Who this guidance is for

This guidance is for clinicians and accommodation providers working with newly arrived migrants in England, in particular people seeking asylum who have arrived by small boat where there may be an increased risk of skin lesions compared to other arrival routes.

This guidance should be used in conjunction with Outbreak management in short term asylum seeker accommodation and the Migrant Health Guide. The Migrant Health Guide has more comprehensive advice and guidance on the health needs of migrant patients for healthcare practitioners.

Scope and purpose

The scope and purpose of this guidance is to:

• improve recognition of infections of public health importance presenting as skin lesions within a higher risk population
• enable prompt public health actions including appropriate infection prevention and control (IPC) measures to reduce risk to the public, including the prevention of onwards transmission and outbreaks

This guidance is not intended to give comprehensive management advice on all skin and soft tissue lesions. Important clinical features, IPC considerations and required public health actions for ulcers, rashes, and cellulitis with potential outbreak or public health risk are summarised in a table below.

Background

The UK Health Security Agency (UKHSA) has a remit to reduce harm from infectious diseases and other health security hazards, to promote more equitable health outcomes for all people present in the UK and to protect the public from infectious disease threats. Registered medical practitioners have a duty to notify their local UKHSA health protection team (HPT) when they suspect or diagnose certain notifiable infectious diseases to facilitate surveillance and public health action.

People arriving by small boat are more likely to present with skin lesions than migrants arriving to the UK by other routes. Skin lesions may be a sign of infection, underlying non-communicable disease or may relate to skin trauma, including chemical burns mixing with salt water (1). It is important to recognise clinical signs of infectious disease, both to ensure appropriate individual patient management and to prevent onward transmission. Diseases such as diphtheria which may present with skin lesions have potentially serious implications for the individual and wider public health (2, 3). Communal accommodation settings, where these individuals will be living upon arrival to the UK, are associated with increased risk of infection transmission (8).

People arriving by small boat may be at greater risk of developing skin lesions due to:

• lower vaccination rates
• travelling from or via countries with a higher prevalence of infectious diseases
• greater risk for exposure as a result of living and travelling in shared and potentially unsanitary conditions
• underlying chronic conditions exacerbated by prolonged poor access to healthcare and medications

Skin lesions can be challenging to assess, diagnose and manage, particularly as individuals may be in temporary accommodation or in transit where opportunities for diagnostic testing and follow up assessment may be limited.

Guidance for clinicians

Assessment

Clinical considerations

Detailed histories may be challenging due to time constraints and language barriers; use face-to-face interpreters or language line services. Record the following clinical information:

• location of lesion (be aware of the risk of genital lesions and ask about these)
• onset and duration of symptoms and signs
• presence of itch
• associated systemic conditions such as fever, malaise, or respiratory symptoms
• travel route and country of origin
• contact with other migrants with known infectious skin disease or with similar lesions

Skin lesions may present differently in different skin tones. Images used in routine textbooks often focus on pale skin, and if used solely, may bias recognition or increase stigmatisation. For examples of lesions on other skin tones see Mind the gap: a handbook of clinical signs in black and brown skin.

It is often impossible to identify the causes of skin lesions without diagnostic testing. Some individuals may be infected with multiple pathogens, and it is not always possible to determine a likely causative pathogen from clinical examination. Have a low threshold for swabbing any affected lesions so that appropriate culture-directed therapy can be given.

If a viral infection cause is suspected, and a positive diagnosis will impact management or notification, send a second swab in viral transport media. Give clinical details (including the likely differential diagnosis) on the request form. Include ‘asylum seeker’ or ‘asylum seeker accommodation’ where relevant, and whether the individual has had contact with a confirmed diphtheria case; this will help the laboratory in setting up the correct tests.

The most common causes of skin infections in people seeking asylum are group A Streptococcus (GAS) and Staphylococcus aureus. However, these infections can occur alongside scabies or diphtheria. Individuals may be colonised with multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta lactamase (ESBL) producing gram-negative bacteria (5, 6).

Individuals who have travelled by boat across the channel may also have some specific skin conditions related to travel, for example dermatitis and abrasions secondary to water and fuel exposure (7, 8).

Where a notifiable infection is suspected, clinicians should contact the local HPT. Table 1 summarises common clinical features and IPC considerations and required public health actions. The table does not list all lesions mentioned in this document.

The information below provides a summary of common presentations of skin lesions.

Cellulitis

This is an infection of the dermal and subcutaneous layers of the skin leading to red, hot, swollen, and painful skin. It is most commonly caused by GAS and Staphylococcus aureus.

If there is no clinical improvement with first-line therapy, consider alternative antibiotic therapies. Due to the high rates of MRSA infection in this population, there should be a low threshold for switching antimicrobial therapy. Contact a local hospital microbiologist for individual guidance.

Impetigo

Impetigo is a highly contagious blistering skin disease typically found on the face. Though normally a mild illness, impetigo has the potential to causes outbreaks in setting for newly arrived migrants due to overcrowded conditions. Advise people with suspected impetigo to cover their lesions where possible. People are considered infectious until lesions are crusted or healed, or 48 hours after starting antibiotic treatment or hydrogen peroxide cream.

Ulcers

There are a wide range of infections that may present as ulcers. The most common causes are Staphylococcus aureus and GAS. Non-healing ulcers should raise the suspicion of more unusual causes such as diphtheria, leishmaniasis, tropical ulcer, donovanosis or skin cancer. Consider onward referral to an infectious diseases or dermatology specialist for non-healing ulcers or any deep ulcer that probes to bone. Specialists will direct any further investigations needed.

Rashes

Depending on the presentation and accompanying symptoms, the differential diagnosis of rash in people seeking asylum includes scabies, measles, mumps, chickenpox, enterovirus, tinea and less commonly rubella or mpox.  Rashes that present in conjunction with a non-specific illness (for example, viral exanthem such as measles) need careful consideration of transmission risk, because early outbreak control may be needed. Suspected measles, mumps, diphtheria and rubella and mpox are all notifiable by registered medical practitioners.

Identification, clinical features and required actions for common pathogens causing skin lesions of public health importance (Table 1)

Cellulitis

Main features

Cellulitis makes skin painful, hot and swollen. The area usually looks red, but this may be less obvious on brown or black skin. Skin may also be blistered.

Practice points

• MRSA can co-exist with methicillin-susceptible Staphylococcus aureus (MSSA)
• there can be co-infection of skin lesions with GAS and MSSA/MRSA
• any invasive GAS should be managed in hospital setting

Mode of transmission

• contact
• droplet

Should you contact a health protection team (HPT)?

If in doubt, contact the HPT; iGAS is always notifiable

Infection prevention and control (IPC)

• gloves
• apron

Additional investigations

• wound swab
• contact local specialist if not responding to first line antibiotics or showing signs of systemic infection

Links

Group A Streptococcus: Information and guidance on group A streptococcal infections.

Chickenpox

Main features

There may be a prodromal illness, followed by crops of vesicles on the face and scalp, which spread to the trunk and eventually the limbs. The blisters are often intensely itchy. At any time there will be vesicles at different stages of formation.

Practice points

Secondary bacterial infection is a common complication.

Mode of transmission

• droplet
• airborne

Should you contact a health protection team (HPT)?

Yes; the organism is not notifiable, but due to outbreak potential in asylum seeker accommodation settings please notify local HPT.

Infection prevention and control (IPC)

• fluid repellent surgical mask (FRSM)
• gloves
• apron

Additional investigations

Clinical diagnosis; however swab confirmation may help in this setting where there are higher numbers of susceptible individuals.

Links

Chickenpox: public health management and guidance

Diphtheria

Main features

Small vesicles that quickly form small, clearly demarcated and sometimes multiple ulcers.

May be difficult to distinguish from impetigo.

Practice points

Individuals may have both respiratory and cutaneous symptoms.

Transfer people with suspected respiratory diphtheria to a hospital setting where additional IPC precautions will be required.

Mode of transmission

• pharyngeal contact
• pharyngeal droplet
• cutaneous contact

Should you contact a health protection team (HPT)?

Yes, urgently.

Infection prevention and control (IPC)

• fluid repellent surgical mask (FRSM)
• gloves
• apron
• eye protection while taking nose or throat swabs or when providing wound management if there is a splash risk

Additional investigations

Take nose and throat swabs in cases of cutaneous diphtheria to exclude respiratory carriage of toxigenic strains.

Links

Diphtheria: public health control and management in England

Measles

Main features

There may be a prodromal illness. After several days, a rash appears with large, flat blotches usually on the face and upper neck. It can spread, eventually reaching the hands and feet and lasts 5 to 6 days before fading.

Practice points

Measles is commonly confused with other infections that can lead to a rash.

Consider travel history and contact with other potential cases.

Mode of transmission

• droplet
• airborne

Measles is spread through coughing and sneezing, close personal contact, or direct contact with infected nasal or throat secretions.

Should you contact a health protection team (HPT)?

Yes, urgently.

Infection prevention and control (IPC)

• FFP3 or FRSM
• gloves
• apron
• eye protection if taking oral swab
• confirmed or suspected cases of measles should wear a FRSM if this can be tolerated

Additional investigations

Clinical diagnosis; however confirmation by oral fluid samples may help in this setting where there are higher numbers of susceptible individuals.

Links

• Measles: guidance, data and analysis
• Managing measles in asylum seeker accommodation settings

Mpox

Main features

There may be a prodromal illness. The rash (typically vesicular or ulcer or nodule) develops, often beginning on the face or genital area before spreading to other parts of the body, including the soles of the feet and palms of the hands.

Practice points

Consider travel history and consider migratory routes. If individuals have been in any of the countries affected by clade I mpox in the 21 days before symptom onset, discuss with imported fever service (IFS) as these patients may need to be managed as having a potential high consequence infectious disease (HCID).

See guidance on when to suspect a case of mpox for further information.

Mode of transmission

• contact
• droplet

Mpox is spread through direct contact with skin lesions or scabs, contact with bodily fluids such as saliva, snot or mucus, or contact with clothing or linens (such as bedding or towels) used by someone with mpox.

Should you contact a health protection team (HPT)?

Yes.

Infection prevention and control (IPC)

If clade is unknown, all cases meeting the HCID case definition should be managed as per an HCID case.

Additional investigations

Suspected cases must be discussed with local infection clinicians

See HCID status of mpox for further guidance.

Links

• Mpox (monkeypox)
• Mpox (monkeypox): guidance - GOV.UK (www.gov.uk)
• NHS England; Infection prevention and control measures for clinically suspected and confirmed cases of mpox in healthcare settings

Scabies

Main features

Intensely itching rash associated with burrows, nodules, and redness. The degree of redness may vary in different skin tones.

Practice points

Secondary bacterial infection is a common complication – burrows may be hidden by secondary bacterial infection.

Mode of transmission

Contact: transmission normally only occurs with prolonged direct contact with an affected person. However, scabies can be spread indirectly via the sharing of clothing, towels, or bedding.

Should you contact a health protection team (HPT)?

Yes – although the organism is not usually notifiable, due to outbreak potential in asylum seeker accommodation settings please notify local HPT.

Infection prevention and control (IPC)

• gloves
• apron

Additional investigations

Skin swab if suspect secondary bacterial infection.

Links

Guidance on the management of scabies cases and outbreaks in long-term care facilities and other closed settings

For more information, see IPC advice for health care settings.

Infection prevention and control considerations

Clinicians treating individuals with skin lesions need to be familiar with safe ways of working in relation to IPC to minimise the risk of transmission of infection. This includes appropriate use of personal protective equipment (PPE) and safe management of the environment. Clinicians should follow best practice regarding hand hygiene, including when removing PPE. Alcohol-based hand sanitiser can be used as an alternative to soap and water for visibly clean, dry hands when managing skin lesions.

When assessing skin and soft tissue infections, follow the PPE recommendations in the national IPC manual.  Appendix 11 of the National IPC manual outlines the transmission-based precautions required for a range of pathogens/diseases.

Important points for staff and providers of communal accommodation settings

Lesions should be covered with a clean dressing. Provider staff and residents should ensure that potentially infectious skin lesions are covered when in communal accommodation areas.

Providers should support residents with suspected infectious skin lesions to isolate in their room immediately. Where access to single rooms is limited, seek advice from the local HPT or infectious disease clinician as soon as possible. Advice to individuals, including the rationale for isolation, should be given using appropriate translating facilities.

Provide equipment and products for residents to clean their room and to bag laundry and waste. Residents should leave bagged laundry outside their room (this should be double bagged if sent to a commercial laundry).

Provide meals in the individual’s room and ensure the resident has their own individual crockery, utensils, linen, razors, and towels.

Undertake regular welfare checks and ask individuals about the development of new symptoms, which should be reassessed as appropriate.

Control measures

If any outbreak is suspected, notify the HPT immediately to seek advice on control measures, case management and prevention of further spread.

Staff are advised to see their own GP if they develop any skin conditions. They should seek urgent care if they develop symptoms suggestive of a systemic infection, including high fever. Any health and care worker exposure should be discussed with the HPT and managed on a case-by-case basis. All health and care staff involved in the care of recent arrivals should have their immunisation status reviewed and those with incomplete schedules should be brought up to date.

Additional restrictions may be required if staff working in asylum seeker accommodation are in a vulnerable risk group. If FFP3 respirators are indicated following local risk assessment, they should be fit checked at every use.

References

1. Pavli A and Maltezou H. ‘Health problems of newly arrived migrants and refugees in Europe’ Journal of Travel Medicine 2017: volume 24, issue 4, page tax016
2. Bartovic J, Padovese V and Pahlman K. ‘Addressing the challenges to skin health of refugees and migrants in the WHO European region’ Tropical Medicine and International Health 2021: volume 26, issue 5, pages 602-606
3. Chaves NJ and others. ‘The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline’ Medical Journal of Australia 2017: volume 206, issue 7, pages 310-315
4. UKHSA. The risk of infectious disease transmission posed by communal accommodation 2024
5. Eiset AH and Wejse C. ‘Review of infectious diseases in refugees and asylum seekers-current status and going forward’ Public Health Reviews 2017: volume 38, page 22
6. Angeletti S and others. ‘Unusual microorganisms and antimicrobial resistances in a group of Syrian migrants: Sentinel surveillance data from an asylum seekers centre in Italy’ Travel Medicine and Infectious Disease 2016: volume 14, issue 2, pages 115-22
7. Manfredi L and others. ‘Health status assessment of a population of asylum seekers in Northern Italy’ Globalization and Health 2022: volume 18, issue 1, page 57
8. Knapp AP, Rehmus W and Chang AY. ‘Skin diseases in displaced populations: a review of contributing factors, challenges, and approaches to care’ International Journal of Dermatology 2020: volume 59, issue 11, pages 1,299-1,311

Acknowledgements

The following guidance has been produced with UKHSA and external partners – with thanks to Dr Joyeeta Palit (UKHSA) and Dr Anna Riddell at Barts Health NHS Trust.