Derma lecture

1. S. TENTISHEV MEMORIAL ASIAN MEDICAL INSTITUTE
DEPARTMENT OF THERAPEUTIC DISCIPLINES
LECTURER: KAN PAK
Bacterial
Infections
(pyodermas)

2. • Pyodermas (from the greek pyon - pus, derma - skin) - purulent skin
diseases. They represent a group of skin lesions that are diverse in
clinical manifestations. They occupy the first place in frequency among
all dermatoses, accounting for 38-45 % and the fourth place among all
diseases in children after influenza and acute respiratory infections
during the epidemic and after cardiovascular diseases.

3. ETIOLOGY
• Pathogens: staphylococci, streptococci, but suppurative processes in the skin can also be caused by
gonococci, meningococci, fungi, vulgar protea, pseudomonas aeruginosa.
• Staphylococci are morphologically Gram-positive cocci that are facultative anaerobes, that do not form
capsules and spores. There are 3 types:
 Aureus (pyogenic)-the most pathogenic, especially nosocomial strains.
 Epidermal (conditionally pathogenic) - genetic factors causes pyoderma in certain circumstances
 Saprophytic - causes pyoderma in the presence of obvious immunodeficiency states, HIV infection.
• Properties of pathogenic phagotypes:
 Hemolytic
 Plasma coagulating
 Fibrinolytic
 Lecithinase activity
 Production of hyaluronidase (lidase)
 Exfoliative toxin.

4. • Streptococci are gram-positive, non motile, non spore forming, catalase-negative cocci that
occur in pairs or chains. Most streptococci are facultative anaerobes, and some are obligate
(strict) anaerobes.
• They are divided into three groups by the type of hemolysis on blood agar:
β-hemolytic (clear, complete lysis of red cells)
α hemolytic (incomplete, green hemolysis)
γ hemolytic (no hemolysis)
• Produce exotoxins:
hemolysin,
leukocidin,
necrotoksin,
lethal toxin,
erythrogenic toxin.

5. PATHOGENESIS
• The mechanism of development of pyodermitis, the clinic and their course depend on:
The type of pathogen, its quantity, pathogenicity and virulence of a particular strain.
Age features of the individual.
Immunobiological reactivity of the body.
The peculiarity of the interaction of micro and macroorganisms.
The pathway of the pathogen.
Localization of the pathological process

6. • Among the factors contributing to the onset of the disease, external (exogenous) and internal (endogenous) are distinguished:
Exogenous pathogenetic factors:
 Mechanical microtrauma (abrasion, cuts, abrasions).
 Damage to the epidermis with solutions of a weak concentration of acids, alkalis.
 Maceration of the skin (loosening of the stratum corneum of the epidermis with prolonged contact with a humid environment).
 Dustiness of air.
 High and low temperature.
Endogenous pathogenetic factors:
 Violation of water metabolism (overdrying of the skin).
 Violation of carbohydrate metabolism (diabetes mellitus).
 Hypovitaminosis (often A and C).
 Psycho-emotional overstrain.
 Gastrointestinal tract diseases and hepatobiliary system.
 Hyperhidrosis.
 Inhibition of the immune system during prolonged steroid therapy, cytostatics and others.
 Foci of chronic infection (tonsillitis, carious teeth, cervical erosion).
 Intoxication.
 AIDS and others

7. In pathogenesis, toxic and enzymatic substances produced by streptococci and
staphylococci also play a role.
Staphylococci penetrate the skin through the hair follicles, glands, and streptococci
through the stratum corneum.
Staphylococcal skin lesions are more common in men, and streptococcal in women
and children.
Pyoderma can be an independent disease or a complication of another disease
(scabies, neurodermatitis, lice), which is accompanied by itching, and this leads to
damage to the skin, an entrance gate is formed for microbial infection.

8. CLASSIFICATION
• Three groups are distinguished depending on the pathogen:
Staphyloderma.
Streptoderma.
Strepto-staphyloderma.
• Depending on the duration of the process:
Acute (to 2 months)
Chronic (more than 2 months)
• Depending on the depth of skin lesions:
Deep
Superficial
• Depending on the mechanism of development:
Primary
Secondary

9. • Staphylococcal pyodermas of newborns:
Vesiculopustulosis
Finger's pseudofurunculosis
Epidemic pemphigus of newborns
Staphylococcal scalded skin syndrome
• Staphylococcal pyodermas of children and adults:
Ostiofolliculitis
Folliculitis
Furuncle
Carbuncle
• Staphylococcal pyodermas only in adults:
Hidradenitis
Vulgar sycosis

10. VESICULOPUSTULOSIS
• Purulent inflammation of the excretory duct of
eccrine sweat glands. Develops in premature
babies, with artificial feeding, violation of the
rules of swaddling children ( high temperature and
humidity).
• Localization – scalp, neck, skin folds. Numerous
pustules surrounded by a hyperemic rim. The
disease duration with a favorable outcome of 7-14
days.
• Treatment – antiseptic agents (0.25-1% silver
nitrate solution, 2% brilliant green solution),
ointment with antibiotics.

11. FINGER'S PSEUDOFURUNCULOSIS
(MULTIPLE ABSCESSES OF CHILDREN)
• Purulent inflammation of sweat glands, deeper comparatively
to vesiculopustulosis. Develops in weakened, premature,
artificially fed and not well-groomed babies with increased
sweating.
• Localization – the scalp, the back surface of the body,
buttocks, thighs. Nodes of a bluish-purple color are formed,
which are then softened, opened with the discharge of cream-
like pus, without a necrotic rod, followed by the formation of
fistulous passages and ulcers, with scar formation in outcome.
• Treatment: lesions are wiped with disinfecting alcohol
solutions. Abscesses are opened and lubricated with aniline
dye solutions, ointments (levomekol, levosin), zinc paste. On
abscesses – UVA, dressings with 10% sodium chloride
solution.

12. EPIDEMIC PEMPHIGUS OF NEWBORNS
Caused by staphylococci of the 2nd phage group, it
releases a special exfoliative toxin, which causes the
ability to exfoliate the skin. It occurs in the first days,
mainly until the 7-10th day after birth. Source of
infection: nurses, medical personal.
Localization – trunk, folds. It begins with the
appearance of bulla on a hyperemic background, with
serous, then serous purulent content. Bullas burst
easily, forming erosive surfaces with uneven pale pink
bottom and flaky skin. With a favorable course the
erosions epithelialized with the formation of
temporary pigmentation and peeling. Under
unfavorable course of erosion, they merge with each
other capturing a significant part of skin cover and
may cause life-threatening condition.

13. STAPHYLOCOCCAL SCALDED SKIN SYNDROME
Severe form of neonatal pemphigus. The causative agent is Staphylococcus aureus 2 phage
groups, which release exfoliative toxin and cause massive acantholysis in the epidermis and the
formation of large surface blisters. Infection of newborns occurs in the first days after birth, from
mothers and medical personal infected with S. aureus.
Localization – the beginning of the navel and mouth with spread to other skin areas and folds.
There are 3 stages:
Erythematous – blisters occur on the erythematous skin.
Exfoliative – sluggish blisters with a loose tire, opened with the formation of erosion,
characterized by peripheral exfoliation and positive Nikolsky’s sign.
Regenerative – reduction of hyperemia and swelling of the skin.

14. SSSS usually starts with fever, irritability and widespread
redness of the skin. Within 24-48 hours fluid-filled blisters
form. These rupture easily, leaving an area that looks like a
burn.
Characteristics of the SSSS rash include: tissue paper-like
wrinkling of the skin is followed by the appearance of
large fluid-filled blisters (bullae) in the armpits, groin and
body orifices such as the nose and ears. Rash spreads to
other parts of the body including the arms, legs and trunk.
In newborns, lesions are often found in the diaper area or
around the umbilical cord. Top layer of skin begins peeling
off in sheets, leaving exposed a moist, red and tender area.
Other symptoms may include tender and painful areas
around the infection site, weakness, and dehydration.

15. • Treatment of SSSS usually requires hospitalisation, as intravenous antibiotics are
generally necessary to eradicate the staphylococcal infection. A penicillinase-
resistant, anti-staphylococcal antibiotic such as flucloxacillin is used. Other
antibiotics include nafcillin, oxacillin, cephalosporin and clindamycin.
Vancomycin is used in infections suspected with methicillin resistance (MRSA).
Depending on response to treatment, oral antibiotics can be substituted within
several days. The patient may be discharged from hospital to continue treatment at
home.

16. Ostiofolliculitis is an acute inflammation of the
inlet of hair follicle. On the skin: a small cone-
shaped pustule pierced by a hair. Around a small
rim of hyperemia. When healing, a crust forms,
the hair does not fall out. Predominant sites: lower
limb, post waxing on thighs or deltoid region.
Folliculitis is an acute purulent inflammation of
most (1/3) or the entire hair follicle.
Localization – face, scalp, neck, limbs, trunk.
On the skin: pustule, around which there is an
infiltration and a more extensive zone of
hyperemia. After healing, a point scar forms.
Subjectively the pain or itching may appear.

17. Furuncle – acute purulent necrotic inflammation of
the hair follicle and sebaceous gland.
Localization – shoulders, buttocks, thighs, body,
more often – on the face, in the area of the nasolabial
triangle, chin, neck, axillary hollows. It begins with
ostiofolliculitis, which is transformed into a deep
folliculitis, and then into a skin abscesses (infiltration
stage). The node is opened with the release of pus,
which exposes the dead tissue of greenish color –
“necrotic core” (abscessing stage), it is rejected with
the formation of a granulating crater-like ulcer,
which is scarred (stage of ulcer and scarring). With
single furuncles, the general condition does not
suffer. With multiple boils and furunculosis there
may be fever, weakness, headache.

18. Carbuncle – conglomerate formed from a
confluence of many furuncles.
The skin over the infiltrate is bright pink, then
purple-red with a bluish tinge in the center. After 8-
12 days, the infiltrate slowly softens, pustules form
on the surface of the node. Several perforations are
formed on the surface of the carbuncle, from which
thick pus with blood is released. Then melting of
the entire skin with the formation of a deep ulcer,
the bottom of which is a solid necrotic mass of
dirty green color. The ulcer is filled with
granulations and heals the formation of a rough
scar. Subjectively- sharp pain, temperature rise up
to 38-39 degrees.
Complications such as phlebitis, thrombophlebitis,
cerebral thrombosis and common sepsis.

19. Furunculosis – is chronical
recurrent developing of
furuncles, boils appear
sluggishly in certain areas of
the body, for example, at first
boils appear on the buttocks,
appear after a while on the
face (and then disappear on the
buttocks). There are some
predisposing factors as
endocrinopathies,
immunocompromised patients.

20. Vulgar sycosis
Chronic recurrent purulent inflammation of the hair
follicle in the area of the beard, mustache, eyebrows,
pubis, external openings of the nasal cavity, axillary
fossa. It occurs exclusively in men – after shaving.
Follicular pustules appear, ostiofolliculitis develops.
The skin is hyperemic, infiltrate, cyanotic-purple;
pustules, erosion-purulent crusts are visible on its
background. Hair does not fall out, but is easily
pulled out; loose hair is surrounded at the root of the
vitreous clutch, which is a swollen root sheath.
Heals without scars.
Treatment: antibiotics, topically – it is forbidden to
shave in the affected area, treatment with an alcohol
solution of salicylic and boric acids,
chloramphenicol, fucorcinum, to the infiltration
areas – antibiotic ointment, combined
corticosteroids.

21. Hidradenitis – acute or recurrent purulent
inflammation of the apocrine sweat glands.
Localization axillary region, inguinal folds, in the
region of the labia, scrotum, around the nipples
of the mammary glands, in the perianal region.
Children before puberty and the elderly do not
get sick, because in children the apocrine glands
have not yet developed, and in the elderly , the
function of the glands fades away.
One or more painful knots with a cherry bone or
hazelnut, which may increase in size, are
soldered to the surrounding skin.
During abscess formation, the skin above the
nodes become thinner, softens, and fluctuation
appears. Nodes open with a large amount of
cream-like pus (without necrotic rod) and ends
with scarring.

22. STREPTODERMA
• SUPERFICIAL
Impetigo streptococcal - hyperemia
appears on the apparently unchanged skin,
and then a flaccid, flabby pustule (conflict)
with a very thin tire forms. Pustules quickly
open, the tire sticks to the bottom with pus,
which externally manifests itself as serous-
purulent crusts. The exudate is clear or
cloudy. After rejection of the crust - a slight
depigmentation, which passes without a
trace.
Impetigo bullous - characterized in that the
tire is thicker and does not tear. Bubbles
inflate. Further evolution is similar

23. Streptococcal jam (synonyms for
impetigo of the corners of the mouth,
slit-like impetigo) - occurs in the
corners of the mouth, and is no
different.
Streptococcal paronychia (tourniole) is
an inflammation of the periungual
platen. On the skin appears conflict,
which evolves with the formation of a
crust. Heals without a scar.

24. Papular syphil-like impetigo -
characterized by the presence on
the skin of multiple small-size
conflicts with an infiltrated base
(papule). It resembles Syphilitic
papules. It occurs in children
under 1 year old.
Dry streptoderma (simple lichen) -
is characterized by the appearance of
white slightly flaky spots on the skin
that looks like skin sprinkled with
flour (the stratum corneum of the
epidermis is affected).

25. Deep
Ecthyma vulgaris occurs in patients with hypovitaminosis, alcoholism
and vascular diseases of the lower extremities. Large conflicts 1.5-2 cm
in size appear on the legs and thighs, which dry up into a brown crust,
under the crust there is a round or oval ulcer with purulent discharge.
Ulcers are soft and painful. During healing, a scar forms.
Penetrating (boring) ecthyma can penetrate the fascia, muscles, and
bones.
Gangrenous ecthyma - accompanied by gangrene. Refers to deep
vasculitis.

26. STREPTO-STAPHYLODERMIA
Superficial
• Impetigo vulgar proceeds more aggressively. The contents of the pustules are
not serous-purulent, but clearly purulent. It is accompanied by skin infiltration.
Deep
• Chronic ulcerative pyoderma is a more extensive process (provided by
streptococci) and deep (provided by staphylococci).
• Chronic ulcerative vegetative pyoderma - purulent focus + vegetation of
microorganisms.
• Chancriform pyoderma (reminiscent of a hard chancre) - the diagnosis is made
on the basis of syphilis exclusion.

27. • Pyogenic granuloma - refers to benign vascular tumors of the skin. A volumetric
formation consisting of overgrown dermis vessels that bleed easily, bulge and
resemble a “raspberry berry” on top of the formation is covered with a purulent
crust. As a rule, it has a leg. It occurs on the area of the skin that is constantly
being traumatized (ankle area, face in the area of shaving in men).

28. The principles of treatment of pyoderma
Local (external) therapy
Opening and removal of the tire of the abdominal element.
Removal of purulent contents with a 3% solution of h202 (with large foci).
Treatment of erosion with an antiseptic solution or aerosol (diamond greens,
fucorcin), an antibiotic ointment (gentamicin).
Lubricating the elements with an antibacterial ointment (cream, gel, lotion).

29. General (systemic) treatment)
1. Etiotropic.
• Antibiotics.
• Sulfanilamides with intolerance to antibiotics.
• Their combination with stable forms of pyoderma.
2. Pathogenetic.
• Specific immunotherapy (staphylo- or streptococcal toxoids, antifagins,
gammaglobulins) - in the chronic course of the pyodermatitis process to prevent
relapse and stimulate the body’s defense mechanisms.
• nonspecific immunotherapy (immunomodulatory, autohemotherapy, pyrogenic,
UFO blood, interferons: cycloferon, amiksin; dekaris).

30. 3. Symptomatic
• Vitamin therapy - vitamin C, vitamins of groups A and E , purified sulfur, which stimulate the
compensatory protective reactions of the body, normalize redox metabolic processes in the
body.
• Enzyme preparations obtained from the pancreas of cattle (when the necrotic stem was formed)
- helak-forte, bifidum-bacterin . They have anti-inflammatory, proteolytic, anticoagulase
effects, thin the viscous secretion.
• Physiotherapeutic procedures (UV, UHF, ultrasound, electrophoresis).
• Chronic treatment is used only for abscess formation of hydrogenation, furunculosis, carbuncle
and multiple abscesses in children.
4. Sedative therapy.
With prolonged pyoderma (sycosis, furunculosis), a thorough examination of the patient is
necessary in order to identify predisposing factors (diabetes, anemia, gastritis) and their
elimination. To prevent the occurrence of a necrotic core, ichthyol, Vishnevsky ointment,
glucocorticosteroids under an occlusive dressing are used.
Restriction or complete prohibition of water procedures. Diet with a restriction of salt and easily
digestible carbohydrates (glucose, sucrose), carrot juice is recommended.

31. Criteria for prescribing systemic treatment
• Violation of the general condition.
• Fever.
• Dangerous localization of the process (nasolabial triangle).
• High prevalence and deep skin damage.
• The reaction of the lymph nodes (involvement of the lymphatic
system).
• The development of complications.
• Chronic course.

32. Prevention of pyodermatitis: Treatment and preventive measures and compliance with the rules of
personal hygiene.
Treatment and preventive measures:
• Elimination of production adverse factors of a sanitary-technical and
sanitary-hygienic nature.
• Conducting medical examinations.
• Suspension from work of persons in contact with substances sensitizing and
irritating, in the presence of seborrhea and acne vulgaris.
• Supervision of workers with recurrent forms of pyoderma.
• Systematic medical briefings on the prevention of skin diseases.
• Training workers on the use of skin care products, microtrauma treatment,
and assistance.
The rules of personal hygiene
• Swim at least 1 time per week, and with severe pollution - more often.
• Wash hands with soap.
• Monitor the cleanliness of the nails, cut them shortly.
• Timely treatment of microtrauma with iodine solutions, aniline dyes.