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Cutaneous Infections of skin disease management
- 3. Impetigo A common, highly contagious, superficial (subcorneal) skin infection Primarily affects children Organisms Non bullous Staphylococcus aureus, Streptococcus pyogenes Bullous Staphylococcus aureus Predisposing factors: Warm temperature High humidity Poor personal hygiene Underlying skin diseases • Transmission – direct contact
- 4. Non bullous Impetigo • 70% of all cases of impetigo • Single erythematous macule, rapidly evolves into a vesicle or pustule extend to surrounding skin • Hall mark: ‘honey-coloured’ yellow crust • Typical sites: face, peri- nasal, peri-oral, extremities
- 5. Bullous impetigo • Most common in neonates • Associated with weakness, fever and diarrhea • Sites: face, trunk, buttocks, perineum or extremities • Small vesicles flaccid, superficial bullae shiny, dry erosion • No surrounding erythema, or systemic symptoms
- 6. Other Bacterial Infections • Ecthyma • Erysipelas • Cellulitis • Folliculitis • Erythrasma
- 8. Ecthyma - Dermis Crusted sores beneath which ulcers form Strep and Stapyh main organisms More of a deep impetigo Heal with scarring
- 9. Ecthyma Predisposing factors: Lesions of neglect (lower extremities) excoriations insect bites minor trauma - diabetics elderly alcoholics
- 10. Impetigo & Ecthyma Treatment: • Erythromycin – EES improves compliance • Ampicillin/amoxycillin • Augmentin • Cephalosporin – Cephalexin, Cefuroxime
- 11. Erysipelas • Primarily an infection of dermis, significant dermal lymphatic involvement • Organisms: Strep pyogenes (GAS) • Clinical features: – a small plaque of erythema, clearly demarcated from uninvolved tissue • Sites: face, lower extremities • Regional lymphadenopathy • Treatment: – Penicillin (cloxacillin) * 10-14 days – Macrolides for penicillin allergy
- 12. Cellulitis Very common skin infection deeper dermis & subcutaneous fat Organisms: • Immuno-competent • GAS, Staph aureus • Immuno-compromised • mixture of gram +ve cocci and both gram –ve aerobes and anaerobes Erysipelas Cellulitis
- 13. Cellulitis
- 14. Cellulitis Sites : – Adults: extremities; Children: head & neck Portal of entry: • break in skin barrier, e.g. cuts, ulcers, toe web spaces fungal infection • hematogenous route Diagnosis: Clinical Treatment: – Mild : Oral Cloxacillin 50–100mg / kg / 24 hours QID * 7–10 days – Severe : Diabetics or decubitus ulcers broad spectrum antibiotics (e.g. piperacillin / tazobactam » Immobilization, elevation +/- wet dressing
- 15. Furuncles (Boils) • Inflammatory nodule affecting a hair follicle • Tender induration and severe inflammation followed by necrosis • Heals with scarring • Affects all ages • Several boils coalesce to form a carbuncle Furuncle Carbuncle
- 17. Fungal Infections • Dermatophyptes (Trichophyton, epidermophyton and microsporum ) – Tinea corporis, cruris, etc • Yeast : Tinea versicolor, Candidiasis • Mould : Aspergillus Dermatophytosis Long filaments Candidiasis
- 21. Tinea pedis • Athletes foot • Singapore foot • Hong Kong foot
- 22. Tinea capitis Wood’s lamp Fluorscence with Woods light
- 23. Tinea Manum • Tinea affecting unilateral palm Tinea Nigra Tinea Imbricata
- 24. Diagnosis of Fungal Infection in the Office 40% KOH + Parker’s ink 40% KOH
- 25. Skin scraping for microscopy The scale from the edge of a scaling lesion is scraped on to a glass slide with a No. 15 scapel blade
- 26. Potassium hydroxide preparations for fungal infection Aspirate 40% KOH and put a few drops onto slide Cover slide with a cover slip
- 27. Potassium hydroxide preparations for fungal infection View under microscope Septated hyphae
- 29. Dermatophytes Treatment: • T. corporis, cruris – Localised – topical – Extensive - systemic • Tinea capitis, T.pedis, Onychomycosis – Systemic antifungal – Griseofulvin – Terbinafine – itraconazole
- 32. Candidiasis • Topical – Azoles eg Miconazole, Clotrimazole • Systemic – Azoles eg Itraconazole, Fluconazole • Determine underlying cause – Diaper rash – Obesity – diabetes
- 33. Case 4 Tinea versicolor Pityriasis versicolor
- 34. Tape test for pityriasis versicolor Stick the cellophane tape onto the scaly area Remove the tape gently
- 35. Tape test for pityriasis versicolor Put a few drops of Parker’s blue ink, mixed with KOH onto glass slide Cover the slide with the cellophane tape
- 36. Tape test for pityriasis versicolor View under microscope Hyphae and spore – ‘spaghetti and meatball’ appearance
- 37. Tinea versicolor Treatment: • Topical – Azoles eg miconazole, clotrimazole – Selsun shampoo – Nizoral shampoo • Systemic – Itraconazole – Ketoconzole – risk of fulminant hepatitis • Maintenance – Nizoral shampoo wkly as soap – Sastid soap
- 38. Principles of diagnosis and treatment • Consider a fungal infection in any patient where isolated, itching, dry, and scaling lesions occur without any apparent reason—for example, if there is no previous history of eczema . Lesions due to fungal infection are often asymmetrical examined after treatment with 10% potassium hydroxide but culture results take at least two weeks • Lesions to which steroids have been applied are often quite atypical because the normal inflammatory response is suppressed—tinea incognito. The patient often states that the treatment controls the itch but the rash persists and may change into a tender form of folliculitis. In such cases microscopy of lesions is usually strongly positive • Wood’s light (ultraviolet light filtered through special glass) can be used to show Microsporum infections of hair, as they produce a green-blue fluorescence
- 39. Case 5 Scabies
- 40. Scabies o Highly pruritic and contagious parasitic disease o Caused by obligate human adult female mite Sarcoptes scabiei var hominis o strongly associated with poverty and overcrowding o Prevalence commonly higher in children and sexually active adults o Transmission by direct skin-to-skin contact with an infested person, fomites possible o History of outbreak in family and or Asrama o Characteristic nocturnal itch
- 41. Scabies mite - morphology • Pearly white, ovoid body, eyeless (therefore blind, “kudis buta” in Malay ?connections) • 0.4 x 0.3 mm in size (can’t be seen with naked eye) • Cannot fly or jump or walk • Cannot survive outside its human host for longer than 3 days x100
- 42. Detection of scabies mite Put a drop of oil on the blade Scrape the area ( papules or burrows) with the blade Sprade the oil on the glass slide
- 43. Detection of scabies mite View under microscope Scabies mites See mites faeces or eggs
- 44. Treatment of scabies Topical medications • Topical benzyl benzoate lotion – (25% for adults, 12.5% for children aged 3 to 12) – 3 applications at 24-hour intervals • Topical lindane ( 1%) – 2 applications for 8 hours • Topical permethrin 5% lotion – single application, washed after 8 hours • Crotamiton cream ( Eurax) repeat nightly for 3 to 5 night • Sulphur in calamine lotion : useful in pregnant or nursing mother and neonates Oral medication • Ivermectin • 200ug/kg
- 45. Treatment of scabies • Procedures – apply the entire skin from neck below – pay special attention to the groin, fingerwebs, toewebs • Adjuvant therapy – Antihistamine for relief of itch – Topical corticosteroids • Environmental measures – Treatment of all close contacts even if asymptomatic – Wash all bed linens, towels and clothes that were worn in the 2 days before each application. Use hot water Itch may take a few weeks to subside because of hypersensivity reaction
- 46. Case 6 Herpes labialis (Cold sores) Genital herpes Herpetic Whitlow
- 47. Herpes simplex Infections • General – Topical antiviral not useful – Topical antibiotic – N/saline, KMnO4 • Mouth – Systemic antivirals only in primary episode • Cutaneous and genital – Systemic • Acyclovir, Valcyclovir
- 49. Viral Warts • Cryotherapy with Liquid Nitrogen • Topical applications – Immune response modifiers eg Imiquimod cream – Duofilm – Wart/corn plaster • Distinguish warts from corns
- 51. Molluscum contagiosum • Cryotherapy • Enucleation • TCA • Imiquimod cream (Aldara) • Leave alone – Extensive – Child uncooperative
- 52. Molluscum contagiosum in Adults • STD • Check immune status • Differential diagnosis – Penicilliosis – Penicillium manerfei – Cryptococcosis – Histoplasmosis
- 53. Case 9 Varicella zoster Virus Infection
- 54. Varicella zoster Virus Infection • Chickenpox – Indications for Acyclovir, Valcyclovir, Famciclovir • Adults – more complications, scars esp face • Children – complications
- 55. Varicella zoster Virus Infection • Herpes zoster – Prevent post-herpetic neuralgia – Prevent eye damage – Systemic antiviral • Acyclovir 800 mg 5x/day x 7days • Valcyclovir 1 g tds x 7 days • Famciclovir 500 mg tds x 7 days – Antibiotics – N/Saline,KMnO4 – Neurobion, Princi-B-Forte
- 56. Cutaneous larva migrans Treatment Oral Albendazole or Ivermectin
- 57. Leprosy
- 60. Compications of leprosy Hand deformities Non healing chronic ulcer of the foot with underlying osteomyelitis