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Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011

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Bacterial Infections & Acne

Chad Hivnor, MD

Associate Program Director

Chief, Pediatric

Dermatology

San Antonio, Tx

Disclaimer

All authored materials and statements

constitute the personal statements of

Chad Hivnor, MD and are not intended to

constitute an endorsement by Wilford Hall

Medical Center, the US Air Force, or any

other Federal Government entity."

Perspective

Patients

Parents

Jrnl Am Acad Dermatol Apr 2007



Epidemiology

Physiologic

85%

Familial

Only 20% visit dermatologist

Pro-active/OTC

Primary physicians

Pathophysiology

Skin cells

Follicular hyperkeratinization

Oil production

Bacteria

Propionibacterium acnes

Inflammation

Increase cell turnover

Androgens may play role



Sebum secretion higher

Decreased sebum production improves acne

Free fatty acids may play a role

Balloon

P. acnes

Chemotactic factors

Lipases and enzymes

Culture:

Not necessary unless G – suspected



Aggrevating Factors

Popping

Occlusion

Friction/ Pressure

Medications

Stress

Other:

Drugs (steroids, lithium, INH)

Androgens (menses as example)

Aggrevating Factors

Endocrine Testing

Not indicated in most patients

Young child

Body odor, axillary/pubic hair, clitoromegaly

Adult women (PCOS)

Late-onset acne, menses, hirsutism, alopecia,

infertility, acanthosis nigricans

Acne Subtypes

Semantics

Recent Consensus Statement Most employ lesion counting & Global

5 point scale; mild mod severe

Non-inflammatory

Closed comedo

Open comedo

Inflammatory

Papules

Pustules

Nodules



Open comedomes

Inflammatory

Acne

Differential:

Syndromes

SAPHO (synovitis, acne, pustulosis, hyperostosis,

osteomyelitis)

Keratosis pilaris

Tuberous sclerosis

Other genetic conditions

Polycystic Ovarian Syndrome

Testosterone (Free/Total), LH/FSH, DHEA-S



Acne Treatment

Multifactorial

Multiple pronged approach: EDUCATION

Previous Treatment

Compliance

Acne Treatment

Compliance

Teenagers

Treatment failure

Compliance #1 reason

You have to ask:

What are you USING? How often?

5 of 7 vs 2 of 7

Expect non-compliance

Acne Treatment

Multifactorial

Multiple pronged approach: EDUCATION

Previous Treatment

Severity - scarring

Duration

Perspective



Acne Treatment: Washing

Not a dirty problem: ―Fine china‖

Process:

Water

Salicylic acid wash – lather

Comedolytic

Lipophilic

Splash

Pat dry air dry

Acne Treatment

Retinoids

Benzoyl peroxide

Topical antibiotic

Combo of these 3

Work horse of acne

Combo is more effective than alone

Pathophysiology

Follicular hyperkeratinization

Alter keratinization (Retinoid, Salicylic Acid, BP)

Oil production

Alter sebaceous gland (Retinoid, Salicylic Acid)

Bacteria

Decrease load (BP)

Inflammation

Anti-inflammatory (Retinoid)



Acne Treatment: Retinoids

Under utilized

46.1% of acne visits for dermatologists vs

12.1% for pediatricians Pediatr Dermatol. 2008 Nov-Dec;25(6):635-9.

Early and often

Most effective comedolytic

Anti-inflammatory

Enhances penetration of other drugs

Synergism

PREVENTATIVE

Retinoids: Education

Compliance can be difficult

Use at Night dry face

Every other night or short contact

Moisturize

SPF

Creams and lotions

Not gels



Acne Treatment:

Benzoyl peroxide

GREAT: anti-bacterial

Decrease bacterial population

Decrease hydrolysis of triglycerides

NO antibiotic resistance

Combo with oral and topicals essential

Consensus confirms

Treatment

Retinoids

Benzoyl peroxide

Topical antibiotic

Azelaic acid

Acne Treatment:

Azelaic Acid

Inflammatory > comedomal

Less irriation

Post inflammatory hyperpigmentation

Pregnancy Cat B

Consensus

Trial efficacy

Practice: not so much

Subset



Treatment

Retinoids

Benzoyl peroxide

Topical antibiotic

Azelaic acid

Oral Antibiotic

Oral Antibiotic

Tetracycline

Doxycycline

Minocycline

Bactrim

Azithromycin

3-6 months

Use in combination

Oral Antibiotics

Erythromycin

Effective

High resistance rate

Pregnancy/ <8 yo

No ampicillin, amoxicillin or cephalexin

Should be avoided

Consensus



Bacterial Resistance


Clinically relevant

Cross resistance

S. aureus in nares

Streptococci in oral cavity

Enterobacteria in gut

―S. pyogenes colonization and resistance in the

oropharynx are associated with antibiotic therapy in

patients with acne.‖

Antibiotics

Two fold risk

URI/ UTI

Margolis DJ et al. Arch Dermatol 2005;141:1132-6

―Benzoyl-peroxide-based treatment is the

most evidence-based approach‖… to

prevent antibiotic resistance Expert Opin Pharmacother. 2011 Feb 29 (Epub)

Bacterial Resistance


Clinically relevant

Cross resistance

S. aureus in nares

Streptococci in oral cavity

Enterobacteria in gut

Benzoyl peroxide use

Compliance



Treatment

Retinoids

Benzoyl peroxide

Topical antibiotic

Azelaic acid

Oral Antibiotic

Others (Dermatologist)

Spironlactone

Accutane

Accutane

Dryness

May lead to S. aureus colonization

Depression

Some patients with challenge/ rechallenge

No causal relationship

Lipids

Arthralgias

Hyperostosis & epiphyseal closure

No screening

Acne Summary

Follicular hyperkeratosis

Bacterial proliferation

Excess sebum

Inflammation

Excess androgen stimulation

Decrease manipulation

Compliance with medications



Acne - Mild

Comedomal

Retinoid

Salicylic Acid

Papular/ Pustular

Retinoid

Combination (benzoyl peroxide/clindamycin)

Salicylic Acid

Acne - Moderate

Oral antibiotic

Retinoid

Benzoyl peroxide (combination)

Salicylic acid

Women – spironlactone

OCP

Acne - Severe

Isotretinoin



Gram Positive OrganismsStaphylococcal Infections

Staphylococcal Cutaneous

Manifestations

Impetigo—bullous and nonbullous

Folliculitis/Furunculosis

Pyodermas

Botromycosis

Paronychia

Pyomyositis

Staph Scalded Skin Syndrome

Toxic Shock Syndrome

Septic Emboli

Staphylococcal Infections S. aureus is a normal inhabitant of the anterior

nares in 20% -40% of adults

MRSA Suspected if:

Local resistance patterns,

Lack of response to initial Antibiotics

Predisposing Factors:

Age > 65

Exposure to MRSA+ infection

Recent hospitalization

Chronic illness – i.e. HIV, Atopic Dermatitis



Staph Scalded Skin Syndrome

Flaccid bullae in

superficial epidermis

SSSS Predominantly a disease of infancy and

early childhood

Kids under age 6 and adults with renal dz

Due to one of two staph exotoxins: ET-A

and ET-B

3-5% mortality kids, 30-50% adults

Spares palms, soles, mucous membranes

SSSS Clinical Features

Sudden onset of fever, irritability, cutaneoustenderness and scarlatiniform erythema

Erythema accentuated in flexural and periorificial areas

Flaccid blisters and erosions develop within 24-48 hours

+Nikolsky’s sign

If culture, sample from mucous membranes



SSSS

Infections leading to SSSS typically

originate in the nasopharynx

Other foci of infection

Umbilicus

Urinary tract

Conjunctivae

Blood

Treatment

Beta-Lactamase resistant (Diclox,

Cephalexin) x 1 week

Supportive skin care

Isolation of newborns

Fluid and electrolyte management

Identify and treat S. aureus carriers

Superficial Pustular

Folliculitis

Superficial folliculitis

Thin-walled pustules at the

follicle orifices

Extremities and scalp

Yellowish, white, domed

pustules in crops

S. aureus most frequent

cause



Sycosis Vulgaris

(Sycosis Barbae)

Deep-seated folliculitis

Bearded area

Involves the entire depth of the follicle

Erythematous follicular papules and pustules, usually affecting the upper lip

Vs Tinea Barbae rarely affects uppr lip

Many patients have seborrhea tendancy.

Bullous Impetigo

Occurs characteristically in newborns and young

Common sites are the face and hands

4-10 days old: bullae on face and hands, weakness, fever, or low temperature Diarrhea w/ green stools

Warm climates, adults with strikingly large fragile bullaein axillae or groin (not scalp)

Circinate, weepy/crusted lesions (impetigo circinata).

Treatment First-Line

Antibacterial soap and water TID

Mupirocin (Bactroban)/ retapamulin (altabax)

Topical Clindamycin (I don’t use)

Topical Chlorhexidine/ Benzoyl Peroxide wash

Second-Line

First-generation cephalosporin

Penicillinase-resistant penicillin

oxacillin, cloxacillin, dicloxacillin

Acute Inflammation

Soaks with Burow’s solution diluted 1:20 (Domeboro)

Drysol nightly for chronic folliculitis has been

reported to be useful



Abscesses & Furuncles

Walled off collections of pus

Abscess – can occur anywhere; fluctuant

Furuncle (―Boil‖) - bacterial infection of hair follicle with extension into surrounding tissue

Carbuncle – collection of furuncles, extend deep into tissue

Usually caused by S. aureus

Furuncle

Abscess

Furuncle/Carbuncle

Local barrier compromise

predisposes to infection

Systemic Disorders:

Alcoholism

Malnutrition

Blood dyscrasias

Disorders of neutrophil

function

Immunosuppression (AIDS)

Diabetes

Treatment

Warm compresses +/- antibiotics

First generation cephalosporin or lately

MRSA coverage

Bactroban to anterior nares for 5 days to

prevent recurrence

Inflammed: Don’t I & D

If localized and definite fluctuation,

*** I & D ****

Pack cavity with Wicking/ Vaseline gauze



Staph/MRSA

Options

Sensitivities: Key to culture

Doxycycline/ Minocycline

Bactrim

Prevention: Self- Contamination

Clorox baths

Benzoyl peroxide wash

Zinc pyrithione: prevents binding

Chlorhexidine: daily bath reduced incidence

MRSA

I&D

Know susceptibilities locally

Don’t forget rifampin;

Colonization

Creams, bar soap, towels, BP cuffs, Gym

lockers/ mats, Day care changing table,

Also follows Strep pharyngitis



Pitted Keratolysis

Bacterial infection of the plantar

stratum corneum

Men with sweaty feet, during hot,

humid weather are most susceptible

Organisms

Corynebacteria,

Micrococcus sedentarius

Treatment

Topical antibiotics

Erythromycin or clindamycin

Miconazole or clotrimazole

cream

Benzoyl peroxide gel

Alumninum chloride solution

Green Nail Syndrome

Onycholysis of the distal

portion of the nail

Greenish discoloration of the

separated areas

Treatment

Soaking nails in 1% acetic acid

solution BID x 1 hour

Trimming the affected portion of

the nail plate and Neosporin

BID

Pseudomonal Toe Web

Infection Often begins with a dermatophytosis

Prolonged immersion can cause maceration of

the interdigital spaces

Leads to overgrowth of gram-negative

organisms

Pseudomonas aeruginosa is the most

prominent

Can also see E. coli and Proteus

Treatment

Topical antifungals

Topical antibiotics

Acetic acid compresses *******

Systemic antibiotics (if severe)

3rd generation cephalosporin

Fluoroquinolone (cipro or ofloxacin)



Pseudomonas Aeruginosa

Folliculitis 1-4 days after bathing in a hot tub,

whirlpool, or public swimming pool

Sides of the trunk, axillae, buttocks, proximal extremities

Lasts 7-14 days without therapy

Treatment 3rd generation cephalosporin

Fluoroquinolone

Prevention Water filtration, automatic chlorination,

pH 7.2-7.8, frequent changing of waer

pruritic follicular,

maculopapular,

vesicular or pustular

THANK YOU!!!

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