Bacterial Infections & Acne Disclaimer Perspective

Home , Body odor, Pitted keratolysis, Sycosis vulgaris

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

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

This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute. Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine –June 10-12, 2011

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

 Propionibacterium acnes  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

 Propionibacterium acnes

 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 Organisms Staphylococcal 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, cutaneous tenderness 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 bullae in 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  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

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

pruritic follicular,  Prevention maculopapular,  Water filtration, automatic chlorination, vesicular or pustular pH 7.2-7.8, frequent changing of waer

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This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.