The most common causative agents of the primary skin infections are the coagulase-positive micrococci (staphylococci) and the b-hemolytic streptococci. Superficial or deep bacterial lesions can be produced by these organisms.
In managing the pyodermas certain general principles of treatment must be initiated.
Improve the bathing habits: More frequent bathing and the use of bactericidal soap, such as Dial, is indicated. Any pustules or crusts should be removed during the bathing to facilitate penetration of the local medications.
General isolation procedures: Clothing and bedding should be changed frequently and cleaned. The patient should have a separate towel and washcloth.
Systemic drugs: The patient should be questioned regarding ingestion of drugs that can cause lesions that mimic or cause pyodermas, such as iodides, bromides, testosterone, corticosteroids, and lithium.
Diabetes: In chronic skin infections, particularly recurrent boils, diabetes should be ruled out by history and laboratory examination.
Immunosuppressed patients: A good history of abnormal laboratory tests should alert the physician to the many patients now who are on chemotherapy for cancer or are posttransplant patients or have the acquired immunodeficiency syndrome (AIDS).
Body piercing has been frequently associated with localized staphylococcal infection and pseudomonas infection and rarely bacteremia and endocarditis. Tuberculosis, hepatitis C and B, and even HIV may have been transmitted in this way. Noninfectious complications are keloids and allergic dermatitis. This fad should not be recommended, especially in tongue, lips, navels, nipples, and genitalia.
Figure 15-1. Impetigo of the face. The honey-colored crusts are typical. (Abner Kurtin, Folia Dermatologica, No. 2. Geigy Pharmaceuticals)
Impetigo is a common superficial bacterial infection seen most often in children. This is the "infantigo" every mother respects.
PRIMARY LESIONS. The lesions vary from small vesicles to large bullae that rupture and discharge a honey-colored serous liquid. New lesions can develop in a matter of hours.
SECONDARY LESIONS. Crusts form from the discharge and appear to be lightly stuck on the skin surface. When removed, a superficial erosion remains, which may be the only evidence of the disease. In debilitated infants the bullae may coalesce to form an exfoliative type of infection called Ritter's disease or pemphigus neonatorum.
DISTRIBUTION. The lesions occur most commonly on the face but may be anywhere.
CONTAGIOUSNESS. It is not unusual to see brothers or sisters of the patient and, rarely, the parents similarly infected. DIFFERENTIAL DIAGNOSIS
Contact dermatitis due to poison ivy or oak: Linear blisters; does not spread as rapidly; itches (see Chap.9).
Tinea of smooth skin: Fewer lesions; spread slowly; small vesicles in annular configuration, which is an unusual form for impetigo; fungi found on scraping (see Chap.
Bullous impetigo: In infants and rarely in adults, massive bullae (see Fig,15-4) can develop rapidly, particularly with staphylococcal infection. The severe form of this infection is known as the staphylococcal scalded skin syndrome, which is a type of toxic epidermal necrolysis (see Chap 22).
Figure 15-4. Carbuncle on the chin. Notice the multiple openings. (Abner Kurtin, Folia Dermatologica, No. 2. Geigy Pharmaceuticals)
1. Outline the general principles of treatment. Emphasize the removal of the crusts once or twice a day during bathing with an antibacterial soap such as Lever 2000, or chlorhexidine (Hibiclens) skin cleanser.
2. Mupirocin (Bactroban) or gentamicin (Garamycin) ointment or Polysporin ointment-q.s. 15.0 Sig: Apply t.i.d. locally.
1. I routinely add sulfur 5% and hydrocortisone 1% to 2% to the antibiotic cream or ointment for treatment of impetigo and other superficial pyodermas. Many patients with impetigo whom I see have been using a plain antibiotic salve with an oral antibiotic, and the impetigo persists. With this compound salve the impetigo heals.
2. Advise the patient that the local treatment should be continued for 5 days after the lesions apparently have disappeared to prevent recurrences—"therapy plus."
3. Systemic antibiotic therapy. Some physicians believe that every patient with impetigo should be treated with systemic antibiotic therapy to heal these lesions and also to prevent chronic glomerulonephritis. Erythromycin in appropriate dosages for 10 days would be effective in most cases. Resistance to erythromycin can occur, and then dicloxacillin or cephalexin is effective.
Ecthyma is another superficial bacterial infection, but it is seen less commonly and is deeper than impetigo. It is usually caused by b-hemolytic streptococci and occurs on the buttocks and the thighs of children.
PRIMARY LESION. A vesicle or vesiculopustule appears and rapidly changes into the secondary lesion.
SECONDARY LESION. This is a piled-up crust, 1 to 3 cm in diameter, overlying a superficial erosion or ulcer. In neglected cases scarring can occur as a result of extension of the infection into the dermis.
DISTRIBUTION. Most commonly the disease is seen on the posterior aspect of the thighs and the buttocks, from which areas it can spread. Ecthyma commonly follows the scratching of chigger bites.
AGE GROUP. Children are affected mainly.
CONTAGIOUSNESS. Ecthyma is rarely found in other members of the family. DIFFERENTIAL DIAGNOSIS
Psoriasis: Unusual in children; whitish, firmly attached scaly lesion, also in scalp, on knees, and elbows (see Chap 14)
Impetigo: Much smaller crusted lesions, not as deep (see preceding section) TREATMENT
1. The general principles of treatment are listed earlier in the chapter. The crusts must be removed daily. Response to therapy is slower than with impetigo, but the treatment is the same for both conditions.
2. Systemic antibiotics. Commonly with extensive ecthyma in children, but only rarely with impetigo, there is a low-grade fever and evidence of bacterial infection in other organs, such as the kidney. If so, one of the antibiotic syrups or tablets can be given orally q.i.d. for 10 days.
Folliculitis is a common pyogenic infection of the hair follicles, usually caused by coagulase-positive staphylococci. Seldom does a patient consult the physician for a single outbreak of folliculitis. The physician is consulted because of recurrent and chronic pustular lesions. The patient realizes that the present acute episode will clear with the help of nature but seeks the medicine and the advice that will prevent recurrences. For this reason the general principles of treatment listed earlier, particularly the drug history and the diabetes investigation, are important. Some physicians believe that a focus of infection in the teeth, tonsils, gallbladder, or genitourinary tract should be ruled out when pyodermas are recurrent.
The folliculitis may invade only the superficial part of the hair follicle, or it may extend down to the hair bulb. Many variously named clinical entities based on the location and the chronicity of the lesions have been carried down through the years. A few of these entities bear presentation here, but most are defined in the
The physician is rarely consulted for this minor problem, which is most commonly seen on the arms, the scalp, the face, and the buttocks of children and adults with the "acne-seborrhea complex." A history of excessive use of hair oils, bath oils, or suntan oils can often be obtained. The use of these oily agents should be avoided.
Folliculitis of the Scalp (Superficial Form)
A superficial form has the appellation acne necrotica miliaris. This is an annoying, pruritic, chronic, recurrent folliculitis of the scalp in adults. The scratching of the crusted lesions occupies the patient's evening hours.
1. Outline the general principles of treatment.
2. Selenium sulfide (Selsun, Head & Shoulders Intensive Treatment) suspension shampoo 120.0 Sig: Shampoo twice a week as directed on the label.
3. Antibiotic and corticosteroid cream mixture q.s. 15.0 Sig: Apply to scalp h.s.
Folliculitis of the Scalp (Deep Form)
The deep form of scalp folliculitis is called folliculitis decalvans. This is a chronic, slowly progressive folliculitis with an active border and scarred atrophic center. The end result, after years of progression, is patchy, scarred areas of alopecia, with eventual burning out of the inflammation. Cultures are negative.
Chronic discoid lupus erythematosus: Redness; enlarged hair follicles (see Chap,...25). Alopecia cicatrisata (pseudopelade of Brocq): Rare; no evidence of infection (see Chap.ni27).
Tinea of the scalp: It is important to culture the hair for fungi in any chronic infection of the scalp; Trichophyton tonsurans group can cause a subtle noninflammatory clinical picture (black dot tinea in children) (see Chap 19).
Excoriated folliculitis: Chronic thickened excoriated papules or nodules (can be called prurigo nodularis), usually seen on posterior scalp, posterior neck, anus, and legs. When allowed to heal, whitish scars remain. The infection can last for years. Liquid nitrogen applied to the papules is effective or intralesional corticosteroids.
Results of treatment are disappointing. The routine for the superficial form of folliculitis should be followed and oral antibiotics prescribed. Folliculitis of the Beard
This is the familiar "barber's itch," which in the days before antibiotics was very resistant to therapy. This bacterial infection of the hair follicles is spread rather rapidly by shaving, but after treatment is begun, shaving should be continued.
Contact dermatitis due to shaving lotions: History of new lotion applied; general redness of the area with some vesicles (see Chap 9).
Tinea of the beard: Very slowly spreading infection; hairs broken off; usually a deeper nodular type of inflammation; culture of hair produces fungi (see Chap 19).
Ingrown beard hairs (pseudofolliculitis barbae): Hair circling back into the skin with resultant chronic infection; a hereditary trait, especially in African-Americans. Close shaving aggravates the condition. Local antibiotics rarely help, but locally applied depilatories may help. Other local therapy to consider is Retin-A gel, and Benzashave. Growing a beard or mustache eliminates the problem. Hairs may also become ingrown in axillae, pubic area, or legs, especially when closely shaved in places with curly hair.
1. Outline the general principles of treatment, stressing the use of Dial or other antibacterial soap for washing of the face.
2. Shaving instructions:
a. Change the razor blade daily or sterilize the head of the electric razor by placing it in 70% alcohol for 1 hour.
b. Apply the following salve very lightly to the face before shaving and again after shaving. Do not shave closely.
3. Antibiotic and hydrocortisone cream mixture q.s. 15.0 Sig: Apply to face before shaving, after shaving, and at bedtime. Comment: For stubborn cases, add sulfur 5% to the cream.
4. Oral therapy with erythromycin, 250 mg
Sig: 1 capsule q.i.d. for 7 days, then 1 capsule b.i.d. for 7 days.
A stye is a deep folliculitis of the stiff eyelid hairs. A single lesion is treated with hotpacks of 1% boric acid solution and an ophthalmic antibiotic ointment. Recurrent lesions may be linked with the blepharitis of seborrheic dermatitis (dandruff). For this type, sulfacetamide ophthalmic ointment, or cleansing the eyelashes with Johnson's Baby Shampoo is indicated.
Figure 15-3. Multiple furuncles (boils) on the chest. (Abner Kurtin, Folia Dermatologica, No. 2. Geigy Pharmaceuticals)
A furuncle, or boil, is a more extensive infection of the hair follicle, usually due to Staphylococcus. A boil can occur in any person at any age, but certain predisposing factors account for most outbreaks. An important factor is the acne-seborrhea complex (oily skin, dark complexion, and history of acne and dandruff). Other factors include poor hygiene, diabetes, local skin trauma from friction of clothing, and maceration in obese persons. One boil usually does not bring the patient to the physician, but recurrent boils do.
Primary chancre-type diseases: See list in Djcti.onary—I.ndex. Multiple Lesions
Drug eruption from iodides or bromides: See Chapter^.. Hidradenitis suppurativa: See later in this chapter. TREATMENT
A young man has had recurrent boils for 6 months. He does not have diabetes, is not obese, is taking no drugs, and bathes daily. He now has a large boil on his buttocks.
1. Burow's solution hot packs.
Sig: 1 packet of Domeboro powder to 1 quart of hot water. Apply hot wet packs for 30 minutes twice a day.
2. Incision and drainage. This should be done only on "ripe" lesions where a necrotic white area appears at the top of the nodule. Drains are not necessary unless the lesion has extended deep enough to form a fluctuant abscess.
3. Oral antistaphylococcal penicillin, such as dicloxacillin or cephalexin, should be prescribed for 5 to 10 days. (Bacteriologic culture and sensitivity studies are helpful in determining which antibiotic to use.)
4. For recurrent form:
a. Outline general principles of treatment, use of an antibacterial soap.
b. Rule out focus of infection in teeth, tonsils, genitourinary tract, and so on.
c. Begin oral therapy with erythromycin, 250 mg, which is very effective in breaking the cycle of recurrent cases. Sig: 4 capsules a day for 4 days, then 1 capsule b.i.d. for weeks, until clear.
For Staphylococcus aureus resistant to erythromycin, penicillinase-resistant penicillins, cephalosporins, and azithromycin can be used.
Figure 15-5. Carbuncle on the back of the neck. (J. Lamar Callaway, Folia Dermatologica, No. 4. Geigy Pharmaceuticals)
A carbuncle is an extensive infection of several adjoining hair follicles that drains with multiple openings onto the skin surface. Fatal cases were not unusual in the preantibiotic days. A common location for a carbuncle is the posterior neck region. Large, ugly, criss-cross scars in this area in an older patient demonstrate the outdated treatment for this disease, namely, multiple bold incisions. Because a carbuncle is, in reality, a multiple furuncle, the same etiologic factors apply. Recurrences are uncommon.
Treatment is the same as that for a boil (see preceding section) but with greater emphasis on systemic antibiotic therapy. Sweat Gland Inflammations
Figure 15-6. Sweat gland inflammation of the axilla (hidradenitis suppurativa),
(Abner Kurtin, Folia Dermatologica, No. 2.
Although not true infections, inflammations of the sweat gland are included here because of similar clinical appearance and similar treatment.
Primary eccrine sweat gland or duct infections are very rare. However, prickly heat, a sweat-retention disease, frequently develops secondary bacterial infection. Primary apocrine gland inflammation is rather common. Two types of inflammation exist:
Apocrinitis denotes inflammation of a single apocrine gland, usually in the axilla, and is commonly associated with a change in deodorant. It responds to the therapy listed under furuncles. In addition, a lotion containing an antibiotic aids in keeping the area dry, such as an erythromycin solution (A/T/S, Erymax, EryDerm, Erycette, T-Stat, Staticin).
The second form of apocrine gland inflammation is hidradenitis suppurativa (Fig 15-6). This chronic, recurring, inflammation is characterized by the development of multiple nodules, abscesses, draining sinuses, and eventual hypertrophic bands of scars. The most common location is in the axillae, but it can also occur in the groin, perianal, submammary, and suprapubic regions. It does not occur before puberty. Etiologically, there appears to be a hereditary tendency in these patients toward occlusion of the follicular orifice, and subsequent retention of the secretory products. Two other diseases are related to hidradenitis suppurativa and may be present in the same patient: (1) a severe form of acne called acne conglobata and (2) dissecting cellulitis of the scalp.
The management of these cases is difficult. In addition to the general principles mentioned previously, one should use hot packs locally and an oral antibiotic for several weeks.
Plastic surgery or a marsupialization operation is indicated in severe cases. When draining canals or sinuses are present, the marsupialization operation is very curative and can be done in the office. After the bridge over the canal has been trimmed away, bleeding is controlled by electrosurgery. Etretinate (Accutane) can be tried for 5 to 10 months (see Chap.13).
Erysipelas is an uncommon b-hemolytic streptococcal infection of the subcutaneous tissue that produces a characteristic type of cellulitis, with fever and malaise.
Recurrences are frequent.
PRIMARY LESION. A red, warm, raised, brawny, sharply bordered plaque enlarges peripherally. Vesicles and bullae may form on the surface of the plaque. Multiple lesions of erysipelas are rare.
DISTRIBUTION. Most commonly lesions occur on the face and around the ears (following ear piercing), but no area is exempt. Some authors now think the legs are the most common site.
COURSE. When treated with systemic antibiotics, the response is rapid. Recurrences are common in the same location and may lead to lymphedema of that area, which eventually can become irreversible. The lip, the cheek, and the legs are particularly prone to this chronic change, which is called elephantiasis nostras.
SUBJECTIVE COMPLAINTS. Fever and general malaise can precede the development of the skin lesion and persist until therapy is instituted. Pain at the site of the infection can be severe.
Cellulitis: Lacks a sharp border; recurrences rare
Contact dermatitis: Sharp border absent; fever and malaise absent; eruption predominantly vesicular (see Chap, 9)
1. Institute bed rest and direct therapy toward reducing the fever. If the patient is hospitalized, semiisolation procedures should be initiated.
2. Give an appropriate systemic antibiotic, such as erythromycin or a penicillin derivative, for 10 days.
3. Apply local, cool, wet dressing, as necessary for comfort.
Figure 15-8. Bacterial infections of skin. (Burroughs Wellcome Co.)
Erythrasma is an uncommon bacterial infection of the skin that clinically resembles regular tinea or tinea versicolor. It affects the crural area, axillae, and webs of the toes with flat, hyperpigmented, fine, scaly patches. If the patient has not been using an antibacterial soap, these patches fluoresce a striking reddish orange under Wood's light. The causative agent is a diphtheroid organism called Corynebacterium minutissimum.
The most effective treatment is erythromycin, 250 mg, q.i.d. for 5 to 7 days. Locally the erythromycin lotions are quite effective ( e.g., Staticin, T-Stat, EryDerm, and A/T/S lotion). Apply twice daily for 10 days.
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