CUTANEOUS INFECTIONS

WARTS
- Aso known as verrucae
- Benign proliferation of the skin and mucosa that are caused by infection with papillomaviruses(PVs)
o Large family of small DNA viruses
o More than 200 types are now known, and entire genomes of about 100 are completely sequenced
- Induce a slow, focal expansion of epithelial cells
- Lesions may remain subclinical for long periods or may grow to large fulminating masses that persist for months or even
years
- Incubation period: 3-4 months (range: 1 month to 2 years)
- Clinical manifestations depend on the HPV type, size of inoculation, immune status of the host, and anatomic site
- Patients with impaired cell-mediated immunity are particularly susceptible to persistent HPV infection -> resistant to
treatment

Types of warts
1. Common warts (verruca vulgaris)
2. Plantar and palmar warts (verruca plantaris and palmaris)
3. Flat warts (verruca plana)
4. Filiform warts
5. Epidermodysplasia verruciformis

History
- Newly acquired, slowly expanding, persistent, often scaly lesion of the skin
- Appearance of additional nearby lesions over several weeks to months

Common warts (Verruca Vulgaris)

- HPV type 2 and 4
- Scaly, rough, spiny papules or nodules that can be found on any cutaneous surface (fingers, dorsum of the hands,
paronychial areas, face, knees, elbows)
- Often occur as single or grouped papules on the hands and fingers

Plantar and palmar warts

- HPV type 1
- Thick endophytic and hyperkeratotic papules, which may be painful with pressure
- Sharply demarcated with a ring of thick callus
- Mosaic warts result from coalescence of plantar or palmar warts into large plaques
- Punctuate black dots (“seeds”) that become evident after shaving away of the outer keratinous surface represent
thrombosed capillaries in the papilloma

Flat warts (verruca plana)

- HPV type 3 and 10
- 1-4mm, slightly elevated, flat-topped papules that have minimal scale, velvety, non-verrucous surface; pink to brown
in color
- Most frequent on the face, hands, and lower legs
- Distribution of several lesions along a line of cutaneous trauma is a helpful diagnostic feature
- Often spread by shaving

Filiform warts
- Most commonly seen on the face, neck, and skinfolds
- Papillomatous lesions on a narrow base

Epidermodysplasia verruciformis
- HPV types 5 and 8
- Manifests in childhood with persistent and often widespread warts that do not regress due to unique susceptibility to
specific HPV types
- AR
- Warts progress to squamous cell CA in 10% of patients
 - Lesions typically have either the appearance of flat, scaly, re-brown macules that resemble lesions of pityriasis
versicolor

Histology
- Various types share the basic changes of hyperplasia of the epidermal cells and vacuolation of the spinous keratinocytes,
which may contain basophilic intranuclear inclusions (viral particles)
- Warts are confined to the epidermis only

Diagnosis
- History and PE
- Confirmation by histologic examination

Treatment
- With all types of treatment, recurrences are frequent
- Majority of warts resolve spontaneously within 1-2 years
- Most treatments involve physical destruction of the affected cells
- Existence of multiple treatment modalities: not one is uniformly effective or directly antiviral

*cutaneous HPVs
- cryotherapy with liquid nitrogen pulsed dye laser
- Use of keratolyric agents (salicylic acid plasters or solutions)

Molluscum contagiosum
- Benign but frequently troublesome viral infection that generally affects young children
- Prolonged, may persist for months to years
- Characterized by smooth, dome-shaped discrete papules that occasionally develop surrounding areas of scale and
erythema (molluscum dermatitis)
- MCV: large, brick-shaped, poxvirus that replicates within the cytoplasm of cells
- dsDNA
- Type I virus causes most infections
- IP: 2-7 weeks
- Transmission occurs via direct skin or mucous membrane contact, or via fomites; spread by autoinoculation
- Swimming pools: common source of infection
- Higher risk of more extensive and prolonged infections
o Immunosuppressed patients (HIV patients)
o Atopy
Clinical findings
- Extremely small, pink, pearly, or flesh-colored papule that then enlarge occasionally reaching sizes of up to 3 cm (“giant
molluscum”)
- As they enlarge, a dome-shaped, opalescent morphology may become more apparent
- Lesions may have central dell or umbilication from which a plug of cheesy material can be expressed
- Most develop multiple papules, often in intertriginous areas (axillae, popliteal fossa, groin)
- Genital and perianal lesion can develop in children, but rarely associated with sexual transmission
- Lesions may be grouped in clusters or appear in a linear array(develop at sites of trauma)
- Erythema and eczematous changes may occur around lesions: molluscum dermatitis
- Patients with AIDS may develop large and extensive lesions involving both genital and extragenital sites

Diagnosis
- Based on clinical presentation
- Confirmation by histologic demonstration of cytoplasmic eosinophilic inclusions (molluscum bodies/Henderson-Paterson
bodies) characteristic of poxvirus replication.

Complication
- Pruritus, particularly among patients with atopic dermatitis
- Chronic conjunctivitis and punctuate keratitis in patients with eyelid lesions
- Secondaty bacterial infections (after scratching)
-
Prognosis
- Spontaneously clears, but over a period of months to years
- Most prefer treatment if lesions persist for more than 1-2 months

Treatment
- Cantharidin 0.7% or 0.9% liquid
o Most efficient and least painful
o Extract of the blister beetle, Cantharis vesicatoria
o Induces vesiculation at the dermoepidermal junction when applied topically to the skin
o Applied and washed off 2-6 hrs later
o Not for the face and genital areas
o Risk of extreme reaction or scarring
- Curettage and cryotherapy
o Painful: may need the use of topical anesthetic agents
- Imiquimod cream
- Retinoid cream
- Salicylic acid
- Cidofovir
- Silver nitrate paste
- Tape stripping
- Oral cimetidine

Prevention
- Avoid shared baths and towels until infection is clear
- Avoid trauma to sites of involvement and avoid scratching to prevent further spread of lesions

CUTANEOUS FUNGAL INFECTIONS

Tinea versicolor
- Common, innocuous, chronic fungal infection of the stratum corneum
- Most prevalent in adolescents and young adults
- Caused by the dimorphic yeast Malassezia globosa
o Part of the indigenous flora, predominantly in the yeast form
o Found in areas of skin rich in sebum production
o Proliferation of filamentous forms occurs in the disease state

Predisposing factors
- Warm, humid environment
- Excessive sweating
- Occlusion
- High plasma cortisol levels
- Immunosuppression
- Malnourishment
- Genetically determined susceptibility

Clinical features
- Scaly hypo/hyperpigmented macules in characteristic areas of the body, including the chest, back, abdomen, and proximal
extremities
- Less common areas: face, scalp, genitalia
- Scale: dust-like or furfuraceous
o Can be produced by lightly scraping a scalpel blade over the involved skin
- Color varies: almost white to reddish brown or fawn colored
- Presenting complaint: cosmetic
o Lesions fail to tan with sun exposure
- Pruritus: mild to absent

Diagnosis
- Scale from involved skin scraped onto a glass slide and treated with 10% potassium hydroxide solution (KOH)
o Confluent and short hyphae and round spores (spaghetti and meatballs)
 - Wood’s lamp
o Yellowish fluorescence of involved skin

Treatment
- Topical
o 2.5% selenium sulphide shampoo
o Daily application for 2 weeks: left on for at least 10 mins then washed off completely
o Application once or twice per month can prevent recurrence
- All topical azole antifungal also effective
o Ketoconazole 2% shampoo
o Lathered on the affected areas and left for 5 mins; repeated for 3 consecutive days
- Topical terbinafine 1% solution
o Applied 2x daily for 7 days
- Systemic
o May be necessary for patients with extensive disease or frequent recurrences or for whom topical agents have
failed
o Oral ketoconazole: 200 mg daily for 7 days
o Oral itraconazole: 200-400 mg daily for 3-7 days
o Fluconazole: 400 mg single dose

DERMATOPHYTOSIS
- Superficial fungal infections
- Confined to stratum corneum
- Caused by dermatophytes
o Group of taxonomically related fungi
o Ability to form molecular attachments to keratin and use it as a source of nutrient allowing them to colonize
keratinized tissues including the stratum corneum of the epidermis, hair, nails, and horny tissues of animals
- 3 genera responsible for infections
o Trichophyton
o Microsporum
o Epidermophyton

1. Tinea corporis (tinea circinata)

- Refers to all dermatophytoses of glabrous skin except the palms, soles, and groin
- Transmission occurs via
o Direct contact with infected humans or animals
o Fomites
o Autoinoculation from reservoir (e.g. colonization of the feet by T. Rubrum)
- Most prevalent organisms
o Trichophyton rubrum
o T. Mentagrophytes
o T. Tonsurans
- Children:
o Microsporum canis (dogs and cats)
- Contributory factors
o Occlusive clothing
o Warm, humid climate
- Clinical findings
o Classic presentation
 Annular lesions with scale across the entire erythematous border
 Border is often vesicular and advances centrifugally
 Center of lesion usually scaly but may exhibit clearing
o Lesions may be serpiginous and annular (ringworm-like)
o T. Rubrum infections may present as large confluent polycyclic or psoriasisform plaques
o Majocchi granuloma
 Infection usually caused by t. Rubrum
 Occurs when fungal hyphae invade hairs and hair follicles
 Seen in women who shave their legs and appears as inflamed folliculocentric papules
 - Diagnosis
o KOH preparations
o Wood’s lamp: no fluorescence
- Treatment
o Topical antifungal agents (allylamines, imidazole, tolnaftate, butenafine, ciclopirox) are effectiveskin
 Applied 2x a day for 2-4 weeks
o Oral antifungals
 For widespread or more inflammatory lesions
 Ultramicrosize griseofulvin
 Fluconazole, itraconazole, terbinafine

2. Tinea cruris
- Common dermatophytoses of the groin, genitalia, pubic area, perineal and perianal
- Transmission via
o Direst contact
o Fomites
- Exacerbated by
o Occlusion
o Warm, moist climates
- 3x more common in men; adults more commonly than children
- More prevalent in obese persons and in persons who perspire excessively and wear tight fitting clothing
- Most common cause
o T.rubrum
o Epedermophyton floccosum
- Less common cause
o T.metagorphytes
o T.verrucosum
- Clinical findings
o Multiple erythematous papulovesicles with a well-marginated, raised border
o Pruritus is common, as is pain with maceration or secondary infection
o E.floccosum
 Central clearing, limited to the genitocrural crease and the medial upper thigh
o T.rubrum
 Coalescent with extension to the pubic, perianal, buttock, and lower abdominal areas
o Genitalia typically unaffected
- Diagnosis
o Culture
o Demonstration of septate hyphae on KOH preparation
- Treatment
o Same meds as for tinea corporis

CANDIDIASIS

- Fungal infection caused by a related group of yeasts, whose manifestations may be localized to the skin, or rarely, may be
systemic and life threatening
- Most common cause
o Candida albicans (dimorphic yeast)
- Not part of the indigenous skin flora but is a frequent transient on the skin and may colonize the human GIT and vagina as a
saprophytic organism
- Predisposing factors
o Alteration of normal GI flora d/t broad spectrum antibiotics
o DM
o Chronic intertrigo
o Oral contraceptive use
o Cellular immune deficiency
- Diagnosis
o Direct microscopic examination of specimens for the presence of yeast and isolation of yeast in culture
- Treatment
o Oral candidiasis
 Nystatin suspension: 400,000-600,000 units 4x a day
 Clotrimazole troches: 10mg dissolved in the mouth 5x a day
o Intertrigo
 Topical antifungals: nystatin, topical imidazole creams
 Miconazole powder can be used to dry moist intertriginous areas

1. Oral candidiasis
- Acute pseudomembranous candidiasis or thrush: most common form
- Predisposing factors
o DM
o Systemic steroid use
o Antibiotic use
o Pernicious anemia
o Malignancies
o Radiotherapy to head and neck
o Cell mediated immunodefiency
- Discrete white patches that may become confluent on the buccal mucosa, tongue, palate, and gingivae
- Friable pseudomembrane resembles milk curds and consists of desquamated epithelial cells, fungal elements,
inflammatory cells, fibrin, and food debris
o Scraping the patches exposes a brightly erythematous surface underneath
o Microscopic examination: mass of tangled pseudohyphae and blastospores

a. Acute atrophic candidiasis

- Erythematous candidiasis
- Occurs after sloughing of the thrush pseudomembrane
- Associated with
o Broad spectrum antibiotic therapy
o Glucocorticoid use
o HIV infection
- Most common location
o Dorsal surface of the tongue, where there are patchy depapillated areas with minimal
pseudomembrane formation
- With an asymptomatic and symptomatic variant (burning/pain)

b. Chronic atrophic candidiasis

- Denture stomatitis
- Common form seen in 24-60% of those wearing dentures
- Female> male
- Chronic erythematous and edema of the palatal mucosa that contacts the dentures; angular cheilitis
- Chronic low grade trauma and occlusion provided by dentures predispose to colonization and subsequent
infection

c. Candidal cheilosis
- Angular cheilitis
- Perleche
- Erythema, fissuring, maceration and soreness at the angles of the mouth
- In habitual lip lickers, usually in the young and in elderly patients with sagging skin at the oral commissures
- Predisposing factors
o Loss of dentation
o Poorly fitting dentures
o Malocclusion
o Riboflavin deficiency
2. Cutaneous candidiasis
- C. Albicans
o Predilection for colonizing moist, macerated folds of the skin
- Intertigo
o Most common clinical presentation on glabrous skin
- Usual locations
o Genitocrurual
o Axillary
o Gluteal
o Interdigital
o Inframammary
o Between folds of skin on the abdominal wall
- Predisposing conditions
o Obesity
o Wearing of occlusive clothing
o DM
o Occupational factors
- Appears as pruritic, erythematous, macerated skin in intertriginous areas with satellite vesicopustules
o Pustules break open, leaving an erythematous bas with a collarette of easily detachable necrotic
epidermis

a. Candidal diaper dermatitis

- Caused by yeast colonization from patient’s GIT
- Aggravated by chronic occlusion by wet diapers
- Lesions appear first in the perianal area and spread to the perineum and inguinal creases, which show
pronounced erythema

b. Erosio interdigitalis blastomycetica

- Interdigital candidal or polymicrobial infection of the hands or feet
rd th
- Usually affects the 3 or 4 interspace

c. Candida miliaria
- Often affects the back in bedridden patients
- Lesions start as isolated vesicopustules that contain yeast

- Diagnosis
o Based on the typical appearance of skin lesions and the presence of satellite vesicopustules
o Should be confirmed by KOH examination and culture of skin scrapings
o Direct microscopic examination of the specimens for the presence of yeast and isolation of yeast in
culture
- Treatment
o Oral candidiasis
 Nystatin suspension (400,000 – 600,000 units 4x a day)
 Clotrimazole troches (10mg dissolved in the mouth 5x a day)
o Intertrigo
 Topical antifungals (nystatin, topical imidazole creams)
 Miconazole powder can be used to dry moist intertriginous areas