bacterial infections col. (dr.) rajesh verma m.d. dnb. (derm & ven) (prof & hod) maj. (dr.)...
DESCRIPTION
Introduction Pyoderma: Bacterial infections of skin. Caused by mainly 2 Gram positive organisms: Staphylococcus aureus : Intact skin Group A beta-hemolytic Streptococci : Traumatic skin Other bacteria: Corynebacteria Kytococcus (Erstwhile Micrococcus) PseudomonasTRANSCRIPT
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Bacterial Infections
Col. (Dr.) Rajesh VermaM.D. DNB. (Derm & Ven) (Prof & HOD)
Maj. (Dr.) Pankaj Das Dept. of Dermatology,
Armed Forces Medical College, Pune
Digital Lecture Series : Chapter 03
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CONTENTS
Introduction Classification Primary pyodermas
• Superficial folliculitis• Impetigo• Ecthyma• Sycosis barbae• Furuncle• Carbuncle• Chronic folliculitis• Erysipelas• Cellulitis
• Necrotising fasciitis• Paronychia• Staphylococcal scalded skin
syndrome• Toxic shock syndrome• Corynebacterial infections
Secondary pyodermas Management principles
MCQs Photo Quiz
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Introduction
Pyoderma: Bacterial infections of skin.
Caused by mainly 2 Gram positive organisms:• Staphylococcus aureus : Intact skin• Group A beta-hemolytic Streptococci : Traumatic skin
Other bacteria:• Corynebacteria• Kytococcus (Erstwhile Micrococcus)• Pseudomonas
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Primary • Superficial :
– Follicular : Superficial folliculitis Follicular impetigo
– Non-follicular : Impetigo• Deep :
– Follicular : Sycosis barbae, Furuncle, Carbuncle– Non-follicular : Ecthyma, Cellulitis, Erysipelas, Paronychia,
Necrotising fasciitis Secondary• Infected eczemas, Infected ulcers, etc
Classification : Pyoderma
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Superficial infection of the hair follicle
Staphylococcus aureus
Scalp and face
Follicular pustules with a rim of erythema
Superficial Folliculitis
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Superficial Folliculitis
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Pre-school children
Face, arms, legs
Predisposing factors: close contact, atopic dermatitis, warmth, poor
hygiene, minor trauma etc.
Staphylococcus aureus, Group A beta hemolytic Streptococci
Clinical types :
• Impetigo Contagiosa
• Bullous Impetigo
Impetigo
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Predilection for peri-oral and
peri-nasal area.
Honey-coloured crusted plaques.
Heal without scarring
Impetigo Contagiosa
Peri-oral & peri-nasal area showing Impetigo Contagiosa
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Bullous impetigo is caused by an Epidermolytic Toxin.
Produced at the site of infection by Staphylococcus aureus.
Causing intra-epidermal cleavage, clinically manifesting as - Bullae.
Bullous Impetigo
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Vesicles / Bullae with
Clear / Turbid fluid
Brownish crusts
Moist erosions.
Bullous Impetigo
Lower abdomen and groin of an infant with Bullous Impetigo
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Diabetes, Immune-compromised
Legs & buttocks
Thick, chocolate coloured, adherent
crust, with a rim of erythema.
When removed, a punched-out ulcer
results.
Heals with scarring.
Ecthyma
Thigh of a patient with Ecthyma
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Sycosis barbae
Furuncle(Boil)
Carbuncle
Deep Folliculitis : Types
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Staphylococcus aureus
Erythematous folliculardiscrete papules or pustules
Coalesce
Raised plaque, studded with pustules.
“Fig like” appearance
Sycosis barbae
Beard region in a patient with Sycosis barbae
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Acute, deep infection of a hair follicle.
Hair bearing areas.
Staph aureus.
Tender, inflammatory nodule.
Pus discharge.
Heals with scarring.
Furuncle
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Thigh of a patient, showing a Furuncle
Furuncle
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Deep infection of a group of contiguous hair follicles.
Diabetes, immune-compromised.
Nape of neck, shoulders, hips and thighs.
Pus discharge from multiple points- “Sieve like appearance".
Carbuncle
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Nape of neck with Carbuncle
Carbuncle
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DCPA (Dermatitis Cruris Pustulosa et
Atrophicans)
Recalcitrant, lasting for several years.
Young Indian males
Involves anterior aspect of lower legs
bilaterally; may extend up to the thigh.
Usually clears after development of
atrophy
Chronic Folliculitis
Legs of a patient with Chronic Folliculitis
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Soft tissue infections of skin.
Group A beta-hemolytic Streptococci
Staphylococcus aureus
Characterised by
• Local : Erythema, edema, tenderness, pain.
• Regional: Lymphangitis, Lymphadenitis
• Systemic: Fever, Leukocytosis
Erysipelas and Cellulitis
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Group A beta-hemolytic Streptococci
Superficial dermis & lymphatics
Raised plaque
Well demarcated edge
Warm and tender
Erysipelas
Arm of a patient with Erysipelas
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Staphylococcus aureus or Group A beta-
hemolytic Streptococci
Deeper dermis & subcutaneous tissue
Diffuse edge- not well demarcated
Warm and tender
The surface may show focus of pus and
necrosis, which may ulcerate
Cellulitis
Left leg with Cellulitis
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Progressive destruction of
• Muscle fascia
• Overlying subcutaneous fat.
Muscle tissue is frequently spared: generous blood supply.
In initial stages- the overlying tissue may appear unaffected.
It is this feature that makes necrotizing fasciitis difficult to diagnose
without surgical intervention.
Necrotising Fasciitis
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The affected area may become
erythematous, edematous, warm, shiny, and
exquisitely tender.
If diagnosis is delayed- skin breakdown and
frank cutaneous gangrene results.
Compartment syndrome: surgical
emergency.
Fasciotomy
Necrotising Fasciitis
Dorsum of right foot and toes with necrotising fasciitis.
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Paronychia is the infection of the lateral and/or of the proximal nail folds. Predisposing factors - Cuticular damage• Overzealous manicuring, especially with unsterile instruments. • Nail biting, thumb-sucking• Diabetes mellitus• Ingrown toe nail• Occupations in which the hands are frequently immersed in water.
(home-makers, chefs etc) Classified as:• Acute• Chronic
Paronychia
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Characterized by acute onset of pain
and erythema of the posterior and/or
lateral nail folds.
With subsequent development of a
superficial abscess.
Staphylococcus aureus and Group A
beta-hemolytic Streptococci
Acute Paronychia
Nail with Acute Paronychia
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Treatment:• Topical :
– Warm compresses or soaks without abscess– Topical antibiotics
• Systemic antibiotics & NSAIDs
• Systemic : – Antibiotics– NSAIDs with abscess
• Surgical : – Incision and drainage.
Acute Paronychia
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Etiology :• Damage to cuticle of nail • Chronic Eczema• Chronic Candida infection
Treatment :• Difficult to treat• Keeping hands as dry as possible• Avoid irritants and allergens • Topical anti-fungals and
corticosteroids
Chronic Paronychia
Middle, ring and little fingers with Chronic Paronychia
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A disease affecting the neonates, infants and young children.
Febrile and irritable.
Diffuse blanching erythema and flaccid blisters, especially in flexural
areas, buttocks, hands and feet.
Gentle pressure applied to the skin results in separation of the upper
epidermis from the underlying dermis. (Nikolsky's sign).
Staphylococcal Scalded Skin Syndrome
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Foci of infection of Staphylococcus aureus.
Epidermolytic toxin
Acts on intra-epidermal desmosome complex
Fragile, tense bullae and vesicles
Erosions
Staphylococcal Scalded Skin Syndrome
Staphylococcal ScaldedSkin Syndrome
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Neck of a child with Staphylococcal Scalded Skin Syndrome : showing widespread peeling of skin, on a background of diffuse erythema.
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Acute febrile multisystem disease.
Staphylococcus aureus toxin- mediated disease.
TSST-1: Toxic Shock Syndrome Toxin-1
Predisposed individuals: Post surgical and those with catheters and
canulae.
Diffuse erythema of body with systemic symptoms.
• Systemic antibiotics
• Intensive supportive treatment
Toxic Shock Syndrome
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Cardinal signs and symptoms :• Fever with chills• Myalgia• Dizziness, headache, syncope and hypotension• Diffuse erythema• Reduced urine output • Edema of extremities• Severe diarrhoea, nausea, vomiting and abdominal pain • Confusion, dizziness, irritability, agitation and hallucination.
Toxic Shock Syndrome
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Corynebacterium minutissimum
Asymptomatic red-brown macules,
plaques at body folds
Wood’s lamp: Coral Red fluorescence.
Oral : Erythromycin
Topical : Fusidic acid
Erythrasma
Groin fold showing a hyper-pigmented macule- Erythrasma
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Corynebacteria
Axillae and groin
Adherent yellow, brown-black
deposits on hair shaft.
Topical : Clindamycin
Shaving/clipping.
Systemic : Erythromycin
Trichomycosis Axillaris
An up close clinical photograph of axilla of a patient with
Trichomycosis axillaris
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Kytococcus sedentarius (Micrococcus
sedentarius).
Hyperhidrosis of feet; occlusive
footwear
Foot odour, itching
Discrete / confluent pits
Oral : Erythromycin
Topical : Fusidic acid, Benzoyl Peroxide
Pitted Keratolysis
Sole with Pitted Keratolysis
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Pyodermas developing in a pre-existing
dermatosis.
e.g. infected eczema, infected vasculitic
ulcer etc.
Secondary Pyodermas
Pyoderma secondary to Candidial Intertrigo of 4th web
space of the foot.
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Identify and assess the predisposing factors : • Poor hygiene• Malnutrition• Recurrent trauma• Diabetes mellitus• Pre existing skin diseases• Congenital and acquired Immunodeficiency
Investigations :• Work up for any predisposing factors. • Smear, Culture and Antibiotic Sensitivity test (SCABS).
Management Principles
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Soaks / compresses : Condy’s solution (KMNO4) Topical antibiotics: • Mupirocin• Framycetin• Sisomicin• Nadifloxacin• Neomycin• Gentamicin • Polymyxin B• Bacitracin• Fusidic acid
Management Principles : Topical Therapy
Topical agents used in the treatment of Pyodermas
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Indications of systemic therapy :• Fever, tachycardia• Regional lymphadenopathy• Danger area of face• Pyodermas not responding to topical therapy• Rapidly progressing pyodermas Available systemic agents :• Semi-synthetic Penicillins• Cephalosporins• Macrolides• Tetracyclines• Quinolones
Management Principles : Systemic Therapy
Some of the available systemic agents
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Q.1) Toxic Shock syndrome is caused by A. TSST-1 B. TSST-2C. TSST-3 D. TSST-4
Q.2) Drug of choice for Erythrasma is :E. DicloxacillinF. Amoxycillin + Clavulanic acidG. DoxycyclineH. Erythromycin
MCQ’S
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Q.3) Bullous impetigo is caused byA. Staphylococcus aureusB. Group A beta- hemolytic StreptococciC. Corynebacteria minutissimumD. Hemophilus influenza
Q.4) The organism causing Pitted Keratolysis - Kytococcus was previously known as
E. StreptococcusF. PeptostreptococcusG. CorynebacteriaH. Micrococcus
MCQ’S
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Q.5) A 3 month old infant, presented to the Dermatology OPD with diffuse erythema of the body with fever and irritability of 02 days and flaccid blisters on neck and axillae of 01 day duration. On examination, Nikolsky's sign was found to be positive. What is the likely diagnosis?
A. Toxic Shock SyndromeB. Staphylococcal Scalded Skin SyndromeC. Bullous impetigoD. Impetigo contagiosa
MCQ’S
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Q. What is the Diagnosis?
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Q. What is the Diagnosis?
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Q. What is the Diagnosis?
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Thank You!