulitis

34. Causes  Any area of skin can become infected if skin is broken, e.g. from a sore, insect bite, boil, rash, cut, burn or graze  Most common pathogens Staph.aureus, Strep.pyogenes, Group C and G strep

35. Management  Cellulitis is a serious infection that needs to be treated with antibiotics  Keep area elevated  Periorbital / severe cellulitis refer to hospital  Consider swab of moist lesion if high risk of recurrence or MRSA

36. Impetigo  Impetigo (or school sores) is characterised by small infectious blisters, which later develop a honey coloured scab like crust

37. Impetigo

38. Causes  May be caught from other person with impetigo or boils or may ‘appear out of the blue’  Often starts at sight of minor injury  Most common pathogens Strep.pyogenes, Staph.aureus

39. Management  Consider swab of moist lesion if risk of recurrence or complicated factors  Localised staph infections may be managed using wound care and antiseptics for local application  Routine use of topical antibiotics e.g. fucidic acid or mupirocin is not advised due to increasingly resistant forms of staph

40. Boils / abscess  Boils are a deep infection of the hair follicles and present as one or more tender red spots, lumps or pustules  An abscess is a cavity containing pus which may also have surrounding cellulitis of the skin and tissue  Staph aureus is common pathogen

41. Boil and infected scratch

42. Management  Swab at least one moist lesion  Localised infections can be managed with wound care (including I&D of large boils & abscesses)  Routine use of topical antibiotics e.g. fucidic acid or mupirocin is not advised due to increasingly resistant forms of staph  Use a/bs if fever, cellulitis or co-morbidity e.g. eczema

43. Scabies  Scabies is a skin infestation that can be passed easily between people  Caused by tiny mites  The mites burrow into the upper layers of the skin and lay eggs along the way  Small blisters, red spots and itchy red patches form on the skin above the burrows

44. Causes  Almost always acquired by skin to skin contact  Occasionally acquired by bedding or furnishing – as mite can survive few days off human host

45. Symptoms  Rash small areas of red, itchy bumps and blisters most often noticed:  Between the fingers  On the wrist  On the elbow  Around the waist  On the bottom and private parts  Can lead to secondary infection

46. Scabies

47. Treatment  Scabicides – chemical insecticides used to treat scabies  In NZ most common are:  5% Permethrin cream  0.5% Aqueous malathion lotion, left for 24 hours  See scabies fact sheet

48. Treatment and prevention  All people living in the household, and other close contacts, should be treated at the same time whether or not they have symptoms of scabies  On the same day as applying the treatment, all clothes worn against the skin in the last 3 days must be washed in hot water and dried

49. Bedding and towels  Sheets, pillowcases, towels and face-cloths should also be washed in hot water  It is not necessary to wash blankets, duvets or quilts, you can just hang them out in the sun for a day

50. Key prevention messages  Skin infections are preventable  If left untreated skin infections can lead to serious health problems  Serious skin infections are a major cause of avoidable hospitalisations in New Zealand

51. Healthy skin messages  Wash and dry hands with soap and water often  Keep skin clean with regular showers  Clean wounds and hands, Cut fingernails and Cover injuries

53. Healthy skin messages  Healthy food and adequate sleep is important for healthy skin  Skin infections often start with an insect bite – treat animals for fleas regularly  Wear clean clothes  Keep house clean inside and out  Wash sheets and towels regularly

55. Action messages  Families / whanau / individuals should be advised to seek medical attention if a sore or area of redness has any of the following features….

56. Action messages  Is greater than the size of a ten cent coin (approximately 1.5cm)  Increasing size  Has pus  Has red streaks coming from it  Is not getting better within two days  Is located close to the eye

59. www.healthshare.health.nz/public/skin-conditions- resources

60. Further information…  Healthy skin resources are available to download from :  http://www.ttophs.govt.nz/healthyskin_resourc es http://www.ttophs.govt.nz/healthyskin_resourc es  http://www.healthliteracy.org.nz/research- and-projects/ http://www.healthliteracy.org.nz/research- and-projects/  www.healthshare.health.nz/public/skin- conditions-resources www.healthshare.health.nz/public/skin- conditions-resources