Definisi
Infeksi kulit yang disebabkan oleh
Staphylococcus aureus &
Streptococcus hemolyticus.
Kolonisasi the nares, perineum,
axillae 20%.
Normal skin :
• Colonized by bacterial flora.
• The most common are various
non pathogenic Gram-negative
bacteria.
Faktor predisposisi
- Higiene buruk,
- Daya tahan tubuh menurun.
- Ada penyakit kulit lain.
klasifikasi
1. Pioderma primer kulit normal.
2. Pioderma sekunder pada
kelainan kulit lain.
terapi
1. Topical treatment :
• Mupirocin ointment highly
effective apply 3 times daily for
7 – 10 days.
2. Systemic antimicrobiol treatment
1. Organism: Group A Streptococcus
• Drug of choice / dose :
Penicillin 250 mg qid for 10 days
Benzathine penicillin
• 600,000 units IM in children 6 years or
younger
• 1.2 million units if 7 years or older. if
compliance is a problem
• Alternative drugs :
Erythromycin 250 – 500 mg
(adults) qid for 10 days.
Cephalexin 250 – 500 mg
(adults) qid for 10 days.
2. Organism : Staphylococcus aureus
• Drug of choice / dose :
Dicloxacillin 250 – 500 mg
(adults) qid for 10 days.
• Alternative drugs :
Cephalexin 250 – 500 mg
(adults) qid for 10 days; 40 – 50
mg/kg/d (children) for 10 days.
Amoxicillin plus clavulanic acid
(-lactamase inhibitor) : 20
mg/kg/d tid for 10 days.
3. Organism : GAS & Staphylococcus
aureus in pencillin-allergic patients
if organism is sensitive.
• Drug of choice / dose :
Erythromycin ethylsuccinate : 1
– 2 g/d (adults) in four divided
doses for 10 days; 40 mg/kg/d
(children) qid for 10 days.
• Alternative drugs :
Clatrithromycin 250 – 500 mg bid
for 10 days.
Azithromycin 250 mg qd for 5 – 7
days.
Clindamycin 150 – 300 mg
(adults) qid for 10 days; 15
mg/kg/d (children) qid for 10
days.
4. Organism : Methicillin-resistant
Staphylococcus aureus.
• Drug of choice / dose :
Minocycline 100 mg bid for
10 days.
• Alternative drugs :
Trimetoprim-sulfamethoxa-zole
160 mg trimethoprim + 800 mg
sulfamethoxazole bid.
Ciprofloxacin 500 mg bid for 7
days.
Impetigo & Ecthyma
Staphylococcus aureus &
Streptococcus pyogenes :
• Superficial infections of the
epidermis (impetigo).
• Extending into the dermis (ecthyma).
• Characterized by crusted erosions or
ulcers.
epidemiologi
• Primary infections more children.
• Secondary infections any age.
• Bullous impetigo children, young
adults.
etiologi
• Staphylococcus aureus & GAS or
mixed.
• Bullous impetigo 80% caused by
Staphylococci which produce exotoxin
& cause SSSS.
portals of entry of infection
• Primary impetigo arises at minor
breaks in the skin.
• Secondary impetigo
(impetiginization) underlying
dermatoses & traumatic breaks in
the integrity of the epidermis.
Underlying dermatosis
• Inflammatory dermatoses
Atopic dermatitis
Contact dermatitis
Stasis dermatitis
Psoriasis vulgaris
Chronic cutaneous lupus erythematosus
Pyoderma gangrenosum
• Ulcers :
Pressure.
Stasis.
• Dermatophytosis :
Tinea pedis.
Tinea capitis.
Riwayat anamnesis
• Duration of lesions :
Impetigo days to weeks.
Ecthyma weeks to
months.
Gambaran klinis
• Impetigo variable pruritus,
especially associated with atopic
dermatitis.
• Ecthyma pain, tenderness.
Pemeriksaan fisik
LESI KULIT
• Non bullous impetigo :
Vesicles or pustules rupture,
erosions, crust.
Golden-yellow crusts often
seen but are not
pathognomonic.
• Bullous impetigo :
Vesicles & bullae containing clear
yellow or slightly turbid fluid
without surrounding erythema,
erosion form.
Distribution : > intertriginous
sites.
• Ecthyma :
Ulceration with a thick adherent
crust.
Lesions may be tender, indurated.
Distribution : > distal extremities.
DIAGNOSIS BANDING
• Perioral dermatitis.
• Allergic contact dermatitis.
• Herpes simplex.
• Epidermal dermatophytosis.
• Scabies.
• Herpes zoster.
• Excoriated insect bite.
PEMERIKSAAN LABORATORIUM
• Gram’s stain Gram (+) cocci
• Culture Staphylococcus aureus
DIAGNOSIS
Clinical finding confirmed by
Gram’s stain or culture.
PROGNOSIS
• Untreated impetigo : forming
ecthyma invasive infection with
lymphangitis, suppurative
lymphadenitis, cellulitis or
erysipelas, bacteremia, septicemia.
• Ecthyma : often heals with scar.
• Recurrence : failure to eradicate
organism or reinfection from a
family member.
Folliculitis
Is a pyoderma beginning
within the hair follicle.
Classified :
• Superficial folliculitis.
• Deep folliculitis.
Superficial folliculitis :
• Termed follicular or Bockhart’
impetigo.
• Pustules at the infundibulum
hair follicle.
Local treatment :
• Local antibiotics (mupirocin).
• Warm saline compresses.
More extensive case :
• Systemic antibiotic a first-
generation cephalosporin, or a
penicillinase - resistant penicillin
such as oxacillin, cloxacillin or
dicloxacillin.
Furuncles & Carbuncles
Furuncle
• Deep seated inflammatory
nodule hair follicle.
• Usually from a preceding
superficial folliculitis
elvolving into an abscess.
• The neck, face, axillae &
buttock.
• Complicate preexisting
lesions.
• Start as a hard, tender, red folliculo
centric nodule in hair-bearing skin
enlarges painful & fluctuant
rupture occurs pus & necrotic
material pain surrounding the lesion
subsides redness & edema diminish
several days to weeks.
Carbuncle
• Larger, more serious
inflammatory with a deeper base.
• Fever, malaise patient appear
quite ill.
• Involved area is red & indurated,
multiple pustules on the surface
yellow-gray irregular crater at
the center heal slowly by
granulating.
Furuncle & carbuncle
bacteremic spread of infection &
recurrence individuals perspire
excessively or poor skin hygiene.
Treatment of furuncles & carbuncles :
• Drainage.
• Systemic antibiotic if surrounding
cellulitis or associated fever :
Dicloxacillin 250 – 750 mg
PO qid 4 – 6 h in adult.
Clindamycin 150 – 300 mg
PO qid.
Erythromycin 250 – 500 mg
PO qid.
• Severe infection in
dangerous area maximal
antibiotic by parenteral &
immobilized vancomycin
1 – 2 g i.v. daily.
• Antibiotic at least 1 week.
• Topical treatment :
mupirocin 2% ointment.
Caused by Staphylococcus
aureus commonly occur in
folliculo centric infections
folliculitis, furuncles &
carbuncles.
• Can also occur at sites trauma,
burns or site of insertion of
intravenous catheters.
• Initial lesion erythematous
nodule enlarges with the
formation of a pus-filled cavity.
Treatment :
• Incision & drainage.
• Similar management of folliculitis,
furuncle & carbuncle.
Soft Tissue Infections
Characterized by an acute,
diffuse, spreading, edematous,
suppurativa inflammation of the
dermis & subcutaneous tissues.
Systemic symptoms :
• Malaise.
• Fever.
• Chills.
Erysipelas
Superficial cutaneous cellulitis
with marked dermal lymphatic
vessel involvement painful,
bright-red, raised, edematous,
sharply marginated from the
surrounding normal skin.
• Predilection : face, lower
legs, areas of preexisting
lymphedema, umbilical
stumps.
• Age of onset : any age.
• Incubation period : few days.
Cellulitis
• Has many of the features of
erysipelas but extends into the
subcutaneous tissue.
• Not raised the lesion &
demarcation from ininvolved skin
is indistinct.
• Tissue feels hard on palpation &
painful.
• Age of onset : any age.
Caused :
• Staphylococcus aureus.
• Streptococcus B hemolytic.
Incubation period : few days.
Laboratory
• Direct microscopy smears :
Gram stain.
• Biopsy (Dermato-pathology).
Diagnosis
• Clinical feature.
• Confirme by culture in only
25% of cases in
immunocompetent patient.
• Biopsy & frozen-section
histopathology.
Management
• Rest, immobilization.
• Drain abscess, debride necrotic
tissue.
• Antimicrobiol therapy :
Antimicrobial agent (dosing (PO
unless indicate), usually for 7-14 days
1. Natural penicillins :
• Penicillin V : 250 - 500 mg
tid/qid for 10 days.
• Penicillin G : 600,000 - 1.2
million U IM qd for 7 days.
• Benzathine penicillin G :
600,000 U IM in children 6
years, 1.2 million units if 7
years, if compliance is a
problem
2. Penicillinase-resistant
penicillins :
• Cloxacillin : 250 – 500 mg
(adults) qid for 10 days.
• Dicloxacillin : 250 – 500 mg
(adults) qid for 10 days.
• Nafcillin : 1.0 – 2.0 g IV q4h.
• Oxacillin : 1.0 – 2.0 g IV q4h.
3. Aminopenicillins :
• Amoxicillin : 500 mg tid or 875 mg
q12h.
• Amoxicillin plus clavulanic acid (-
hemolytic inhibitor) : 875 / 125 mg
bid; 20 mg/kgd tid for 10 days.
• Ampicillin : 250 – 500 mg qid for 7 –
10 days.
4. Cephalosporins :
• Cephalexin : 250 – 500 mg
(adults) qid for 10 days; 40 –
50 mg/kg/d (children) for 10
days.
• Cephradine : 250 – 500 mg
(adults) qid for 10 days; 40 –
50 mg/kg/d (children) for 10
days.
• Cefaclor : 250 – 500 mg q8h.
• Cefprozil : 250 – 500 mg q21h.
• Cefuroxime axetil : 125 – 500
mg q21h.
• Cefixime : 200 – 400 mg q12 –
24h.
5. Erythromycin group :
• Erythromycin
ethylsuccinate : 250 – 500
mg (adults) qid for 10 days;
40 mg/kg/d (children) qid
for 10 days.
• Clatrithromycin : 50 mg
bid for 10 days.
• Azithromycin : 500 mg on
day 1, then 250 mg qd
days 2 – 5.
6. Clindamycin : 150 – 300
mg (adults) qid for 10
days; 15 mg/kg/d
(children) qid for 10 days.
7. Tetracycline :
• Minocycline : 100 mg bid
for 10 days.
• Doxycycline : 10 mg bid.
• Tetracycline : 250 – 500
mg qid.
8. Miscellaneous agents :
• Trimethoprim-
sulfamethoxazole : 160 mg TMP
+ 800 mg SMZ bid.
• Metronidazole : 500 mg qid.
• Ciprofloxacin : 500 mg bid for 7
days.
