IMPETIGO ECTHYMA FOLLICULITIS FURUNCLE Cellulitis

E: staph, strep, both (ULCERATIVE IMPETIGO) E: staph, candida, pseudomonas

Staphylococcus aureus – primary E: GABHS, staph, both Evolved from staphylococcal folliculitis
pathogen

NON-BULLOUS BULLOUS ulcer within an ulcer Inflammation of hair follicles characterized by: erythema, warmth, edema, pain,
tenderness
acute spreading infection of the dermis and the
Face Infants - indurated ulcer - painless or tender pustule that heals Nose, neck, face, axilla, buttocs (where there are subcutaneous tissue (mas malalim)
Intertiginous without scarring hair follicles or areas subject to friction)
- dirty yellowish gray crust - dirty yellow or gray with erythema  erythematous, hot, edematous,
Oozing Vesicles / Bullae Acute, deep seated, hot, very tender  very tender
lesion/thin on bland non - pruritus - pustule – ostium of hair follicle inflammatory nodule  vary in size
roofed vesicle inflammed skin - tenderness for weeks  borders are usually sharply defined, irregular,
increase in size - tight fitting jeans Hard nodule  fluctuant abscess with necrotic and slightly elevated
rapdly - very common among central plug  rupture  ulcer  lymphangitis
Dried collapsed school children
Honey colored roofs Folliculitis barbae Bright red indurated round plaque
crush cover the very - staph; shave
Sugar granular superficial lesions Hot tub dermatitis Predisposing factors: RISK FACTORS:
- pseudomonas aeroginosa  Chronic staph carrier – nares/perineum • diabetes mellitus
folliculitis ; trunk  Friction of collar/belts • hematologic malignancies
Periporitis Suppurativa  Obesity • IV drug use
- candida albicans; back  Bacterial defects • immunocompromise
 May complicate: • chronic lymphedema
Scabies
Pediculosis
abrasions
Gramstain: Incision and drainage of abscess There are 4 Clinical Presentations of Cellulitis:
gram (+) cocci in clusters - gramstain
- staph - culture
- antibiotic sensitivity
culture:
staphylococcus aureus blood culture
candida albicans - with fever
pseudomonas aeruginosa - with constitutional symptoms before
treatment
 Erysipelas H. Ecthyma Infectious
Influenza Gangrenos Gangrene
- Cellulitis um
Inflammat - < 3 y/o e:
ory form of P.
cellulitis aeoginosa - extensive
-lymphatic necrosis of
involveme - rapid SQ tissue
nt becomes and
(streaking) necrotic overlying
-more ulcer  skin
superficial -sites: leads to - rapidly
-sites: cheek ulcer progressiv
lower legs periorbital e
face head & usually:
ears neck most lower
umbilical common extremities
stump site in
areas of children easy to
pre- treat,
existing takes time
lymphede to heal
ma
Treatment on next page Treatment on next page Treatment on next page
Treatment on next page Treatment on next page

Simple furunculosis
Cloxacillin Removal of exciting agents - local application of heat, IND, no systemic
Gentamycin Dicloxacillin Topical antibiotics antibiotic
Mupirocin bactroban Erythromycin (for sensitive S. Systemic antibiotics - systemic antibiotic  risk of bacteremia or
Fusidic acid aureus) furunculosis with surrounding cellulitis or
fever (1-2 weeks)
Recurrent furunculosis
- diff to treat
- persistent staph at nares, perineum, body
folds
- should use germicidal soap; frequent bathing
- RIFAMPICIN + DICLOXACILLIN (7-10 days) plus
application of MUPIROCIN

Give prophylactic dose once a day to control no.

of organisms; continue antibiotics until all
lesions have resolved
mamaso bakokang pigsa
Without scarring With scarring Without scarring
 Tinea capitis Tinea Corpuris Tinea Pedis Tinea Cruris
Transmitted: - any ages - athlete’s foot - had had
direct contact – child to child - more common warm climates - anyone - more common in men
Cultured from objects – barber’s instruements, hairbrush, theater - buni - moist feet - jock itch
seats, hats - ring worm - excessive sweating - tinea of groin
Infected pet - occlusive footwear
Spores are shed in the air in the vicinity of the patient broad range of manifestations with lesions varying in: - friction/mall summer months
Direct contact from contaminated clothing - size after sweating
Isolate patients with proven infection - degree of inflammation Clinical patterns: wearing wet clothing
- depth of involvement - ringworm pattern
Most frequently occurs: prepubertal children - interdigital tinea pedis (toe web winter
Fever does not tend to resolve spontaneously at puberty infection) after wearing several layers of clothing
- plantar hyperkeratotic or mocassin-
High incidence in: urban areas, low socio, crowded type tinea pedis Predisposing:
- warm moist environment
Primary causative organism: Trichophyton tonsurans - men
- child – rare
Microsporum Canis
- still a major cause in some parts of US
- small spored ectothrix
Clinical presentations: Clinical presentation: Clinical presentation: Itching becomes worse as moisture accumulates
Macerates the intertriginous area
Asymptomatic – balakubak Pattern: Interdigital Tinea Pedis Bilateral and begin in crural fold
Kerion – parang may pigsa yung scalp and painful Round Annular Lesions - most common causative agent:
- INFLAMMATORY TINEA CAPITIS - classic ring worm T. Mentagrophytes Half moon shaped plaque formation
- severe inflammatory rxn with a boggy indurated tumor - flat, scaly spots - toe webs: itchy, burning, painful, Well defined scaling
like mass that exudes pus - raised border that extends out at variable malodor Vesicular border advance out of the crural fold
- represent hypersensitivity reaction to fungus rates in all direction - scaling and pealing w/o maceration onto the thigh
bacterial flora unchanged
Patterns of Invasion with active inflammatory border - with maceration Turns red brown less scaly  may develop red
 Small spored ectothrix - advancing scaly border may have red raised interaction of bacteria and fungus papules
 Large spored ectothrix papules or vesicles - dermatophytes initiates damage to the
 Large spored endothrix - central area becomes brown or stratum corneum Differentials:
hypopigmented - hands may be similarly affected Intertrigo
Arthrospores - rare to see both palms and soles - forms after moisture accumulates
- hyphae grow inside and fragment into the short segments there may be just one ring  resolves infected simultaneous - touch opposing skin surface
- large 6-10 mm LPO several annular lesions that enlarge  cover large - two feet one hand - groin, thing, axilla
- small 2-3 mm HPO areas of body surface - 2 hands one foot - red macerated half moon shaped plaque
- obesity
Endothrix pattern large lesions: Plantar Hyperkeratotic - mixed flora: bacteria fungi, yeast
- arthrospores remain inside the hairshaf - mildly itchy - T. rubrum - mixed triple combination
- asymp - Diminish immune response, inhibits
ectothrix pattern - may reach acertain size stratum corneum turnover Erythrasma
- arthrospores dislodge, obscure, penetrate the surface - remains for years with no tendency to resolve - Tibak - C. minutissimum
cuticle on the hair shaft surface and form a sheath of - clear central areas are yellow brown - bacterial infection
 closely packed spheres - borders are serpiginous Acute Vesicular (ring worm) - half moon shaped plaque
- acute form of infection - non inflammatory
Patterns of Invasion - often originates from chronic web - uniformly brown scaly
NON INFLAMMATORY BLACK DOT PATTERN infection - no advancing border
- most distinctive pattern - few or many vesicles evolve rapidly on - fluoresces coral red on wood’s light
- large areas of alopecia w/o inflammation the sole or dorsum of foot exam
- arthrospores weaken the hair  cause to break off at or - buni sa paa
below the scalp surface - vesicles may fuse into bullae
- black dot appearance of scalp - vesicles may remain as collections of
- hair long enough to be pulled are generally not infected fluid under the thick scale of the sole
- most of the time presents with: OCCIPITAL ADENOPATHY and never rupture thru surface
- 5% - secondary bacterial infection – eroded Prevent:
areas of bullae
INFLAMMATORY TINEA CAPITIS OR KERION - manage: Salicylic acid Boxer brief cotton
- multiple, inflammed, bogy, alopecial with pustules on or in
surrounding skin Dermatophytid or id reaction
fever, OCCIPITAL ADENOPATHY, leukocytosis, diffuse - second wave of vesicles in same sites
morbiliform rash or distant sites
- postive skin test FOR TRICHOPHYTON ANTIGEN - arms, chest, sides of fingers
- (-) culture
- (-) KOH
- 35%

SEBORRHEIC DERMATITS
- scaling on scalp with black dot pattern
- tiny perifollicular pustules or hair stubs that have broken
off – hindi nabunot, naputol lang yung buhok
- diffuse or patchy, fine, white, adherent scale
- usual site: glabella, nose, post auricular, chest, arms, back
- cultures often necessary
- 29% - (+) KOH

PUSTULAR TYPE
- butlig na may nana
- discrete pustules or scabbed areas without scaling or
significant hairloss
- suggest  bacterial infection
- may receive antibiotics before the correct dx is made
- (-) culture
- (-) KOH

Mgt:
Topical and oral antifungals Terbinafine
Griseofulvin Initially if there is inflammation  antifungal + - fungicidal
- 15mg/kg/day ultramicronized corticosteroid - more rapid response
- absorbed more efficiently with a fatty meal - higher cure rates
 - with ice cream or milk (Alaska) - persistent clearing

ketoconazole Flucanozole
- some children require larger doses - effective when taken
- can cause hepatic problems - once a week
- 150mg
Terbinafine
- dry noninflammatory tinea capitis
- 3 – 6 mg/kg/day

Itraconazole
- 3 – 5 mg/kg/day
 Tinea Ungium or onychomycosis
- tinea of nails
- may predispose as trauma
- “na murder”
- manicure
- infection of nail or nail beds with dermatophytes
T. rubrum
T. mentagrophytes

Others non pathogens:

T. violaceum
T. tonsurans
Aspergillus
Cephalosporium
Fusarium
Scopulariopsis

Patterns of Infection: Mgt. with recurrence

DISTAL SUBUNUAL ONYCHOMYCOSIS Terbunafyl or Lanisyl orally

- most common pattern of nail invasion
- fungi invade the hyponychium (distal area of nail bed)  16 weeks – fingernails
- turns yellows (distal nail plate) – proteolytic glycans
- onycholysis  nail separates from nail bed  20 weeks – toe nails

WHITE SUPERFICIAL ONYCHOMYCOSIS ketoconazole, miconazole and periungal areas – pulse therapy
- T. mentagrophytes
- Surface invasion of nail plates
- Soft dry powdery
- Easily scraped
- Absent oncholysis

PROXYMAL SUBUNGUAL ONYCHOMYCOSIS

- T. Rubrum
- Most common pattern seen with AIDS
- microorganisms enter the posterior nail fold cuticle area
- migrate to the underlying matrix
- finally invade the nail plate below
- surface remains intact
- hyperkeratotic debris accumulates and causes the nail to separate

CANDIDA ONYCHOMYCOSIS
 - Candida Albicans
- Seen in almost exclusively in CHRONIC MUCOCUTANEOUS CANDIDIASIS
- ALL FINGERNAILS
- Nail plate thickens
- Yellow brown in color

Other patterns:
Linear, yellow or dark brown streaks appear at the distal end and grow proximally
Some or all of the nail can be separated from the underlying nail bed
Common warts (verruca vulgaris)
Kulog
Begins as smooth, flesh colored
papules
Dome shaped gray brown
Hyperkeratotic growth – kumakapal
ibabaw
Useful dx sign: Black dots on surface
– thrombosed capillaries
Found:
Any skin surface
m/c – hand
Treatment:
Lactic acid + salicylic acid once a day
 slow
Topical salicylic acid 10 %
Standard procedure: electrocautery
Blunt dissection – for resistance or
very large lesions
Cryotherapy – liquid nitrogen
applied at the lesion  cause blister
formation  removal of blister
together with warts (extreme cold -
98 degrees)
Disadvantage: after healing new
lesions may be formed
Apply imikimod (Aldara) – usually for
extragenital warts, every other day
to increase local immunity and
prevent recurrence
Filiform and Digitate Wart Flat warts (Verruca Plana) Plantar warts (Verruca Plantaris) Periungual warts or Subungual
Fingerlike Pink, light brown, light yellow Thick painful callus forms in response to Warts next to the nails
Flesh colored projections Slightly elevated, flat topped papules pressure
emanating from a narrow or Foot is repositioned in walking – result to
broad base Vary in size = 0.1 – 0.3 cm distortion of posture, pain in other parts of foot,
leg or back
Spread in a linear distribution by scratching
Painful, lasting source of discomfort
Spread over a wide area following an abrasion Cluster of many warts that appear to fuse 
mosaic wart
Found typically:
Found: Forehead Diff dx: (see notes)
Mouth, eyes Around the mouth Corns (clavi), black heel, black warts Found:
Ala nasi Back of the hands
beard Shaved areas- legs, beard Found: Tips of fingers and toes
Plantar surface
Points of maximum pressure – metatarsal bones
or heels
Treatment: Treatment: Treatment: Treatment:
more resistant to both chemical and surgical
Easiest to treat Special therapeutic problem: Do not require therapy as long as they are methods of treatment than are warts in
- lengthy painless other areas
Curretage - may be resistant to treatment
- generally located in cosmetically impt areas Minimal discomfort – relieved by periodically Cryosurgery
Electrocautery where aggressice scarring procedures are to removing the callous with a blade of pumice - Small periungual warts respond to
be avoided stone conservative cryosurgery
Apply EMLA first at periorbital - Warts that extend under the nail
area tretinoin cream Painful warts must be treated do not respond
- if raccoon eye happens - moa: decrease intracellular adhesion  Techniques that does not cause scarring should - Aggressive cryosurgery over
(possible complication) exfoliation be used superficial nerves on the volar or
- ice pack - applied at bedtime lateral aspects of the proximal
- frequent application is subsequently Keratolytic treatment - phalanges or the fingers has
adjusted in order to produce a fine scaling - salicylic acid caused neuropathy
with mild erythema - conservative initial tx - Permanent nail changes may occur
- weeks or months - treatment is nonscarring if the nail matrix is frozen
- often not effective – given to patients - effective
apprehensive with electrocautery - requires persistent application of Cantharidin (Cantharone)
medication once each day for many - Cause blister formation at the
gold standard: electrocautery weeks - dermoepidermal junction
- Does not cause scarring
cryotherapy + liquid nitrogen may also be done blunt dissection Adverse effect
- surgical alternative · Postinflammatory
5 florouracil cream (efudex 5%) - fast hyperpigmentation
- once or twice a day for 3-5 weeks - effective · Painful blistering dissemination of
- may produce a dramatic clearing of flat - 90% cure rate warts to the area of blistering
watrs - nonscarring
- worth the attempt if other measures fails - superior to both electrodissection Keratolytic preparations
- se: persistent hyperpigmentation, warts may curettage and excision because normal - Salicylic acid
reappear in skin inflammed by 5-fu tissue is not disturbed - Lactic acid paint

chemotherapy
- acids have been successfully employed
to treat plantar warts

Imikimod (Aldara)
- to prevent recurrence
Formalin
- for resistant cases
- for mosaic warts or large involved areas
Lazerformaldehyde solution (10%
formaldehyde)
- Commercially available for direct
- application to warts risk of inducing
sensitization to formalin
Blunt dissection
§ When conventional measures fail
§ An excellent surgical alternative
A technique of unproven efficacy
§ May be worth attempting for children
when conservative approach is
desired
§ Completely cover the wart tip of the
finger is wrapped with tape
§ Tape remains over the place for 6
daysà removed à reapplied in a
similar manner 12 hours laterà
remains in place another 6 days

Cryosurgery
- May produce a deep, painful
blister and interfere with mobility
- Repeated light applications of
liquid nitrogen are preferred to
- aggressive treatment

Immunotherapy
- Has been reported to be very
successful for treatment of resistant
warts
· Dinitrochlorobenzene (DNCB)
· Diphenylcyclopropenone

Intralesional Bleomycin
- May be considered when all other
treatments fail