Page 130 - 2022 Ranger Medic Handbook

Fungal Skin Infection
DEFINITION: Dermatophyte (tinea) infections are common worldwide and are common causes of tinea corporis, tinea
pedis, tinea cruris, and tinea capitis.
Tinea Corporis: A dermatophyte infection of the skin that occurs predominantly on the core (body surfaces other than
the feet, groin, face, scalp hair, and beard hair), also known as ringworm. Tinea corporis is typically acquired by skin-to-
skin contact. S/Sx: Initially: Pruritic, circular or oval, erythematous, scaling patch or plaque that spreads centrifugally.
An annular, raised border, plaque appears after a few days in a “ringed appearance.” Treatment: Apply terbinafine or
Itraconazole once to twice per day × 1–3 weeks.
Tinea Pedis: An infection of the skin that occurs on the feet (also known as athlete’s foot). Tinea pedis is typically
acquired by direct skin contact, usually from showers or locker rooms. S/Sx: Pruritus; erythematous erosions or scales
between toes, soles, medial, or lateral aspect of the foot. Treatment: Apply topical terbinafine 1% once to twice daily
× 4 weeks.
SECTION 3 Tinea Cruris: A dermatophyte infection of the skin that occurs in the crural fold (also known as jock itch). Tinea cruris is
typically associated with an active tinea pedis infection. S/Sx: Initially begins with an erythematous patch on the proxi-
mal medial thigh, then spreads centrifugally with slightly elevated erythematous, sharply demarcated borders with tiny
vesicles possibly present. The infection may spread to the perineum, gluteal cleft, buttocks, but sparing the scrotum in
males. Treatment: Apply terbinafine or Itraconazole once to twice per day × 1–3 weeks.
Tinea Capitis: A dermatophyte infection of the skin that occurs in the scalp. Tinea capitis is typically associated with
direct contact from an infected person or object (i.e., hat or comb). S/Sx: Pruritis and scaly patches present on scalp.
Treatment: Oral systemic antifungal therapy (griseofulvin, terbinafine, fluconazole, or itraconazole). Topical antifungal
creams are ineffective.
SPECIAL CONSIDERATIONS: Dermatophyte infections that do not resolve with topical antifungal creams should be
treated with oral systemic antifungals. Consult a medical provider for any dermatophyte infections that do not respond
to topical antifungal creams. A boggy, pustular area on the scalp (kerion) can develop secondary to tinea capitis. Do
not confuse with abscess and do not I&D. Treatment is oral antifungals in consultation with a medical provider. Note:
fungal infections can be complicated and diverse in nature, so consult a medical provider if you are unsure of the nature
of the infection.
Gastroenteritis
(Diarrhea/Nausea/Vomiting)
DEFINITION: Usually due to an acute viral infection of the GI tract, but bacteria or parasite infections are common in
deployed environments.
S/Sx: Acute onset of nausea, vomiting, and diarrhea; fever may or may not be present; abdominal cramping, discomfort,
or distension may or may not be present; possible S/Sx of dehydration.
MANAGEMENT:
1. If severe pain, rigid board-like abdomen, fever, and/or rebound tenderness develop, or moderate to large amounts of
blood are present in the stool, then treat per Abdominal Pain Protocol.
2. Treat per Nausea and Vomiting Protocol and/or Dehydration Protocol.
3. Either allow diarrhea to pass for 24 hours OR if diarrhea has already persisted for > 24 hours, then consider admin-
istering loperamide 4mg PO initially, then 2mg PO after every loose bowel movement with a maximum dose of 16mg
per day (do not use loperamide in the presence of fever or bloody stools).
4. If bloody diarrhea, fever > 100.4°F at onset/development or persists > 48 hours after initial treatment, azithromycin
500mg PO qd for 3 days or ciprofloxacin 500mg PO bid for 3–5 days.
5. Bloody diarrhea should remit within 2–3 days of starting antibiotics. Consider metronidazole 500mg PO tid for 5 days
if persist and consider advanced workup or evacuation.
DISPOSITION: Urgent evacuation if grossly bloody stools or circulatory compromise. Priority evacuation if dehydra-
tion occurs despite above therapy. Routine evacuation if diarrhea persists after 3 days of therapy or if it develops while
already on antibiotics.
SPECIAL CONSIDERATIONS:
1. Antibiotics are generally not needed for routine bacterial causes.
2. Emerging fluoroquinolone resistance among enteropathogenic E. Coli and Campylobacter and recent black box
warning makes azithromycin the new primary agent for therapy.
3. Consider antibiotic-related diarrhea if on antibiotics at onset.
4. Consider parasitic infection if symptoms persist for 3 or more days.
5. Must rule out malaria if fever and GI symptoms exist in a malarious area.
6. Azithromycin is considered treatment of choice for traveler’s diarrhea.
116 SECTION 3 TACTICAL MEDICAL EMERGENCY PROTOCOLS (TMEPs) & SICK CALL