Integumentary Disorders: Diagnosis and Treatment

Unit 7: Integumentary Disorders

Terminal Learning Objectives

• Determine what exams and questions to ask to accurately identify the correct treatment plans for integumentary disorders

Enabling Learning Objectives

• Analyze facts and principles related to integumentary disorders
• Distinguish signs/symptoms/findings of common and life-threatening integumentary disorders
• Comprehend importance of patient interviewing to arrive at correct diagnosis
• Differentiate integumentary disorders
• Calculate treatment plans and patient education for integumentary disorders
• Appropriately identify red flags

Unit Overview

• Conditions discussed include: Fungal Infections, Intertrigo, Pityriasis Rosea, Acne Vulgaris, Rosacea, Impetigo, Erysipelas, Cellulitis, Furunculosis Folliculitis, and Pseudofolliculitis barbae (PFB)
• Also covers: Warts, Molluscum Contagiosum, Scabies, Pediculosis, Epidermal Inclusion Cyst, Actinic Keratosis, Squamous Cell Carcinoma, Basal Cell Carcinoma, and Malignant Melanoma

Important Integumentary Note

• Note, most diagnoses lack a description or pictorial representation of the various disorders for people of color
• Conduct a thorough and careful history and examination as presentations vary with all skin tones
• Skin exams will sensitive patient areas, be respectful

Skin Structure

• The skin has two layers called the Dermis and Epidermis
• The Epidermis has 5 cell layers and 3 cell types
• Keratinocytes provide strength and waterproofing
• Melanocytes provide pigment of epidermis and absorb/scatter UV radiation
• Langerhan's cells are macrophages
• The epidermis lacks blood vessels

Dermis Characteristics

• Functionally comprises fibrous connective tissues with nervous tissue and blood supply
• Hair follicles, nails, skin glands (eccrine & apocrine sweat glands), sensory receptors, blood vessels and smooth muscle fibers originate in the dermis

Subcutaneous Layer Traits

• Connects the skin to underlying organs
• Contains major blood vessels that supply skin
• There is no sharp boundary between it and dermis
• Insulates for thermoregulation which conserves body heat and keeps heat out

Skin Lesion Terminology

• Macule: Usually <1cm
• Patch: Usually >1cm
• Scale
• Papule
• Plaque
• Nodule
• Pustule
• Vesicle
• Bulla
• Wheal
• Crust
• Erosion
• Fissure
• Ulcer
• Hypertrophic Scar
• Keloid
• Excoriation
• Lichenification
• Cyst
• Milia
• Comedones
• Petechia
• Purpura
• Telangiectasia

Calluses and Corns

• Areas of hyperkeratosis occur at a site with high intermittent pressure or friction
• Calluses are generally superficial, often covering broad areas of skin lacking a central plug
• Corns are deeper lesions frequently painful or tender when pressure is applied

Signs and Symptoms for Calluses and Corns

• Thick superficial lesions are more likely calluses; extreme friction makes calluses become thick and irritated
• Deeper skin lesions are more likely corns, frequently painful and tender when pressure is applied

Focused History for Calluses and Corns

• Inquire about shoe type
• Check for poorly fitting military boots
• Assess activity level and note any recent changes

Physical Exam for Calluses and Corns

• Calluses lack a central plug and have a more even appearance
• After paring, calluses show smooth translucent skin
• Corns feature a keratinous plug, pea-sized or slightly larger, that extends through most of dermis
• Soft Corns: Form between toes
• Hard Corns: Over prominent bony protuberances
• Paring shows a sharply outlined yellowish to tan translucent core

Differential Diagnosis for Calluses and Corns

• Bunion: valgus deformity of great toe
• Metatarsalgia: pain on the plantar surface of 2nd and 3rd metatarsals
• Plantar wart: verrucous papule that may have pain with pressure
• Molluscum contagiosum: pearly umbilicated papules
• Furuncle: painful inflammatory swelling

Treatment for Calluses and Corns

• Clinic: Manual removal (paring) using a dermablade or scalpel to gradually shave off layers of hyperkeratotic tissue
• Home: Nail file, emery board, or pumice stone immediately after bathing to remove keratotic tissue
• Use of keratolytics like salicyclic acid
• Cushioning and altering foot biomechanics can help prevent corns and help existing corns
• Reduce the pressure of the affected surface by redistributing where possible, use pads rings, and moleskin to help
• Wear soft, well-fitting shoes where toes can move freely

Calluses and Corns: Follow Up Actions

• Return for further evaluation if symptoms do not improve within 1 month
• Green Directive: Routine Review by Preceptor IAW 44-103

Subungual Hematoma

• Occurs when blood becomes trapped between the nail plate and the nail bed

Subungual Hematoma: Signs and Symptoms

• Pain results from pressure in a confined space
• Possible eventual separation of and temporary loss of the nail plate

Subungual Hematoma: Focused History

• Trauma or injury history will provide vital information

Subungual Hematoma: Physical Exam

• Look for swelling, ecchymosis, and disruption of nail plate
• Blood may be visible under nail and the nail may be tender to palpation

Subungual Hematoma: Differential Diagnosis

• Fracture if trauma is suspected, x-ray is needed
• Subungual melanoma shows a pigmented nail, is painless, nail grows and spot doesn't move and no trauma history
• Subungual keratoacanthoma presents suddenly with pain, swelling, and inflammation without trauma history

Subungual Hematoma: Treatment

• Nail trephination can be used within 24-48 hours
• Create a hole in nail plate to permit blood escape with an 18-gauge needle in a rotary, drilling motion/electrocautery device
• Do not perform if nail is injured or deformed
• Video reference to watch is https://www.youtube.com/watch?v=o7zB0uHT_lc

Subungual Hematoma: Follow-up Actions

• Follow up for further evaluation if symptoms do not improve within 1-2 days
• Green Directive: Routine Review by Preceptor IAW 44-103

Ingrown Toenail

• Incurvation or impingement of a nail border into it's adjacent nail fold causes severe pain
• Causes can be excessive trimming of nail plate tight shoes, abnormal gait, bulbous toe shape or various congenital variations in nail countour
• Infection can eventually occur along the nail margin referred to as paronychia

Ingrown Toenail: Signs and Symptoms

• Pain can be felt along corner of the nail fold or less commonly the entire lateral margin.
• Discomfort initially is mild (especially with offending shows) but will increase over time

Ingrown Toenail: Focused History

• Note any shoes worn (ex: military boots)
• Activity Level
• History of nail trauma
• Nail trimming, either too short or rounded edges is a common cause

Ingrown Toenail: Physical Exam

• Assessment presents clear incurvation or impingement of a nail border into the adjacent nail fold

Ingrown Toenail: Differential Diagnosis

• Osteochondroma: Benign bone tumor common in young adults, X-rays are needed
• Paronychia: Infection of the periungual tissues that causes pain along the nail margin
• Amelanotic melanoma: occurs in older adults, granulation tissue surrounds toe
• Tinea unguium (onychomycosis): presents as lusterless, brittle, discolored, hypertrophic nails
• Bunion presents with valgus deformity of great toe

Ingrown Toenail: Treatment

• In mild cases, insert cotton between ingrown nail plate and painful fold using a thin instrument
• In more moderate development of infection, nail partial or occasionally total nail excision occurs
• For recurrent ingrown nails, consider destruction of adjacent nail matrix with phenol or trichloro-acetic acid, ask for preceptor guidance if you chose a permanent solution

Ingrown Toenail: Follow-Up Actions

• Wear well-fitting shoes, a larger toe box may help!
• Warm Epsom salt soaks may relieve some symptoms
• Proper nail trimming, cut straight across
• Change socks often if in the field environment
• Return for further evaluation if symptoms do not improve in one week or sooner if symptoms worsen
• Green Directive: Routine Review by Preceptor IAW 44-103

Paronychia: Cause and Onset

• Infection of tissues surrounding nail margin
• Causative organisms: Staphylococcus aureus or streptococci
• Organisms most often enter through a epidermal break causing inflammation, hangnail, trauma on the nail fold, loss of cuticle/ chronic irritation
• In toes, infection starts as an ingrown toenail

Paronychia: Signs and Symptoms

• Symptoms appear across margin of redness, swelling warmth and swelling
• Discharge usually develops across nail margin/sometimes beneath

Paronychia: Physical Exam

• Note, redness, swelling pain
• Possible discharge / pus
• Nail borders tender to palpation
• Gait abnormalities

Paronychia: Differential Diagnosis

• Felon: painful swollen pad of digit (“fingertip”), and often requires incision/drainage procedures
• Osteochondroma: benign bone tumor common in young adults, X-rays needed
• Amelanotic melanoma: occurs in older adults, granulation tissue is often seen surrounding toe
• Ingrown toenail: incurvation or impingement of nail border into adjacent nail fold
• Bunion: presents with valgus deformity of great toe

Paronychia: Treatment - Antibiotics, Drainage, and Potential for Infected Ingrown Toenail

• Antibiotics will often consist of dicloxacillin or cephalexin, some CA-MRSA (community acquired methicillin resistant S. Aureus) cases will call for use of trimethoprimsulfamethoxazole or doxycycline
• If the case has a fluctuant swelling or visible pus, drain with using with a #11 scalpel blade inserted between nail and nail fold. Skin incision is unnecessary
• For an infected ingrown toenail, nail excision is used

Paronychia: Follow-Up & Preventative Actions

• Warm compress and Epsom salt will likely help, initially.
• Return for further reevaluation of symptoms don't improve in 1 week or sooner, symptoms worsen
• Green Directive: Routine Review by Preceptor IAW 44-103

Urticaria

• Consists of migratory, well-circumscribed, erythematous, pruritic plaques on the skin
• Results from stimuli on an immunologic or nonimmunologic basis
• The most common immunologic mechanism is mediated by IgE
• Nonimmune-mediated mast cell activation by certain drugs, physical or emotional stimuli- mechanism is poorly understood
• Most incidents are acute and self-limited (1-2 weeks)
• Acute urticaria is often the result of food ingestion, infection, insect bite or sting, or medications.

Urticaria: Chronic vs Angioedema

• Chronic urticaria lasts more than 6 weeks, often autoimmune or idiopathic in orgin
• Angioedema may accompany urticaria
• Angioedema is the involvement of deeper subcutaneous tissue with swelling of the lips, eyelids, palms, soles, and genitalia.
• If the patient with angioedema involving lips, tongue, and mouth, immediately assess for signs of airway compromise

Urticaria & Angioedema: Signs & Symptoms

• Well demarcated
• Transient
• Often involving the dermis
• Red
• Varies in size
• Intensly pruritic
• Lasts <24hrs
  • often only 2-4 hours

Urticaria & Angioedema: Focused History

• Exposure history is key
  • Assess use of medications, food, and infections

Urticaria & Angioedema: Physcial Exam

• Swellings range from millimeters to centemeters
• The morphology of the lesion may vary over time, often resulting in bizarre or geographic patterns
• Dermatographism may also be present
• Wheal may appear after even small amounts of pressure to the skin
  • ie; scratching the skin

Urticaria: Differential Diagnosis

• Papular urticaria is often correlated with insect bites, with it's central component
• Those with hereditary angioedema have an extremely positive family history of gi or respiratory problems
• Urticarial vasculitis often presents as serum sickness or an extreme drug reaction
• Diffuse, symmetric, drug eruptions is associated with exposure to antibiotics such as anticonvulsants
• Cellulitis is a diffuse, spreading infection from dermis w/ subcutaneous tissue, w a smaller/localized area

Urticaria Treatment & Follow-up

• First generation antihistamines like hydroxyzine or diphenhydramine can be effective
• Second generation antihistamines should be used 1st line and be less sedating

H2-blockers as Adjunct Therapy

• H2 blockers like cimetidine can be utilized, systemetic corticosteroids are used in diffused areas with severe symptoms/with preceptor approval
• To note corticosteroids are not chronic urticaria
• Avoid all inciting factors such as hot air, food, stress, and drugs
• Track all episodes with a episode diary, for those with unknown factors
• Consistently maintain airway patency with frequent monitoring
• Return for further evaluation if no airway has been compromised in 1 day
• Blue Directive: Contact Preceptor Immediately

Drug Eruptions

• Presents as cutaneous drug reactions, typically have acute abrupt onset due to symmetric widespread erythematous reactions
• Rashes are most adversive and frequently are caused by antibiotics and other anti-convulsants
• Often caused by - Amoxicillin - Ampicillin - TMP-SMX

Drug Eruption: Intensity Factor

• Intensity ranges from little pigment changes to an exfoliative dermatitis or even toxic epidermal nercrolysis, which causes hospitilization and extensive blistering that has a great affect on the membranes

Drug Eruptions: Signs and Symptoms

• Simple drug eruption:
  • Often attributed from antibiotics
  • Has a component of diffuse exanthem (rash) with little constitutional symptoms
  • Complex drug eruption, often attributed from - sulfonamides - Allopurinol/anticonvulsants -Has a feverish constitutional that can present as a Arthralgia or malaise

Drug Eruptions: Physical Exam, Diagnosis,

• Assess any morbiliform or exanthematous that displays an exfloliative dermatitis
• Determine if there is angioedema and any vasculitis symptoms
• Be aware of Stevens-Johnson syndrome, which will require quick treatment, as the symptoms can be life threathening
• Key to diagnosis, check medication hystory prescription & OTC
• After any discontinuation, evaluate any additional issues, this helps to make sure that what's helping is working
• Rechallenge could cause danger so it may need to be avoided if other options are exhausted

Drug Eruptions: Differential Diagnoses

• Check for Angioedema and Urticaria that has diffused into a skin lesion with pruritic reactions
• In drug eruptions there may be papillae, which needs to be investigated
• Once a diagnosis is determined, stop offending agent

Drug Eruptions: Medication & Follow-up

• Anti-histamines can help with uritcarial effects
• Severe reactions can be stopped with EVAC and immediate transfer for treatment
• Add any past allergies to the patient allergy logs with the proper reactions
• Blue Directive: Contact Preceptor Immediately and monitor those symptoms, evaluate is symptoms persist after 48 hours or sooner

Contact Dermatitis

• Acute or chronic dermatitis from direct skin contact with irritants or allergens
• Types include Irritant Contact Dermatitis and Allergic Contact Dermatitis
• ICD is caused by non-immune-modulated irritation of the skin by a substance leading to skin changes
• ACD is a delayed hypersensitivity reaction in which a foreign substance comes into contact with the skin; skin changes occur with reexposure
• 80% of occupational contact dermatitis; highest among those with "wet work" exposures - food handlers, health care workers etc.
• Most common causes are poison /oak, topical antimicrobials, anesthetics, hair care products, jewelry (nickel), rubber, essential oils

Contact Dermatits: Signs and Sympthoms

• Irratant Contact Dermatitis: - Acute is more painful than pruritic - Possible erythema, scaling & edema to erosions, crusting+blistering - Chronic is more often pruritic
• Allergic Contact Dermatitis: - Pruritic rather then painful - Possible erythema, scaling & edema through vesiculation to severe swelling with billie
• Localisation: Suggest the cause, hair dyes, or shampoo for scalpe + Face creams, cosmetics for face wash

Contact Dermatitus: Focused History & Physical

• Occupational exposures, outdoor activities, or new body/hare products can help reveal cause
• Also asess household duties, cosmetics habits + clothing choices
• Physical:
  • Inspect if the skin is scaling, eruthmia, fissuring of scaling or crusting of the lesion
  • A linear streak pattern of the skin, suggest & allergic irratation cause by a type of plant

Contact Dermatits: Differentials

• The differentials could easily be similar to dermatitis, psoriasis, seborrheric eczema - Seborrheric is known to be frequent w greesey apperasing, as well as scaley and oily - Stapyplaccocal is known to cause a Atopic flare-up, which has weepy symptoms

Contact Dermatits: Treatment

• Prevent any irritation and prevent contact with any irratent
• Resoluation can occur from to 3 weeks , where your body will react to help
• Supportive Care- With cool compress-Oral antihistamines-Hydroxyzine: or diphenhydramine Medication: Mild moderate Contact Dermatitis- Topical Corticodserids Triamcinolone- (0.1%) Ointment use for localized area like the face

Contact Dermatits: Follow-Up

• Always promote protective clothing
• Contact/Avoidace
• Make sure to return for further evaluation - for about 3/5 days

Atopic Dermatitis Traits

• Eczema, a chronic relapsing inflammatory skin disorder with complex pathogenesis involves genetic susceptibility, immunologic and epidermal barrier dysfunction, and environmental factors
• Typically associated with a personal family family history of allergic issues

Diagnosing Atopic Dermatitis

• Pruritus (Itching)
• Dry Skin
• Typical morphology/distribution: Eczema, flexural lichenification
• Onset: Usually in Childhood/or Late Adulthood:
  • Chronically (Chronic)

Distinguishing Atopic Dermatitus

• Pruritic exutive infection of the face, hands, neck upper trunk, as well as popiteal folds
  • Flexural Elbows, Knees

Examining History

• Often those who suffer it often have an Atopic disease or have relatives that do that are know to have had
  • Asthma, allergic rhinitis etc

Examination

• Rough reddish amorphouse plaques
• Presentation in the dermis/or present colord pappules.visicles
• Dry leathery and infection

Differntials

• Similar traits can be confused that with that of Seborrheic

Atopic Dermatitis : Treatments

• Low potency coricosteriods- UseEmollient twice at the first initial use

Skin Care

• Use less warm heat
• Mild soap
• No excess exfoliation

Atopic dermatits: Follow-Up

• Always refer them properly

Seborrheic Dermatitis

• Inflammation of skin regions with a high density of sebaceous glands - face, scalp, upper trunk) - papulosquamous dermatitis - does not affect the extremities

Seborrheic Dermatitis: Symotons

Scaley and dry skin ,located in the face scalpe around upper trunk region Dry flakes that has variable Pruitius and that can be on the scalp, face, and upper trunk where it first started

Seborrheic Dermatitis: Examination

Yelllowish scales, with dry scale that overlie the Emythematic dermis

Seborrheic Dermatitis: treatment for areas

Location dictates how the affected area should be treated:

• Scalp: shampoo containing ketoconazole
• Face: anti-fungal cream, topical corticosteroids
• Non-hairy interiginous low potency steroid cream : Eyelid: margins need geantle shampoo use with a cotton swab

Seborrheic Dermatitis-follow up, recurrences and considerations

• Tendicy for long term, but is easily managable
• Do not use steroid creams
• Return is no improvement as there are many varibale complications

Tinea

• Tinea Corporis or Circumata ( Skin of Ring worms) Tinea Cruis-jook Itch Tinea Manum: Fundgus
• Tinea Pedis: Foot, Athletes Foot
• Tinea Versicolor- Putyruisis Versicolor
• Tinea Lungrum (Onchomycosis) Fingeonails infection

Tinea, Signs and Symptoms/Examinatin

• Tinea Coporis or Circumata: red/pigemnt annyluar patches for promitus
• Tinuea crusis: similar rash, for seveer scratching, especially from the scrotum
• Inspection of a rash is generally scaling or theickened

How Is Tinea Evaluated?

• Inspect the lesions on a direct upper side of the site

• Microscopic Analysis & Preparation

General Tinea Treatment Plans

Can lead systemic treatments if it is nails, and or excessive diseases

Tinea Versicolor- Aide by terbinafine , as well as positive liver enzyme

Tinea Follow Steps

• Most should have thier skin mointirized and should be kept dry Follow-up Actions: After the 2/4 weeks from that it requires a professional to do furuther analizing and more advanced diagnostic measures

Itertrigo

• Macerations in the fodls of the body, due to the heat & or skin and or friction
• Common Risks: - pooe hygiene - incontinence- hyperdydrosis signs and symptons: Hallmarked moist, red, patches with is present on the skin, as it is not there is no presnt testicle - pain and any bad smelling

Intertrigo (Treatment)

Drying Agents if NO: Bacteria or Yeast Detect

• Antipersperants - Aluminum Cholride Bacterial is present with yeast Severe Pruritus and Mid steroid cream = May Help : In the site
• Check for Hygiene
• Ases For recursiions and help, consider the weight of the patient if appropriate

Intertrigo-( Follow-up)

Follow if Evaluation - Symptoms dont imporve with 2 weeks from original, and will help prevent Green Dirtective: Review- IA 44/103

Pityriasis Rosea

• Mild inflammation: with an eruption that caused the virus, can be more common with adults
• 10 To 35 Common Age: as well as temperate to the climate
• 6/8 limited to itself

Pityriasis Rosea: S&S/History

• Herald Patch: May Precende 1/2 Wk - As wellas trunk or limps
• It may has a Mild P, 0 but is a severe itchy reaction
• History as a Prodrome

*Pityriasis Rosea: Exam/Treatments

• Physical Examination - Oval skin- as with a Dark Skin
  • Paper Appearnces Treatments
• Often require no treatment, is a symptomatic plan it should help with
• Oral AntiHistamine - for just symptoms

General Overview of Pityriasis Rosea

• Reassurance for after effects, will disrepair by 6/8 wks The Red Directive is for contact to Proctort

Acne Vulgaris

• Most is caused by all skin conditions
• Marked as comedomes , that are close to the comedomes
• Common is adolescence to the males that persist to be severe, but last longer in women

Acne Vugaris ( The 4 Main Factors)

: EXCESS SEBUM

• Follicular Plagging
• Colinzatoins
• Acner

4. Inflammatory Mediatores or Androgens

Acne Vulgaris S&S / EXAM

• With a Lesions With a mild and or pain , with areas that can be on the areas of the face, shoulders, chest, and or back
  • Skin Care
  • skin/medication

Acne vulgaris:Treatment, Follow-up and referrals

• Avoif manipulatation, as the skin can take up to many months to fade any damage marks
• Low Glymec, to have a great affect
• Refer if 3 montsh or worse it comes

Rosacea

• Characterization includes the common age 30/50 with fair complexion, though dark patients can be a problem
• Facial: flushing with facial telangiectasias
• Papules
• Pustures

Rosacea: Signs & Symptoms,

• Faces that are often in a uncomfortable state Heat, Alcohol, Spicy Food may cause a burning painfull sensation

Rosacea -Examination , Differentials- and Treatments

DURING EXAMINATION: With Normal Inspection , the pateint may have symptoms, so a telaguetas and pstules may be helpful during this - Differentials May Incoorpate - Lypus , Vulagrusa are to conndier , -Medication: metronazole, clindamycin with prescription - Minocycline or doxy for prescription help would be necessary at times

Intertrigo

• Avoid Long Exposures and long sun exposure.

Impletigo

• Honey-Colored - Superfical- Lesison - Infection to cause the skin
• Often due to Staphy/Strep
• Contagous/Can Affect Warm Climaytes - Risk with a stpahlococci carrier

Inpectgo (S7S)

• Lesions tend to invoile the face with extermities
• Low Pain-Pruritus- Mild Discomfort
• Paitnet Has history with contact of rash , history with staff

Implentgo(Differnticals)

With- Felon In mind - With The Amelanotic Cancer that Can be severe on the Dermtis

Paronychia: Treatment - Antibiotics, Drainage, and Potential for Infected Ingrown Toenail

• Antibiotics will often consist of dicloxacillin or cephalexin,
• Some CA-MRSA (community acquired methicillin resistant S. Aureus) cases will call for use of trimethoprimsulfamethoxazole or doxycycline
• If the case has a fluctuant swelling or visible pus, drain with using with a #11 scalpel blade inserted between nail and nail fold (Skin incision is unnecessary)

Cellulitis Traits

• Forms Dermal Lynphatic - With Step tococcici
• Shiny in the Lympha

Cellulitis: Examination

• Red Spot - Leading a Pliac Red Gais Malaise - High Temps: That may lead to Pain

Cellulitis: Distinctions

Differentials

Check for signs of the folloiwng

• C - Contact - Lypus
• C - Cellitsis
• D- Dermatist

Checkpoints that require a quick refer

• Pcn. Cephaluxen -Mssa = Ceohalcxin with rx aide
• Mrca - Doxy & Meds = Rx

Impending actions you need to keep in mind for Celluits

• • A key action to take is monitore for symptoms the spread

Follow Up For Cellulits

• Green Directive Follow Daily for symptoms
• Green Directive-Contact to help

###Furunucle

• Deep hair follicle
• Located: Neck/But/Face

Furunculs :

BoiL ( signs/ Symptons

• Pustles are eryhematis
• Underlyng may have to be enlarged Underlying Symptoms
• Red = Warmth/ Pain

Furuncls: differential / Rx

• Folliculitis is presnet
• Incison may requier Packing : For I&D
• For Any I&D- make sure systemmic Checklist:
• M R /sa 8.040/1

Incurvation/Impingemant - and Treatment

• Aides With-Hygiene

Scabies

• Infesations with Skin mites called scarcoptes scabiei
• Transmit though a close contact- that may cause - Human Host Primary Risks/Factiors- Crowed Long terms - That has a risk for adilts except infancts, the elderly - and or aids

Scabies: Signs and SYM,

• A History- Often contact within a living state -intense
  • Eremyts

-Burrows - For at end

Treatments -Klingi Erumits

• • Lice (Pediculisus :Also Known as Lice (Hair)- the Infesation by Lice . Paticulisus

Key Features - lice

• Body lice- Over Dwelling/Hygenic factos Pubic - Transmided in Adlits / Spread in close family

Lice: Differentials / Medication

: Differentials:

• Aids for a
• D - Dermo With: Cream - /With Aid From Lice

Lice: Prevention

• Often Use to wash all objects and items
• Make sure to follllow and continue actions