PYODEMAS

Pyodermas are the most prevalent of all

dermatoses encountered in paediatric
dermatological practice.
Diverse manifestations of pyoderma occur
primarily (as various independent
nosological forms) or as a complication
(secondary) of other dermatoses,
especially in patients with pruritic
dermatoses (neurodermatoses, scabies,
pediculosis).
 AETIOLOGY
the most common causative agents of
pyoderma are:
 Staphylococcus (Streptococcus haemolyticus,
Staphylococcus aureus, Staphylococcus albus)
 streptococcus
 blue-pus bacillus
 proteus vulgaris
 escherichia coli
 pneumococcus
 gonococcus, and many other micro-organisms
 Factor of risk:
The exogenic factors:
 over-cooling or overheating of the body

 hyperinsolation

 superficial skin injuries

 soiling of the skin
 itching dermatoses
 changes of sweat PH
 maceration
 increasing of sweat
 The endogenic factors are:
 disorders of carbohydrate metabolism (hyperglycaemia),
 endocrine disorders
 functional disorders of the nervous system
 fault in nutrition (lack of fullvalue proteins, i.e.
hypoproteinaemia, particularly a low gamma globulin
content),
 hypovitaminosis (especially A and C),
 acute and chronic emaciating diseases,
 diseases of the gastrointestinal tract (intestinal
intoxication),
 disorders of immunity
 long term using corticosteroids, immunodepressants,
citostatics
The conducive factors for the
development of pyodermas in
children are:

 an imperfect physiological barrier, particularly

increased moistness
 looseness
 fragility of the epidermal horny layer
 labile colloidoosmotic state
 high absorption capacity of the skin
Ways of transmission:
 direct contact
 indirect contact
 airborne
Pathogenesis:
 injuring of the tissues or disturbing their
normal metabolism
 endogenic intoxication
 bacterial sesibiisation
 decrease of antibacterial barrier of the skin
and organism
 activation of microbial flora
 hereditic or acquired immunodeficit
 pyococcal processes
 Classification of pyodermas
According to the aetiological factor:
 staphylococcal
 streptococcal
 mixed
According to the depth of the localization of
the process:
 superficial
 deep
According to the character of their course:
 acute
 chronic pyodermas
The following staphylococcal
pyodermas are distinguished:
Superficial:
 ostial folliculitis

 sycosis

Deep:
 deep folliculitis

 furuncle

 carbuncle

 hidradenitis
Ostial folliculitis

 subjectively: sensation of pain

 generalize symptoms is absent
 acute current
 localization on the face, scalp, neck, forearms
 follicular pustule the size of a millet grain or pin
head, found in the centre of the hair follicle and
surrounded by a narrow hyperaemic band of acute
inflammation
 a few days later the contents of the pustule dry up
and a crust forms, the surrounding inflammation
subsides and the process terminates without a
trace or only a light pigmentation remains
 Sycosis
 subjectively: low sensation of pain and mild itching
 generalize symptoms: sometimes fever
 chronic current
 localization: in the region of the moustache and beard,
and less frequently on the inner surface of the wings
of the nose, on the eyebrows, in the axillae, on the
eyelid margins, on the scalp and on the pubis
 a few lesions of ostial folliculitis appear on a relatively
circumscribed skin area, which tend to spread to
larger and larger areas
 after the top of the pustules opens, the pus dries up
into dirty-yellow crusts which stick to the hairs
 a hair shaft removed from the focus has a gelatin-like
muff around its root
 Deep folliculitis
 subjectively: sensation of pain
 generalize symptoms: sometimes fever
 localization: on the scalp and back of the neck
 damage the greater part or the whole follicle
 red nodules appear at first, which later
transform into pustules pierced with a fine hair
 in a few days the secretions of the pustule dry
into a crust
 necrosis of the connective tissue may occurs
 after small punctate scars form in five to six
days at the site of deep folliculitis
 Furuncle or Boil
 It is acute staphylococcal pyonecrotic
inflammation of the hair follicle and the
surrounding connective tissue
 subjectively: sensation of pain
 generalize symptoms: sometimes fever,
headache
 deep pustule, like a painful nodose infiltrate red
in color, has diameter 3-5 sm
 fluctuation appears
 after few days forms necrotic core
 the core is resolving with a scar
 evolution of furuncle has duration 2 weeks
 Carbuncle
 a carbuncle is a diffuse pyonecrotic inflammation of the
deep layers of the dermis and hypoderm with involvement of
several neighbouring hair follicles into the process
 subjectively: sensation of acute pain
 generalize symptoms: high fever, excruciating pain of a
tearing, pulling character, a chill, and indisposition
 localization: on the back of the head, the back, and the loins
 hard nodules, which coalesce into a single infiltrate.
 this infiltrate grows, sometimes to the size of a child's palm.
 its surface becomes semispherical, the skin is tense and
cyanotic in the centre
 after 8 to 12 days a few pustules form in the area of the
infiltrate, fluctuation appears
 green necrotic masses with an admixture of blood are
discharged from the opening pustules
 after that ulcer forms, which lives deep scar
 Hidradenitis
 is purulent inflammation of the apocrine sweat glands
 subjectively: mild itching and pain
 generalize symptoms: sometime fever
 localization: in the axillae (usually unilateral) or inguinal
folds, less frequently around the nipples and in the region of
the large pudendal lips, scrotum, and anus
 solitary small hard mound-like nodes are palpated in the
thickness of the dermis or hypoderm
 nodes grow rapidly in size, adhere to the skin, become pear-
shaped and protrude like nipples and resemble 'bitch's
udder'
 the skin turns bluish-red, swelling
 the isolated nodes often coalesce, soften, and fluctuation
appears after which they open spontaneously and thick pus
with an admixture of blood is discharged
 ulcers heal in a few days lives deep scar
 The following streptococcal
pyodermas are distinguished:
Superficial:
 Streptococcal Impetigo
 Angulus Infectiosus, Perleche
 Pityriasis Simplex
 Impetigo of the Nail Folds
 Intertriginous Streptoderma
 Posterosive Syphiloid, or Papular Syphiloid
Impetigo
Deep:
 Ecthyma Vulgaris
 Streptococcal Impetigo

The clinical varieties of streptococcal impetigo are:

 Impetigo bullosa

 perleche

 streptococcal cheilitis

 pityriasis simplex

 superficial panaris

 intertriginous streptoderma

 posterosive syphiloid
Impetigo Bullosa
 localization: commonly on the dorsal surface
of the hands and less frequently of the foot
and leg
 is characterized by eruption of phlyctenae as
large as a hazel-nut or a dove's egg
 the erosion forming after the bulla ruptures
grows gradually and remnants of the top of
the bulla are left on its periphery
Angulus Infectiosus, Perleche

 subjectively: the disease is attended with a

sensation of itching, salivation, and pain during
eating
 localization: in one or both angles of the mouth
 is a condition marked by a rapidly rupturing
phlyctena
 flabby vesicles form at first in the angles of the
mouth, which rupture and expose superficial linear
slit-like fissures
 the formed honey-yellow crusts drop off because of
maceration
Pityriasis Simplex
 localization: on the skin around the mouth, the
cheeks, and the region of the lower jaw, sometimes
on the skin of the trunk and limbs
 it is particularly common in children and is
characterized by round or oval, strictly circumscribed
whitish or pink foci, which are abundantly covered
with small scales
 the foci are especially conspicuous in individuals
with pigmented skin
 the disease may be cured by exposure to sunrays,
but the affected areas are tanned weakly so that
mottling of the skin surface occurs
Impetigo of the Nail Folds (Tourniole)
 subjectevely: sensation of pain
 localization: around the fingernails, nail plate
 the disease develops in wounding of the fingers and
hand nails, which create conditions for the entry of
streptococci
 phlyctenae form around the fingernails, first with
serous secretions, which later become cloudy-
purulent
 the affected phalange swells
 after the phlyctena ruptures an erosion forms
embracing the nail plate like a horseshoe
 the process may terminate in the loss of the nail plate
 Intertriginous Streptoderma
 subjectively: sensation of pain
 localization: under the breasts, in the folds on the
abdomen in obese persons, behind the ears, in the
inguinofemoral and interglutteal folds, in the axillae,
etc.
 the primary lesion is a phlyctena the size of a millet
or lentil
 the phlyctenae erupt, coalesce, and burst rapidly
leaving continuous erosive weeping bright-rose
surfaces with scalloped boundaries and a border of
peeling epidermis on the periphery
 In intertriginous lesions of yeast origin the contents
of the bullae and the crusts do not have a yellow
hue and elements of yeast-like fungi are discovered
in the scraps of epidermis on the periphery of the
main foci
 Ecthyma Vulgaris
 The lesion in ecthyma vulgaris is a deep dermal pustule with no
involvement of the follicles.
 localization: on the leg, though ecthyma may also occur on the skin
of the thighs, buttocks and the loins (the number of lesions ranging
from one or two to several dozens)
 the subjective symptoms are mild (moderate tenderness of the
ulcerations)
 the disease sets in with the formation of a small vesicle or
parafollicular pustule with a serous or seropurulent content, which
dries rapidly to a soft, golden yellow bulging crust
 in most cases, the crust consists of several layers and after it drops
off or is removed a round or oval ulcer remains.
 the floor of the ulcer is covered with a dirty-grey film and bleeds,
while its edges are soft, oedematous and with congestive
hyperaemia
 the ulcer heals slowly in two or three weeks leaving a superficial scar
around which a zone of pigmentation forms
 The following mixed pyodermas
are distinguished:
Superficial:
 Impetigo vulgaris
Deep:
 Chronic Ulcerous Pyoderma

 Chancriform Pyoderma
 Impetigo Vulgaris
 the disease prevails among children, girls and young
women
 localization: around the mouth, fissures, and nostrils (less
frequently on the skin of the trunk and limbs)
 the onset is acute and is marked by the formation of
streptococcal impetigo, phlyctenae on a hyperaemic
slightly oedematous skin
 because of the attendant staphylococci the contents of the
phlyctena turn cloudy rapidly and become purulent
 after that the secretions dry into a thick honey-coloured or
yellow crust
 the developmental cycle of a single lesion takes 8 to 15
days after which pigmentation of the skin remains for some
time.
 the regional lymph nodes are often enlarged
Chronic Ulcerous and Ulcero-Vegetative Pyoderma
 the disease is attended with somnolence, weakness,
anaemia, and pain (mild as a rule) and follows a chronic
course of many months or even years.
 the disease begins with the formation of streptococcal
ecthyma, furuncle or a peculiar deep infiltrate, which
undergoes necrosis rapidly with the formation of an
ulcer.
 the ulcer is large, with rounded, oval or scalloped
contours, thick infiltrated and eroded edges, and an
uneven loose floor with poor grey granulations and
copious purulent or seropurulent discharge.
 deep pustules may form on the periphery of the main
focus.
 deep communicating purulent cavities are found in the
depth of the infiltrates.
 the ulcerous process spreads along the periphery
under the crust and takes various contours and
shapes
 new phlyctenae or pustules form continuously
on the edges of the main foci and undergo
pyoulcerous melting.
 the process usually terminates in the formation
of scars.
 Chancriform Pyoderma
 localized on the genitals as a rule, though they may
also be found on the face, lips, eyelids, and tongue
 there are usually solitary, rarely multiple ulcers,
 the appearance of an erosive, most frequently
ulcerative, lesion with regular rounded or oval
contours, hard, swollen elevated edges and an
infiltrated floor, which has a red-meat colour and is
sometimes covered with purulent secretions or
gangrenous decay, is a characteristic symptom
 the course of chancriform pyoderma may drag out
for two or three months and terminate by the
formation of a scar
PYOALLERGIDS
 Pyoallergids are peculiar secondary allergic lesions
of the skin, which occur in persistent deep
pyodermas
 The eruption is preceded by elevation of body
temperature (sometimes to 38°C), headache,
malaise, and weakness.
 Subjectively: itching
 Symmetrically peeling erythematous spots,
papulovesicles, vesicles, bullae and pustules are
present on the skin of the trunk and limbs.
 The lesions disseminate and may involve large skin
areas which are at a considerable distance from the
main foci of affection.
 Regression of the foci begins in 10 to 14 days,
however.
 Treatment
Systemic:
 high-calorie diet
 vitamin (A, E, B, C)
 autovaccines
 antibiotics
 stimulation therapy (autohaemotherapy, lactotherapy,
injections of donor or stored blood and pyrogens)
 painted twice a day of aniline solution (l%Sol.
Gentianvioleti, Castellani's paint, brilliant green)
 The lesions are painted with a 1-2 per cent alcohol boric
or salicilic solution
 ointments and creams containing antibiotics and steroid
hormones (Lorinden C, Locacorten, Oxycort, Hyoxizon)
 Ultraviolet irradiation (erythema doses)
 DERMATOZOONOSES
 Skin diseases caused by animal parasites are
called dermatozoonoses.
 Scabies and pediculosis are most important in
the practice of dermatologists.
 Infestation occurs from direct contact with the
sick individual or through objects and articles
belonging to him (indirect route of infestation),
especially through articles of wear and bed-
clothes.
 SCABIES
 Aetiology: scabies is caused by the itch mite Acarus
scabiei or Sarcoptes Scabiei var hominis. The female
is larger than the male mite
 When viewed with the naked eye, it is seen as a white
pin head. After impregnation, which occurs on the skin
surface, the male dies while the female penetrates the
superficial layers of the epidermis and forms burrows
in them.
 The female drills the horny layer of the skin with
strong chitin jaws. Outside the skin it perishes in a few
days. In six to eight days the female mite lays up to
50 eggs in the burrow. Mature mites develop from
them in three to seven days.
 Clinical picture.
 Subjectively: is itching, which is particularly severe
in the evening and at night
 Icubation period - 2 weeks
 The typical localization of scabies are: the
interdigital webs and the sides of the fingers the
flexor surfaces of the wrists, the extensor surface of
the foreems and elbow, anterolateral surfaces of the
trunk, the anterior axillary folds, around the areola of
the breasts, the abdomen, particularly in the region
of the umbilical ring, the buttocks, thighs, slins, and
the region of the penis.
 A small vesicle forms at the site where the mite had
penetrated.
 the pinpoint papulo-vesicular eruptions, burrows
(grey dash lines) and excoriations from
scratching of the skin form.
 Dry crusts and scales covering papulo-
vesicular lesions may sometimes be found on
the extensor surface of the elbow joints (the
Gorchakov-Ardy’s sign).
 The burrows are found most frequently on the
wrists and interdigital webs of the fingers.
Their length varies from 2-3 mm to 5 mm.
 Sanguineous crusts the size of a pin head
sometimes form in place of the vesicles.
Diagnostics

 Clinical picture
 Gorchakov-Ardy’s sign
 Microscopy
 Either mites or the products of their vital
activity (eggs, excrements) are seen in the
preparation as clusters of dark dots.
 Treatment
 emulsion of benzyl benzoate (20% for adult,
10% for children) It is rubbed into the skin twice
for 10 minutes at an interval of 10 minutes. The
patient then puts on disinfected clothings and
changes the bed-clothes. The next 2 days the
treatment is repeated. After 5-6 days a bath or a
shower is taken and the clothings and bed-clothes
are changed.
 sulphur ointment (20-33 per cent for adults and
10 per cent for children) at the same scheme
 aerosol “spregal” It is rubbed into the skin twice
for 10 minutes at an interval of 10 minutes
 hyposensitizing and antihistaminics (calcium
gluconate, diazolin, suprastin, etc.)
 PEDICULOSIS
Three species of lice may parasitize on human
skin:
 the head louse

 the body louse

 the pubic louse

 Head louse (pediculus capitis)
 This louse is usually passed from one person to
another on direct contact and through hats, kerchiefs
and combs that were used by the patient.
 The female louse deposits up to 150 eggs (nits) during
its life, which are attached to the hair with a chitinous
substance. The nits have a greyish-white colour and
are seen well with the naked eye.
 Lice are found on the hairs of the scalp, on the
eyebrows, beard, and moustache.
 The bites of the lice and the action of their salivary
enzymes induce severe itching as a result of which
scratches are inflicted, pyococci penetrate the skin,
and pyoderma lesions form.
 The diagnosis is confirmed if nits and lice are
detected.
 Body louse (pediculosis corporis)
 They lice are present in the folds of underwear and
clothings and feed on blood.
 The nits are deposited in the seams and folds of
clothings and on long and downy hair.
 The louse bites induce severe itching as a result of
which linear excoriations are formed on the skin,
which may be complicated by pyoderma.
 Their typical localization are the neck, shoulder
blades, and the small of the back, i.e. skin areas,
which come in close contact with the clothings.
 Brown pigmentation remains on these areas for a
long time.
 Pubic loose (Phthirus pubis)
 This louse parasitizes on the pubis, genitals, around
the anus; it is not encountered in children.
 Sometimes the crab louse may spread to other skin
areas with hairs (chest, abdomen, thighs, axillae,
eyebrows, eyelashes).
 There is severe itching.
 Round, haemorrhagic spots, the size of a pea and
light-blue to light-grey in colour (maculae coeruleae)
often remain on the skin where the pubic lice had
parasitized.
 Infestation with the crab lice usually occurs during
sexual intercourse or when sharing a bed.
 Treatment
 Pubic loose (the affected areas are shaved, after
which blue ointment is rubbed into the skin for two
or three days, vinegar sublimate, a 20 per cent
benzyl benzoate or soap-solvent emulsion)
 Body louse (the patient must wash thoroughly
with soap and change the underclothes and
clothings. Underwear, clothings and bed-clothes
used before washing are disinfected)
 Head louse (10 per cent water-soap emulsion of
benzyl benzoate, different shampoo “nithifor”,
“pedilin” ect.)