Aquatic Skin Disorders

Signs and Symptoms

• Skin erythema, urticarial papular pruritus

Treatment

• 1.

  Promptly wash with soap and water to remove toxins.

• 2.

  Treat a mild to moderate reaction with antihistamines and a topical medium-potency corticosteroid preparation ( Table 55.1 ).

  Table 55.1

  Potency Ranking of Topical Steroids

  POTENCY	BRAND	GENERIC	SIZES
  Super high	Temovate cream, ointment 0.05%;	Clobetasol propionate	15, 30, 45, 60 g
  	Psorcon ointment	Diflorasone diacetate	15, 30, 60 g
  Medium	Westcort cream 0.2%	Hydrocortisone valerate	15, 45, 60 g
  	Locoid cream 0.1%	Hydrocortisone butyrate	15, 45 g
  Low	Aclovate cream, ointment 0.05%	Alclometasone dipropionate	15, 45, 60 g
  	DesOwen cream, lotion 0.05%	Desonide	15, 60, 118 mL

  These topical steroids must be applied twice daily. However, the application rate can vary upwards to a maximum of three to four times per day according to the prescriber's discretion.

• 3.

  Treat a severe reaction with PO prednisone, 60 to 100 mg for adults and 1 mg/kg for children, with a 2-week taper.

Signs and Symptoms

• Skin erythema, pain, and pruritus

Treatment

• 1.

  Promptly wash with soap and water to remove toxins.

• 2.

  Treat a mild to moderate reaction with a topical low- or medium-potency corticosteroid preparation (see Table 55.1 ).

• 3.

  Treat a severe reaction with PO prednisone, 60 to 100 mg for adults and 1 mg/kg for children, with a 2-week taper.

Signs and Symptoms

• Irritation, first appearing on the hands and forearms (see Plate 43 )

• Recurrent exposures are more severe, characterized by vesiculated and edematous eruption of the hands, arms, legs, and face

Treatment

• 1.

  Treat as for mild poison oak dermatitis (see Chapter 40 ).

  • a.

    Depending on the severity of the reaction, apply calamine lotion or a topical medium- or high-potency corticosteroid preparation.

  • b.

    Give an oral antihistamine to help control itching.

• 2.

  Treat a severe reaction with PO prednisone, 60 to 100 mg for adults and 1 mg/kg for children, with a 2-week taper.

Signs and Symptoms

• In minutes to hours after exposure, a pruritic, burning, moist, and erythematous rash developing in bathing suit distribution, followed by bullous escharotic desquamation in the genital, perineal, and perianal regions (see Plate 44 )

• Lymphadenopathy, pustular folliculitis, and local infections

• Oral and ocular mucous membrane irritation, facial rash, conjunctivitis

Treatment

• 1.

  Wash the skin vigorously and copiously with soap and water to remove algal fragments.

• 2.

  Apply three sequential brief rinses with isopropyl alcohol 40%.

• 3.

  Apply a topical corticosteroid preparation. This may need to be medium to high potency.

• 4.

  Treat a severe reaction with PO prednisone, 60 to 100 mg for adults and 1 mg/kg for children, with a 2-week taper.

• 5.

  If necrosis is present, use sterile saline cleanses followed by white petroleum jelly or Hydrofera Blue bacteriostatic wound dressings.

Signs and Symptoms

• Superficial cutaneous lesions present as papulonodules or verrucous plaques with or without ulcerations. Bullous lesions or, rarely, eczematous and cellulitis-like lesions may occur (see Plate 45 )

• Olecranon bursitis, with or without spontaneous drainage. A history of preceding trauma should suggest protothecosis

• Systemic infection may occur, particularly in immunosuppressed persons

• A case of esophageal protothecosis has been reported

In cases associated with a traumatic episode, the initial lesion is a nodule or tender red papule, which enlarges, becomes pustular, and ulcerates. There may be a purulent, malodorous, and blood-tinged discharge. Satellite lesions surround the primary lesion and may become confluent. Regional lymph nodes may develop metastatic granulomas. Diagnosis is made by tissue biopsy or culture.

Treatment

• 1.

  Localized lesions can be excised.

• 2.

  Topical medications are unsatisfactory.

• 3.

  Prolonged treatment with algaecidal agents, including ketoconazole, itraconazole, fluconazole, and miconazole, may inhibit or kill the organisms. Amphotericin B has been used successfully.

Signs and Symptoms

• Begins as a pustule at the site of inoculation (see Plate 46 )

• Cellulitis and suppurative necrosis, usually of the lower extremities

• Can cause systemic arterial inflammation and occlusion

Treatment

Treatment is not well established. Antifungal medication, such as amphotericin B or itraconazole given for up to a year, has been attempted.

Signs and Symptoms

• Urticaria on exposure to water of any temperature

• Eruption usually confined to the neck, upper trunk, and arms; the face, hands, legs, and feet are spared. (see Plate 47 )

Treatment

• 1.

  Prevent or inhibit the reaction by applying petroleum ointment to the skin before water exposure.

• 2.

  Consider prophylaxis with an antihistamine 1 hour before exposure.

• 3.

  In persons with recurrent aquagenic urticaria, consider stanozolol 10 mg/day for symptom control.