These  are  the  most  difficult  warts  to  remove.  Peel away the keratotic tissue and apply a concentrated phenol solution. Follow this with an application of  nitric  acid,  and  cover  it  with  a  salicylic  acid plaster and adhesive bandage. Repeat this treat- ment every 5 days; it normally takes from three to  seven  treatments  for  complete  resolution. Patients  may  be  referred  to  a  dermatologist  for other wart removal techniques, such as freezing and elect rosurgical or surgical excision. Impetigo This  is  a  superficial  staph  or  strep  skin infection. SYMPTOMS—Normally   lesions   consist   of small  pustules,  but  they  may  be  larger  with rupturing and crusting. The lesions may remain localized but are often autoinoculated over large areas.  It  is  most  commonly  found  in  children. Impetigo  may  appear  on  apparently  healthy  skin, but sometimes complicates other skin infections. TREATMENT—Topical   antibiotics   will normally result in prompt resolution. Gentle but thorough washing to remove any crust and debris should precede the application of ointment. If left untreated,  impetigo  may  result  in  cellulitis  or furunculosis.   These   complications   should   be treated with systemic antibiotics. Furuncles  and  Carbuncles A furuncle (boil) is an acute tender inflamma- tion around perifollicular areas that is caused by staphylococci. Carbuncles are goups of furuncles adjacent  to  one  another. SYMPTOMS—A  furuncle  has  a  single  core of necrotic tissue. The core exudes a purulent fluid and is most commonly found on the neck, axillae, and  buttocks.  These  lesions  are  extremely painful. A carbuncle has two or more cores with multiple  drainage  sites  and  deep  suppuration. There may be extensive sloughing of the tissues with   large   scar   formation.   A   fever   may   be present  and  the  patient  is  often  prostrated. Carbuncles  occur  more  frequently  in  men. TREATMENT—A  single  furuncle  should  be treated  with  moist  heat  to  facilitate  pointing. Once  it  has  pointed,  incise  and  attempt  to  remove the  central  core.  Implant  an  iodoform  pack  to promote  drainage  and  to  prevent  premature healing. Systemic antibiotics are indicated. Large furuncles and carbuncles require special care in debridement  to  avoid  spreading  the  infection. Refer  severe  cases  to  a  dermatologist. Cellulitis This is a spreading inflammation of the tissues, which usually affects the skin and subcutaneous tissues. Streptococcus and staphylococcus are the causative agents. SYMPTOMS—These  include  fever,  chills, malaise,  headache,  acute  pain  upon  palpation, and   swollen,   red,   and   warm   areas.   Regional lymphangitis  or  lymphadenitis  is  common.  Severe cases will often result in septicemia or bacteremia. TREATMENT—Place   the   affected   part   at rest  and  elevate.  Bed  rest  is  indicated  if  the condition  is  severe.  Apply  moist  heat  and administer  erythromycin  or  lincomycin  systemi- cally.  Continue  the  treatment  until  the  symptoms have  ceased  for  5  days. Folliculitis This  condition  is  the  result  of  a  staphylococcal infection  of  hair  follicles.  Sycosis  barbae  is  a chronic  and  recalcitrant  type  better  known  as barber’s itch. It appears in the bearded area and is aggravated by shaving. SYMPTOMS—Burning   and   itching   are common, and manipulation of hair causes pain. TREATMENT—Apply   hot   packs   to   the affected area. Apply topical antibiotics, and give systemic antibiotics if the areas around the eyes, nose,  or  mouth  are  involved  (dangerous  triangle). Tinea Capitis Ringworm of the scalp is a highly contagious fungal infection usually affecting school children. SYMPTOMS—It   is   characterized   by   small gray lesions in which the hair is broken off, scant, or without luster. It may involve all or a part of the scalp. TREATMENT—Griseofulvin   is   definitive   and 0.5  g  should  be  administered  twice  daily  with meals  for  4  to  8  weeks  or  a  single  dose  of  2  to 6 g repeated every 3 to 4 weeks. 2-26