The UK vaccination guidelines state that skin cleansing is not essential in socially clean patients. This report discusses a 69-year-old type 2 diabetic patient with a 4-week history of left shoulder pain with no precipitating factors other than a ‘flu vaccination without having had skin alcohol cleansing. She sustained a swollen left painful shoulder. Aspiration fluid grew Staphylococcus aureus and imaging confirmed diagnosis of septic arthritis. She underwent shoulder debridement and was started on antibiotics. Imaging 6 months later shows the sequelae of septic arthritis. The patient had ongoing stiffness and pain at 6 months. This report raises the question of whether there needs to be a revision of routine skin cleansing practice before vaccinations in certain groups of individuals.

Pruritis ani is defined as an intense itch in the peri-anal area. About 25% of individuals have no identifiable cause. It presents a diagnostic challenge, due to the multitude of causative factors, and is estimated to affect 5% of the population, more so men than women. Causative factors include faecal soilage and skin infections, however, malignant conditions such as Bowen’s disease have been implicated. It is important to take a thorough and focused history, as symptoms are often abated by removal of causative agents. Physical examination should not be limited to the peri-anal area, as clues may be garnered from peripheral manifestation of systemic conditions. Focus of management involves eliminating risk factors, improving peri-anal hygiene and encouraging compliance to treatment. Novel treatments include capsaicin cream and methylene blue.

Necrotising fasciitis is a severe, life-threatening and rapidly progressive soft tissue infection that often requires aggressive surgical management, with an estimated incidence of about 0.24–0.40 per 100 000 in the UK. Necrotising fasciitis can be classified based on its microbiology or the anatomy or body region affected. Initial signs of necrotising fasciitis can be minimal and non-specific but a patient often presents with pain out of proportion to clinical signs on examination, as well as erythema and oedema, in addition to systemic symptoms associated with sepsis. Diagnosis is often based on high clinical suspicion with biochemical and clinical imaging used as adjuncts. To aid with early diagnosis of necrotising fasciitis, a scoring system known as the Laboratory Risk Indicator for necrotising fasciitis was developed which has a positive predictive value of 92%. Once diagnosed, appropriate resuscitation and antibiotics, along with prompt and aggressive surgical debridement, is the mainstay of treatment.

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