KULIAH REGULER 2014

PYODERMAS

Dr. Asih Budiastuti, SpKK (K)

Department of Dermatovenereology
Medical Faculty of Diponegoro University
Semarang
Definition
Skin infection
Caused by pyogenic bacteria
Easily transmitted

Etiology
•Staphylococcus ( S. aureus, S. albus )
•Streptococcus ß haemoliticus
•Corynebacterium minutissimum
Prediposition factors:

•o Low stamina, malnutrition,

gravis anemia, diabetes mellitus

•o Low hygiene individual

•o Low hygiene area

•o Pre-existing skin diseases

Classification

1. Primary pyodermas
- infection on the normal skin without
other skin diseass
- Caused by: one type microorganisme
Staphylococcus and Streptococcus
- Characteristic skin manifestation
Primary pyodermas (examples)
a) Impetigo
b) Folliculitis
c) Furuncles
d) Carbuncles
e) Ecthyma
f) Erythrasma
g) Erysipelas
h) Cellulitis
i) Paronychia
j) Staphylococcal scalded skin syndrome
2.Secondary pyoderma
Complicating preexisting skin lesions, such
as scabies, eczema, varicella, thus clinical
manifestations are not characteristic.
Examples:
- Hidradenitis supurativa
- Intertrigo
- Ulcers
- Infectious eczematous dermatitis
 PYODERMAS TREATMENT
1. General treatments:
- Medical; personal & environmental
hygiene advices
- Immunological factor
- Antibiotics
Systemic Antibiotics:

a) Penicillin: ampicillin, amoxicillin,

penicillin resistant strain: 
amoxicillin+clavulanate acid (3x125mg,
250-500mg), cloxacillin.
b) Erythromycin 30-40 mg/kg/day  3 doses
c) Cefalexin: 50 mg/kg/day  2 doses
d) Lincomycin: 30 mg/kg/day  3-4 doses
e) Ciprofloxacin 2 x 500-750 mg
Topical Antibiotic
Mupirocin • Tetracycline 3%
Gentamycin • Chlorampenicol
Erythromycin • Neomycin+basitracin
Fucidic acid
• Secondary pyodermas : treatment of the
preexisting diseases
•Chronic cases: culture & resistance test
2.Specific treatments:
 PRIMARY PYODERMAS
4 types of primary pyoderma considered from
the etiology:
1. Staphylococcus
- impetigo contagiosa bullosa
- folliculitis, furuncles & carbuncles
- sycosis barbae
- Staphylococcal Scalded Skin Syndrome
PRIMARY PYODERMAS (etiology)

2. Streptococcus:
q Impetigo contagiosa crustosa
q Ecthyma
q Erysipelas
3. Staphylococcus & Streptococcus:
v Cellulitis
4. Corynebacterium minutissimum:
- Erythrasma
IMPETIGO

A bacterial infection that attacks

superficial epidermal between stratum
corneum and stratum granulosum, very
infectious.
2 types of impetigo:
1. Impetigo contagiosa bullosa
2. Impetigo contagiosa crustosa
1. Impetigo contagiosa bullosa
= Impetigo neonatorum
Neonatal 10-14 days: on the palm of
hand, face, mucous membrane, along
with constitution manifestations
Pre-school children  neck, arm
Flaccid Bullae (hipopion), erosions 
scalded-by-fire-like appearance
2. Impetigo contagiosa
crustosa
Manifestation: erythematous eritema, vesicle
and bullae  pustule  thick crust.
Predilection: face, extremities
Streptococcus group A serotype 2.
Complicationsacute glomerulonephritis
The most serious complication!
 IMPETIGO
Hipopion
Impetigo contagiosa crustosa

Impetigo contagiosa bullosa

FOLLICULITIS
A hair follicle infection.
Course & clinical manifestations:
1. Superficial folliculitis
There are small fragile domeshaped
pustules occur at the infundibulum of hair
follicles, erythematous surrounding
2. Deep folliculitis
Deep microabces + crust  abces collar
button
Deep folliculitis (Examples):
i. Sycosis barbae occuring in the bearded
areas of the face and upper lip.
ii. Hordeolum (stye): a deep folliculitis of the
cilia of the eyelid margin.
Nodule is covered by pustule  swelling of
perifollicular tissue when dried becomes
crust at the edge of palpebra.
Treatment : warm compress
Complication: blepharitis & eye refraction
disorder
FOLLICULITIS

SYCOSIS BARBAE
FURUNCLES
An infection in hair follicles & surrounding tissue
(perifoliculer)
Course & clinical manifestations:
Acute pain, nodules with sharply defined
margins, erythema  5 days: central
suppuration, blind boil.
Predilection: nape, axilla, buttocks.
Predisposition factors:
- Diabetes mellitus -Malnutrition
- Seborrheic dermatitis
 Th/Specific: if there is abscess  incision
FURUNCLE
CARBUNCLES
• the worst form of a furuncle, with coalescence of
furuncles and marked inflammation, there are
multiple pustules.
Course & clinical manifestations:
1. Superficial carbuncles:
Red nodules, multiple perforation : without
leaving deep ulcers.
2. Deep carbuncles:
The nodules appear like carsinoma, multiple
perforations, leaving deep ulcer. Carbuncles
ulcer
Carbuncle (treatment)
Treatment:
Systemic: general pyodermas treatment
Local: - upper nodule : warm compress
- abscess : incision
CARBUNCLE
ECTHYMA

A pyogenic infection, characterized by sticky

crustae. There are ulcers if crusts are
debrided
Course & clinical manifestations:
Predilection: legs, buttocks 
vesiculopustulae  thick crust  the ulcer
has a ‘punch out’ appearance, the margin of
the ulcer is indurated, raised and violaceous.
DD/ Impetigo
ECTHYMA
ERYTHRASMA
A skin disease caused by gram-positive
bacterial infection, superficial lesions with
sharply defined margins.
Etiology: Corynebacterium minutissimum
Symptoms & signs:
The body folds, axilla, genitocrural, toe web 
macula (brownish redness) or plaque, fine
scaly.
Wood’s lamp: a coral red fluorescence.
Predisposing factors: heat, humidity, obesity.
Treatment: erythromycin 4 x 250 mg/ day.
ERYTHRASMA
 ERYSIPELAS
(superficial cellulitis)
An acute infection disorder caused by
Streptococcus betahaemoliticus with cardinal
signs of sharply circumscribed erythematous
skin, fever and chills
Predilections:
face and head  extremities & genital
Predisposition factor: cachexia, diabetes
mellitus, systemic diseases, and bad hygiene
ERYSIPELAS (course & clinical
manifestation)
Beginning from ulcer, wound, pustule.
Quick progress  pain, fever, weakness
Spreading erythema to the periphery,
sharply circumscribed, oedema, palpation:
warm & pain. Vesicles & bullae on the
erythematous skin.
Exacerbation in the same place causes
permanent changes: swelling, oedema can
be caused by blockage of the venous and
lymphatic vessels  on the lips, lower legs
and feet. Elephantiasis nostras
 ERYSIPELAS
Predilections:
face and head  extremities
& genital

Treatments:
v Bed rest
v General pyoderma treatment:
systemic antibiotic
Cold compress

Complication: ELEPHANTIASIS NOSTRAS

ELEPHANTIASIS NOSTRAS
VERUCOSUS
It is caused by recurrent erysipelas
Location: lower legs
Feet: very thick and big (2-3 x normal)
Verrucous lesions are made up of
crowded wart-like growths with
papilomas among them.
Caused by lymphatic vessels blockage
CELLULITIS
acute infection, where the inflammation
involves more of soft tissue, extending
deeper into the dermis and subcutaneous
tissues,
primary sign: skin erythematic without sharply
defined margins.

Etiology:
Group A Streptococcus &Staphylococcus
aureus; Group B Streptococcus  neonatus
Course & clinical manifestations:
vBeginning from insect bite, small wound, ulcers
(porte d’entre). Erythema and severe pain, fever
and chills, palpation: pain and heat.
vVesicles  local abscess  necrotic.
vCelullitis can occur on the head, perianal
cellulitis,
vBecoming march celullitis, gangrene gas,
necrotizing fasciitis if the infections have extended
into the fascia and caused blood vessels
thrombosis  gangrene.
vInitially is edematous, warm, red, extended, raising
vesicles or bullaes  crepitation sign
Cellulitis treatment:
Bed rest  better general conditions
Systemic: general pyoderma treatment:
antibiotic
Topically: acute  cold compress
Abscess/ gangrene  incision, debridement of
necrotic tissues
PARONYCHIA
an infection of the nail fold surrounding the nail
plate.
E/: Staphylococcus or fungal: Candida albicans
Course & clinical manifestations:
Beginning from nail folds – expanding into nail
matrix & nail plate : characterized by the
swelling of the lateral nail fold adjacent to the
side of the nail, a drop of pus may sometimes
be expressed from them.
Chronic paronychia is favored by ingrown nail,
prolonged immersion in water and simple
injuries. There is latitude line on the nail fold.
 PARONYCHIA
Treatments:
o Systemic: acute  antibiotic/ penicillin
o Topical:
 Acute  rivanol 1 %, after drying – antibiotic
ointment
 Chronic/ recurrence  nail extraction
 Candida albicans:
Antibiotic+ Anticandida  nystatin
Prognosis: generally good.
 STAPHYLOCOCCAL SCALDED-
SKIN SYNDROME (SSSS)
A skin infection, caused by typical exotoxin of
Staphylococcus aureus with a characteristic sign
of epidermolysis.
Etiology & pathogenesis:
v Group 11 phage (type 52,55 and 71)
Staphylococcus aureus.
v The exotoxins produce epidermolysis on all over
the body into the epidermis.
v There is no bacteria found on the skin.
v Focal infections are eye, nose, throat & ear
infection.
SSSS (Course& clinical manifestations)

High fever, accompanied by upper respiratory

tract infections
Erythem on the face, neck, axilla, groin  all
over the body in 24 hours.
Characteristic tissue-papers like wrinkling of
epidermis is followed by appearance of large
flaccid bullae (Nicolsky sign +) like combustion
Complication: cellulitis, pneumonia, septicemia
DD: Toxic epidermal necrolysis.
 SSSS (Treatments)

• Systemic: cloxacillin – adult 3x250mg/day

Neonatus 3x50mg/day orally
• Topical: wide lesions  sofratulle/
antibiotic cream
• Intravenous electrolyte and liquid  wide
epidermolysis  produces electrolyte and
liquid imbalance
SSSS
SECONDARY PYODERMA

Examples:
- Hidradenitis supurativa
- Intertrigo
- Ulcers
HIDRADENITIS SUPPURATIVA
A chronic &recurrent suppurativa infection in
apocrine sweat glands.
Affecting apocrine sweat gland, in adult men
& women
E/:Staphylococcus aureus & Proteus Sp
Course & clinical manifestations:
Preceded by injuries, axilla hair cutting,
deodorant using.
Predilection: the axilla, perianal & genital.
HIDRADENITIS SUPPURATIVA
DD/:Scrofuloderma
Treatments:
• Usually very difficult, considering the multiple
lesions and the deep location on the
profundal layer
• Abscess  incision
• Chronic and cicatrix  apocrine gland
excision
PROGNOSIS: poor -- recurrence
HIDRADENITIS SUPURATIVA
INTERTRIGO

An inflammation in the redundant skin

folds, erosion, red-colored
Predilection:
The favorite sites are the groin, axillae,
between the toes, the intergluteal cleft,
under the pendulous breast where the
skin meets
INTERTRIGO (Course & clinical
manifestations)
Initially the skin is red, maceration, hyperemia,
erosions & fissure. e.g: diaper rash
Influencing factors:
• Obesity
• Hot temperature & high moisture, sweat
retention, maceration, irritation on the skin.
• Bacterial populations, flora decompositions 
produces an offensive odor.
• Bacterial populations  causing inflammation 
increased moisture  more macerations
DD: Dermatomycosis
 INTERTRIGO (Treatment)
1. Milid intertrigo: thorough cleansing & dyring of
area 2x/d. All soap should be rinsed off
2. Liberal use of baby powder
3. Using uplifting brassieres preventing hanging
breasts
4. Using cotton underwear  it can absorb the
sweat; looser underpants
5. Using electric fans/ ac  a cool environment
6. Medications:
a. systemic: antibiotic orally
b topical: mild cases  corticosteroid creams
moderate cases  antibiotic creams
INTERTRIGO
ULCERS
a skin disorder caused by tissue necrotic
occurring in the epidermis, dermis and
subcutan expanding into bone tissue.
Ulcers caused by bacteria:
1. Pyogenicum ulcer
2. Carbuncles ulcers
3. Tuberculosis ulcers
4. Tropicum ulcers
5. Durum ulcers
6. Molle ulcers
 Consider these when describing
an ulcer:
Shape:
- round on the pyogenic ulcer
- oval on the tropicum ulcer
- irregular on the traumatic ulcer
Border:
- raised on mycosis fungoides
- Verrucosa on carcinoma ulcer
- Undermined on tuberculosis ulcer
 Consider these when describing
an ulcer
Base:
- dirty on carbuncles ulcer
- Clean on durum ulcer

Surrounding skin:
- red on carbuncles ulcer
- Livide on tuberculosis ulcer
PYOGENICUM ULCER

Round-shaped, 0.5-1 cm in diameter,

red border, covered by pus,
often on the foot,
E/: Streptococcus/ Staphylococcus.
CARBUNCLES ULCERS

Furuncles convalesce, necrotic,

Predilection: on the back and nape,

In diabetes mellitus patient.

TUBERCULOSIS ULCERS
A. Orificialis tuberculosis ulcer
It is on the oral & anal orifice edge. Livide
on the surrounding skin, undermined
border, pale granulation tissue and
hemorrhage easily on the base.
B. Tuberculosis limphadenitis on the neck
and axilla, becomes abscess, fistula &
ulcers.
E/: tuberculosis bacterial toxin
DURUM ULCERS

Initially it appears as asmall erosion,

expanding to the periphery. The base is
verrucous, red, covering serum
sometimes dried. Palpation feels like
cartilage and there is no pain, inguinal
lymph gland enlargement.
E/ Treponema pallidum.
THANK YOU