INFECTIONS CAUSED BY BACTERIA!

Superficial Folliculitis
Infection of the hair follicle that causes a little pustule Treatment: oral antibiotics with good coverage for S. aureus

Usually S. aureus ; can also be gram negative, Pseudomonas species

Typically caused by occlusion, maceration of the skin
Shaving, plucking or waxing hair, use of topical corticosteroids, humidity,
atopic dermatitis and diabetes mellitus may contribute

Sycosis Barbae (Deep Folliculitis)

Same treatment
If using disposable razor blade, change those out

Typically caused by shaving and introduction of S. aureus into the

skin. Important to sanitize razors to avoid re-infection after treatment with
oral antibiotics

Hot Tub Folliculitis

Self controlled
No treatment, if impaired immunity, fluoroquinolone

Generally associated with history of soaking in a hot tub that has not been
appropriately cleaned
Most often caused by Pseudomonas species, sometimes Non-tuberculosis
Mycobacterium NTM

Furuncle (Boil)
Deep-seated inflammatory pustule based around a follicle, usually develops warm compresses to encourage drainage or incision and drainage
from folliculitis Oral antibiotics are also typically used, especially in any immuno-
Hot, red, swollen and very tender compromised patient
Consider culture of drainage

Almost always caused by S. aureus , commonly MRSA

Carbuncle
Larger more inflammatory nodule with deeper base, aggregate of multiple Incision and drainage, Oral antibiotics are also typically used, especially
infected follicles (furuncles) in any immuno-compromised patient
Usually drains through multiple openings Culture and sensitivities of purulent discharge helps aids with diagnosis
Almost always S. aureus MRSA common

Abscess (doesnt have to do with hair follicle)

Painful, tender, red, fluctuant soft tissue mass made up of a walled-off Treatment: Incision and drainage, oral antibiotics are also typically used,
collection of pus especially in any immuno-compromised patient
As opposed to a furuncle, an abscess is not necessarily based around a follicle

Almost always S. aureus, MRSA common

Impetigo
Bacterial infection of the superficial layers of the epidermis Culture of crust or fluid is helpful to identify bacteria and direct treatment
Often seen in kids For uncomplicated impetigo a topical antibiotic like bacitracin or
Non-bullous accounts for the majority (about 70%) and typically presents as mupirocin is effective
crusted lesions Oral therapy is directed against the two common causes: S. aureus and S.
Bullous impetigo presents as blisters filled with purulent material typically pyogenes
caused by S. aureus Cephalexin
Amoxicillin/Clavulanic acid
Clindamycin
Washing with antibiotic soap and scrubbing to de-roof crusts and bullae
can be helpful

Typically caused by S. aureus or S. pyogenes

Cover for both strep and staph

Ecthyma
Deeper form of impetigo, generally an extension of untreated Impetigo Warm compresses and same oral antibiotics as Impetigo treatment
Looks like a punched out ulcer with a necrotic base
Seen most commonly in patients with poor hygiene, (ie. homeless) or
immuno-compromised patients
Pathogens: Group A strep, S. aureus

Staph Scalded Skin Syndrome (SSSS)

Primarily affects infants and young children
Prodrome of staph infection typically of the nose, throat, mouth, GI tract, or
skin
Treatment is dependent on how widespread an area is
effected. Large areas of sloughing should be admitted to hospital
for IV antibiotics, fluids, monitoring. Severe cases often
transferred to burn units.
--lactamase-resistant antibiotics are mainstay of treatment
-Supportive care
-Mortality is 3% for infants, can be over 50% in adults

Caused by toxigenic strains of S. aureus

Bacteria produce exotoxins that are carried in the blood to distant sites,
causing skin to form blisters and slough superficial layers of epidermis

Hidradenitis suppurativa (Inversa)

Begins with occlusion of the hair follicle due to hyperkeratosis Surgical excision may be curative. Clindamycin often used as antibiotic
OVerkeratinization of hair follicle in intertriginous area treatment
The blocked follicle may become infected and form large painful abscesses
and sinus tracts that lead to scarring
Typically effected skin include axillae and intertriginous areas

Chronic, Recurrent

Erysipelas
anti-strep antibiotics (penicillin)
Superficial infection of upper dermis
Clinically appears as a well-demarcated, often shiny very red plaque
Local warmth and painful swelling, with well demarcated raised border
Classically involves the face or legs
Affects very young, elderly, or immuno-compromised
Often preceded by prodrome of fevers/chills, vomiting, headache
Taught, shiny looking appearance (Skin stretched like balloon)

Usually group A strep

Leukocytosis (20K or more)
 Cellulitis
Infection of dermis and subcutaneous tissue local skin care, elevation, systemic antibiotics orally if treated as outpatient,
Affected area usually painful, erythematous, edematous admission for IV antibiotics in more serious cases
Can have ill-defined, non-palpable borders
Generally forms at a break in the skin: bites, surgical procedures or injections,
etc.
Spreads, sometimes involved in lymphatics
S. aureus and group A strep predominate
Cellulitis w/ trauma or abcess most often S. aureus

Cellulitis from cat/ dog bite Pasteurella multocida

Polymicrobial infections can result
Treatment: Careful cleaning and broad spectrum antibiotics: Augmentin

Cellulitis in salt water Vibrio vulnificus

Cellulitis in fresh water or soil Aromonas hydrophilia

Gonococcemia
classic triad of dermatitis, migratory arthritis, tenosynovitis Culture mucous membranes/blood
Scattered necrotic pustules, often on distal extremities, most often hands and Treated with IM ceftriaxone (cephalosporin/antibiotic)
soles of feet. Described as gun metal gray
N. gonorrhoeae bacteremia not treated so it spreads to the skin; Up to 3% of pts
with mucosal gonorrhea will develop gonococcal bacteremia
Increased in patients with complement deficiencies, HIV, SLE

Syphilis
Chancre (Primary Stage)
Eroded, crusted papule appearing 18-21 days after infection
Occur on penis or labia, but also can affect cervix/vagina
Extragenital sites can occur
Usually painless (as opposed to ulcer which hurts)
May have local lymphadenopathy
Heals in 1-4 months without treatment
Secondary syphilis
80% have skin manifestations
Variety of skin lesions (Great Imitator)
Acral (palms/soles) surfaces often involved
Moth-eaten alopecia also possible (about 5%)
 Systemic involvement can include lymphadenopathy, neurologic
(Bells palsy), kidney, liver, or GI dysfunction
Tertiary syphilis
Occurs years after untreated primary disease
Only a minority of patients will progress to this stage (usually
remain latent following second stage)

Sexually transmitted disease caused by the spirochete, Treponema pallidum.

Increasing rates in recent years in the Southeast and certain urban US areas

SKIN CONDITIONS CAUSED BY VIRUSES!

Herpes Simplex
Infection occurs at mucosal surfaces or sites of abraded skin Diagnosis by history and clinical features typically
Characteristic small, grouped, painful, vesicles Preferred test is now by Polymerase chain reaction (PCR)
Tissue culture: still performed, but less sensitive than PCR
Tzanck prep: can be performed rapidly but with low sensitivity of only
about 40%
Fluorescent Antibodies lower sensitivity compared to viral culture

2 types: HSV-1 and HSV-2

HSV-1 causes oral-labial infections
58% of US population seropositive
HSV-2 causes 90% of genital herpes infection
16% of US population seropositive
High rate of transmission
Virus infects sensory and autonomic nerve endings

Virus is transported to nucleus of nerve cells where it may become dormant to reactivate later
Trauma, UV exposure, systemic illness

Contiguous spread and autoinoculation can occur

Acute Herpetic Gingiovostomatitis
First infection with HSV Resolves in 2 weeks
Only seen in approx 1% of infected people
Generally seen in children or young adults
Crops of painful, grouped, vesicles
May rupture to form erosions with crusts
Oral mucosa, hard/soft palate, tongue, lips
Fever, malaise, lymphadenopathy
 Recurrent Herpes Labialis
Recurrence of infection Heal completely within 10 days
Fever blisters and cold sores Antivirals (acyclovir, valacylovir, etc)
Outer portions of lips (usually spares oral cavity) Can be taken at prodrome onset, or daily for suppressive therapy
Can occur on hard palate
Prodrome: stinging, burning, tingling

Viral shedding stops after crusts form

40% have recurrences (average 2/year)

Primary Herpes Genitalis

Multiple erosions on external genitalia Healing complete in 2 to 3 weeks
Occur one week after exposure
Viral shedding ends around 11 days
Pain, itching, dysuria, inguinal adenopathy
90% women have cervical lesions
Only 57% of primary infections are symptomatic

Predominantly HSV-2

Recurrent Herpes Genitalis

Mild to moderate pain for 1 week Clears by 10 days
Decreased local symptoms Like oral-facial disease, can be treated with antivirals (intermittent or
Lesions cover 10% of original area suppressive therapy)
Cervical lesions are uncommon (12%)
Average recurrence rate: 4 per year

Varicella (Chickenpox)
Prodrome: fever, chills, malaise, headache Healthy children: calamine lotion, antihistamines, oatmeal baths
Rash begins on face and spreads to trunk Adults: Acyclovir because of high risk of complications
Thin-walled vesicles surrounded by erythema dew drops on rose petal Immunosuppressed: IV acyclovir, VZ immune globulin
Appear in crops; vesicles soon crust Prevention: VZV vaccine
Lesions in various stages of development
May affect mucous membranes

Complications

Secondary bacterial infection

Secondary bacterial pneumonia, otitis media, suppurative meningitis (rare)
More complications in adult patients, pregnant females and
immunocompromised
Congenital and neonatal varicella can be very serious

No longer contagious when lesions have ALL crusted over and no new
crops

Herpes Zoster (Shingles)

Reactivation of VZV (from primary infection or vaccine) from latent form Diagnosis: clinical, Tzanck, culture, immunofluorescence
Pain often precedes lesions
Unilateral, dermatomal, grouped vesicles Treatment: acyclovir (Zovirax), valacyclovir (VALTREX), famciclovir
Does not cross midline (FAMVIR)
50% occur in thoracic region
Crusting occurs in 7-10 days IV acyclovir for immunocompromised

Complications

Post-herpetic neuralgia (15-25%)

Dissemination occurs in 2 to 10% (immunosuppressed, HIV, malignancy)

Visual impairment (ophthalmic zoster)

Meningoencephalitis

Hand-Foot-Mouth Disease **
Thin-walled, gray vesicles Benign, self-limited viral disease
Tongue, palate, buccal mucosa, fingers, toes, palms, soles Resolves in 10 to 14 days; no treatment needed
Very Common!

Highly contagious; coxsackievirus A16, enterovirus 71

Herpangina
Painful and vesicular erosions of SOFT PALATE, uvula, pharnyx, tonsils and Benign, self-limited viral disease
buccal mucosa Resolves over one to two weeks, no treatment
Highly contagious, caused by Coxsackieviruses A, B and echoviruses
Spread via oral-fecal or respiratory routes

Posterior pharynx, herpes may be

entire mucosa, lips
SKIN INFCTIONS CAUSED BY FUNGI!
Sporotrichosis
Initially presents as a hard non-tender subcutaneous nodule that eventually Diagnosis is by fungal culture or antibody test
ulcerates Treatment with antifungals: Itraconazole, terbinafine for mild disease, IV
May spread through lymphatic drainage Amphotericin B for disseminated disease
Gardners! Prognosis is good for non disseminated disease
Disseminated disease is rare but may occur in immunocompromised patients
and spread to lungs, bone, joints, CNS system

Chronic fungal infection caused by Sporothrix schenkii

Worldwide in distribution
Inoculated into skin from contact with soil, decaying wood, often infected
while gardening. Especially found on rose thorns and twigs

Blastomycosis
Occurs most often in men engaged in outdoor activities Chest xray or CT may show airspace consolidation or masses
Chronic pulmonary infection most common presenting with cough, mild Diagnosis typically by culture of sputum or tissue
fever, dyspnea Treatment is Itraconazole for at least 2-3 months for localized disease
May become disseminated in immunocompromised patients Disseminated disease treated with Amphotericin B
Skin lesions are purple/gray wart-like friable lesions with heaped up borders Regular followup for years to detect relapse

Geographically seen in Canada, South central and Midwestern United States

Histoplasmosis
Most infections are mild and often asymptomatic Skin manifestations take Diagnosis can be made by serum and urine antigen tests
multiple forms, primarily on the face Treatment with Itraconazole for acute pulmonary histoplasmosis and
Symptomatic infections may present as flu-like illness of short duration or Amphotericin B for disseminated disease
progress to a severe pneumonia
Acute pulmonary histoplasmosis may last up to 6 months but is very rarely
fatal
Infection associated with areas with large amounts of bird or bat droppings
Infection occurs by inhalation of infective material
Immunocompromised patients, especially HIV patients with low CD4 counts
(<100 cells/mcL) may develop progressive disseminated Histoplasmosis
May involve rapid progression to multiple organ systems and rapid death
unless treated effectively

Coccidiomycosis
Symptoms of primary coccidiomycosis present in about 40% of patients as Primary coccidiomycosis often resolves with symptomatic treatment
respiratory disease with fever and chills Disseminated disease treated with anti-fungals but death rate still >50% in
Commonly causes arthralgia with periarticular swelling absence of rapid onset of appropriate therapy
May see erythema nodosum later in course
Causes asymptomatic papules that evolve to pustules, nodules, ulcers, draining
sinuses. Oral mucosa usually spared

Infection occurs by inhalation of mold contained in soil in endemic areas of

Southwestern US, Mexico, Central and South America
Disseminated disease occurs in 0.1% of white patients and 1% of non-white
patients
Any organ may be involved but pulmonary findings tend to become more
serious and lung abscesses may rupture
30-50% of disseminated disease results in meningitis

Cryptococcus neoformans
Skin manifestation is umbilicated skin or pink colored papules primarily of the
head and neck that mimics molluscum contagiosum

Most common cause of fungal meningitis

Infection occurs by inhalation
May remain confined to lung and heal, or disseminate to any organ BUT
meningitis predominates

Mycetoma
Chronic inflammatory reaction to chronic fungal infection, typically of the Treatment based on causative organism
feet in agricultural workers

Multiple possible fungal causes

Inoculated into the skin by a thorn or break in the skin
Endemic in tropical and subtropical areas