Editors: Hall, John C.

Title: Sauer's Manual of Skin Diseases, 9th Edition

Copyri ght 2006 Li ppincott Wil l i ams & Wi l kins
> Tabl e of Contents > SECTION III - Infecti ous Di seases i n the Ski n > 21 - Dermatol ogi c
Bacteri ol ogy
21
Dermatologic Bacteriology
John C. Hall
Bacteria exist on the skin as normal nonpathogeni c resi dent fl ora or as pathogeni c
organi sms. The pathogeni c bacteri a cause pri mary, secondary, and systemi c
i nfecti ons. For cli ni cal purposes i t i s justi fi abl e to di vide the problem of bacteri al
i nfecti on i nto three cl assi fi cations (Table 21-1). Some of the di seases l i sted are of
dubi ous bacterial eti ol ogy, but they appear bacteri al, may have a bacteri al component,
can be treated wi th anti bacterial agents, and are, therefore, i ncl uded i n thi s chapter.
Wi th an al terati on i n i mmune capabi l i ti es i n a person, bacteri a and other i nfecti ous
agents can have erratic behavi or. Ordi nary nonpathogens can act as pathogens, and
pathogeni c agents can act more aggressivel y.
Primary Baterial Infections (Pyodermas)
The most common causati ve agents of the pri mary ski n i nfecti ons are the coagul ase-
posi ti ve mi crococci (staphyl ococci ) and the -hemolytic streptococci . Superfi ci al or
deep bacteri al l esi ons can be produced by these organisms. In managing the
pyodermas, certai n general pri nci pl es of treatment must be i ni ti ated.
TABLE 21-1 Classification of Bacterial Infection
Primary Bacterial Infections
Impeti go
Ecthyma
Fol li cul i ti s
Superfi ci al fol l icul i ti s
Foll i cul i ti s of the scal p
Superfi ci al acne mi l i ari s necroti ca
Deep scarri ngfol l i cul itis decal vans
Foll i cul i ti s of the beard
Stye
Furuncl e
Carbuncle
Sweat gl and i nfl ammati ons
Erysi pelas
Secondary Bacterial Infections
Cutaneous di seases wi th secondary i nfecti on
Infected ul cers
Infectious eczematoi d dermati ti s
Bacteri al intertri go
Systemic Bacterial Infections
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l Improve bathi ng habi ts: More frequent bathing and the use of bacteri ci dal soap,
such as Di al , or Lever 2000, are i ndi cated. Any pustul es or crusts shoul d be
removed duri ng the bathi ng to faci l i tate penetrati on of the l ocal medi cations. In
rare instances when these infecti ons are recal ci trant to standard therapi es, I use
to 1 cup of bl each i n a ful l tub of water to soak dai ly as long as indicated.
l General i sol ati on procedures: Cl othi ng and beddi ng shoul d be changed frequentl y
and cl eaned. The pati ent shoul d have a separate towel and washcl oth.
l Systemi c drugs: The pati ent shoul d be questi oned regardi ng i ngesti on of drugs
that can cause l esions that mi mi c or cause pyodermas, such as iodides,
bromi des, testosterone, corti costeroi ds, progesterone, and l i thi um.
l Diabetes: In chroni c ski n i nfections, parti cul arl y recurrent boi l s, diabetes shoul d
be rul ed out by history and l aboratory examinati on.
l Immunosuppressed patients: A hi story of abnormal fi ndi ngs shoul d al ert the
physici an to the i ncreasi ng number of pati ents now who are on chemotherapy for
cancer, are posttransplant, or have the acqui red i mmunodefi ci ency syndrome
(AIDS).
Impetigo
Impeti go i s a common superfi ci al bacteri al i nfecti on seen most often in chi l dren; it i s
the i nfantigo every parent respects.
Primary Lesions
The lesi ons vary from smal l vesi cl es to l arge bull ae that rupture and di scharge a
honey-col ored serous l i qui d (Fi g. 21-1; see al so Fi g. 3-1A). New l esions can devel op in
a matter of hours.
Secondary Lesions
Crusts form from the di scharge and appear to be l i ghtl y stuck on the ski n surface.
When removed, a superfi cial erosi on remai ns, whi ch may be the only evi dence of the
disease. In debi l itated i nfants, the bull ae may coalesce to form an exfoli ati ve type of
i nfecti on call ed Ri tter's di sease or pemphi gus neonatorum.
Distribution
The lesi ons occur most commonl y on the face but may be anywhere.
Scarlet fever
Granuloma i ngui nal e
Chancroi d
Mycobacteri al i nfecti ons
Tubercul osi s of the ski n
Leprosy
Gonorrhea
Ri ckettsi al di seases
Actinomycosi s
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Contagiousness
It i s not unusual to see brothers or sisters of the patient and, rarel y, the parents
simi l arl y i nfected.
SAUER'S NOTES
Body pi ercing has frequentl y been associated wi th l ocal i zed staphyl ococcal i nfecti on
and pseudomonas i nfecti on and rarel y bacteremi a and endocardi ti s. Tubercul osi s,
hepati ti s C and B, and even HIV may have been transmi tted i n thi s way. Noni nfecti ous
compl icati ons are kel oi ds and al lergi c dermati ti s. This fad shoul d not be
recommended, especi al l y i n tongue, l i ps, navel s, ni ppl es, and geni tal i a.
Differential Diagnosis
l Contact dermatiti s due to poi son i vy or oak: Linear bl i sters; does not spread as
rapi dl y; i tches (see Chap. 9).
l Ti nea of smooth ski n: Fewer lesi ons; spread sl owl y; smal l vesi cl es i n annul ar
confi gurati on, whi ch i s an unusual form for i mpetigo; fungi found on scrapi ng;
cul ture i s positive (see Chap. 25).
l Toxi c epi dermal necrolysi s: In i nfants and rarely in adul ts, massi ve bul l ae can
devel op rapi dl y, parti cul arl y wi th staphyl ococcal i nfecti on. The severe form of
this infecti on i s known as the staphyl ococcal scal ded ski n syndrome, whi ch i s a
type of toxi c epidermal necrol ysi s (see Chap. 18).
FIGURE 21-1 (A) Impeti go of the face. The honey-col ored crusts are typi cal .
(Courtesy of Abner Kurti n, Fol i a Dermato- l ogi ca, No. 2. Gei gy Pharmaceuti cal s.)
(B) Bul l ous i mpeti go on the l egs of a young chi l d.
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Treatment
1. Outl i ne the general pri nci pl es of treatment. Emphasi ze the removal of the crusts
once or twi ce a day during bathing with an anti bacterial soap such as Lever 2000
or chl orhexi di ne (Hibicl ens) ski n cl eanser.
2. Mupi rocin (Bactroban) or gentamicin (Garamyci n) ointment or Pol yspori n
ointment q.s. 15.0
Si g: Appl y t.i .d. l ocal l y for 10 days. Treat al l affected fami l y members or other
affected contacts.
3. Oral anti bi oti cs such as a 10-day course of eryth- romyci n, cephal exi n, or
cli ndamycin may be necessary.
4. Methi ci l l i n-resistant Staphyl ococcus aureus i n the communi ty acqui red form
(CAMRSA) now occurs i n epi demi c proporti ons. Fortunatel y i t often i s sensi ti ve to
sul famethoxazol e (Septra) or tetracycl i ne deri vati ves. Abcesses are common.
Ecthyma
Ecthyma i s another superfi cial bacteri al i nfecti on, but i t i s seen l ess commonl y and i s
deeper than i mpeti go. It i s usuall y caused by -hemol yti c streptococci and occurs on
the buttocks and the thi ghs of chi l dren (Fi g. 21-2).
SAUER'S NOTES
1. I someti mes add sul fur 5% and hydrocortisone 1% to 2% to the anti bi oti c cream
or ointment for treatment of i mpeti go and other superfici al pyodermas. Many
patients wi th i mpeti go whom I see have been usi ng a pl ai n anti bi oti c sal ve wi th
an oral anti bi oti c, and the i mpeti go persi sts. With thi s compound sal ve the
i mpeti go heal s.
2. Advi se the pati ent that the l ocal treatment should be conti nued for 5 days after
the l esi ons apparentl y have di sappeared to prevent recurrencestherapy
pl us.
3. Systemi c anti bi oti c therapy: Some physi ci ans bel i eve that every patient wi th
i mpeti go shoul d be treated wi th systemi c anti bi oti c therapy to heal these l esions
and al so to prevent chroni c gl omerul onephri ti s. Erythromycin in appropri ate
dosages for 10 days would be effecti ve i n most cases. Resi stance to
erythromyci n can occur, and then di cl oxaci l l i n or cephal exin are effecti ve.
Bacteri al sensitivi ty testi ng helps to gui de appropri ate anti bi oti c therapy. There
i s a dramati c i ncrease i n the Uni ted States i n communi ty-acqui red methi ci l l in-
resi stant Staphylococcus aureus (CAMRSA).
Primary Lesion
A vesi cl e or vesi culopustule appears and rapi dl y changes i nto the secondary lesi on.
Secondary Lesion
Thi s i s a pi l ed-up crust, 1 to 3 cm i n di ameter, overl yi ng a superfi ci al erosion or ul cer.
In negl ected cases, scarri ng can occur as a resul t of extensi on of the i nfecti on i nto the
dermi s.
Distribution
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