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16H-18H E Caumes Dermatoses Med Voyges DESC MIT 2014 Potential links of Interests • In the past 2 years, I (or my department) have received honoraria for lectures on STDs (BMS) or for participation in advisory boards on TBE (Baxter) or KS (Gallen) • I am the Editor in Chief of the Journal of Travel Medicine (IF = 1.7) Dermatoses tropicales • Introduction • Données épidémiologiques • Infections cutanées bactériennes • Larva migrans cutanée ankylostomienne • Leishmaniose cutanée localisée • Dermatoses prurigineuses • Dermatoses marines • Exanthème fébrile • Dépigmentation volontaire Dermatoses tropicales ?? • Dermatoses vues dans les pays tropicaux • Dermatoses vues dans les pays occidentaux .Voyageurs . Immigrés Consultations médicales au retour de voyage 7767 suisses(1) 8 % 2109 italiens(2) 11 % 779 américains(3) 12 % 200 israeliens(4) 19 % (1) Steffen et al ; J Inf Dis 1987;156:84-91 (2) Bruni et al ; J Travel Med 1997;4:61-64 (3) Hill D ; J Travel Med 2000;7:259-266 (4) Winer ; J Travel Med 2002;9:227-232 Part des dermatoses dans les consultations médicales au retour 93 américains (1) 11 % (4eme) 622 français (2) 24 % (2eme) 17343 Monde (3) 17 % (3eme) (1) Hill D. J Travel Med 2000;7:259-266 (2) Freedman DO et al. N Engl J Med 2006; 354: 119-130 (3) Ansart S et al. Am J Trop Med Hyg 2007; 76 : 184-186 Part des dermatoses exotiques, tropicales, parmi les dermatoses au retour 224 francais (269) (1) 54 % (1995,Hosp) 114 français (149) (2) 34 % (2007,Hosp) 4594 Monde (4742) (3) 24 % (GeoSent) 10 américains (4) 0 % (ville) (1) Caumes E et al. Clin Inf Dis 1995; 20 : 542-548 (2) Ansart S et al. Am J Trop Med Hyg 2007; 76 : 184-186 (3) Freedman DO et al. N Engl J Med 2006; 354: 119-130 (4) Hill D. J Travel Med 2000;7:259-266 What is the most common skin disease diagnosed in returning travellers : 1. Myiasis 2. Syphilis 3. Skin and soft tissue infections 4. Hookworm related Cutaneous larva migrans 5. Arthropod related dermatitis The top nine travel associated dermatoses* in 4594 pts, 1997-2006, WW travellers (GeoS) • Cutaneous larva migrans : 465 (10%) • Insect bites : 388 (8%) • Abcess (pyoderma) : 366 (7%) • Surinfected insect bites : 324 (7%) • Cutaneous allergy : 263 (5%) • Rash of undetermined origin : 262 (5%) • Bite by animals : 203 (4%) • Superficial mycose : 190 (4%) SSTI : 690 • Dengue : 159 (3%) (15%) * 24% tropical; Lederman E et al. Int J Inf Dis 2008, i:10.1016/j.ijd.2007.12.008 The top nine travel associated dermatoses* in 114 pts, 2000s, tourists, migrants, expat • Infectious cellulitis : 21 (14%) • Scabies : 17 (11%) • PUO : 15 (10 %) • Pyoderma : 14 (9%) • Myiasis : 12 (8%) • Tinea : 10 (6%) SSTI : 35 • Filariasis : 9 (6%) • Cutaneous Larva migrans : 8 (5%) (23%) • Urticaria : 8 (5%) * 76 % of 149 dermatoses (34% tropical) Ansart S et al. Am J Trop Med Hyg 2007; 76 : 184-186 Dermatoses in 8.227 ill travelers (19%), GeoSentinel, 2007-2011 Rabies PEP required in 12% 18% CLM = 8% of all skin pbs 16% 14% 12% 10% 8% Derm 6% 4% 2% Sentinel 0% SSTI Insect itch Animal Leder K et al. Ann Intern Med 2013; 158: 456-468 www.medecine-voyages.fr Regarding SSTI acquired during travel in tropical countries, the main cause of concern is : 1. Unusual culprit microbial agent 2. Atypical clinical appearance 3. Importance of serologic results 4. Fear of antibiotic resistance 5. Stool examination Inf Cutanées bactériennes (n = 48) • Impétigo : 19 (39%) - S aureus (40%) [12 (63%) avec piqure/ - Streptococcus sp (20%) morsure d’arthropode] - S. aureus + st (20%) - négative (20%) • Erysipèle : 9 (18%) • Ecthyma : 8 (16%) • Abces : 4 (8%) • Furoncle : 4 (8%) • Intertrigo : 2 (4%) • Folliculite : 1 (2%) • DHBA nécrosante : 1 (2%) Caumes et al - Clin Inf Dis 1995;20:542-548 Infections cutanées bactériennes chez 60 voyageurs; 01/2006-08/2007 Formes N (%) % culture + Sa MS SGA Les 2 Impetigo 21 (35%) 76% 31% 38% 31% Abces 14 (23%) 57% 0100% 0 Ecthyma 11 (19%) 91% 10% 60% 30% Cellulite (19%) 011 NA NA NA Folliculite 3 (5%) 33% 0100% 0 Hochedez P et al. Am J Trop Med Hyg 2009; 80: 431-4 Insect bite, impetigo, cellulitis Insect bite, cellulitis, Abcess, fistulisation to the skin Erysipela vs infectious cellulitis Erysipela vs infectious cellulitis –Peripheral surelevated borderline –Clear borderline with surrounding tissues Bisno AL. N Engl J Med 1996; 334:240-245 « In practice, distinguishing between cellulitis and erysipelas clinically may be difficult…. » Stevens DL. Clin Infect Dis 2005; 41: 1373-1406 Criteria of severity when facing an infectious cellulitis • No clinical response to antibiotherapy • Intense and constant pain (+++) • Cutaneous oedema reaching surrounding tissues • Cutaneous necrosis (blue, white then black) • Gaz (crepitation, Xray) • Loss of cutaneous sensitivity (+++) • Having clinical signs of severe infections Stevens DL. Clin Inf Dis 2005; 41: 1373-1406 Regarding S.aureus related SSTI acquired while being in the tropics, the main causes of concern are: • Transmission in the household • Antibiotic resistance • Reccurences • Portage • All of them Femme, 35 ans, Homme, 41 ans, Retour de Apparition Cote d’Ivoire à J6 des retrouvailles Femme, 35 ans; lendemain d’un retour de voyage en Côte d’Ivoire (J 3 lésion) J 1 : piqure d’insecte J 4 : apparition de la lésion cutanée J 6 : retour; J 7 : consultation Homme de 41 ans, compagnon de N°1 Lésion cutanée localisée sur le pied droit apparue 6 jours aprés les “retrouvailles” avec N°1 Lésion cutanée à J5 de l’évolution spontanée …… Male, 33 y, just returning from Fiji Female, 29 y, wife of Mr Fiji and companion of travel Mr Abcess & Mrs impetigo cellulitis MS PVL+ S. aureus Import and spread of PVL+ S.aureus in travelers with SSTI • 38 travelers with S.aureus + SSTI vs 124 control with other trav-dis; genotyping • S.aureus SSTI were associated with travel duration and location (Africa: OR =4.2) • Pts with PVL+ S.aureus SSTI were also colonized in the nares (73% vs 25%) • SSTI due to PVL+ S.aureus were more likely to be complicated, reduced antibiotic susceptibility and 2ry spread (5 clusters) Zanger P et al. Clin Inf Dis 2012; 54: 483-92 Import and spread of PVL+ S.aureus in travelers with SSTI Sa+ nasal PVL+ nasal PVL+ lesion carriage carriage Abscess 0.5 0.1 0.001 Furuncle Recurrent 0.4 0.002 0.001 Disease Surgical 1 0.2 0.015 drainage SSTI contacts 1.8 0.1 0.1 Zanger P et al. Clin Inf Dis 2012; 54: 483-92 Traveling MRSA Imported MRSA in Sweden, 2000-2003 • 1733 cases MRSA reported in Sweden • 444 (25 %) imported cases (acquired abroad) * 292 (65 %) in Swedish travellers * 56 (12 %) in newly arrived immigrants * 40 (9 %) in internat adopted children * 30 (7 %) in foreign residents * 20 (4 %) in Swedish expatriates • Including 246 (55 %) HA and 146 (33 %) CA Stenhem M et al. Emerg Inf Dis 2010;16:189-196 MRSA Imported by Swedish travelers 2000-2003 : countries at risk (ORs) • Nordic 0.1 (0.01-0.6) • Western Europe Reference* • Southern Europe 2.4 (1.0-5.8) • Central and Eastern Europe 2.8 (1.0-8.1) • UK and Ireland 10.3 (4.4-24.0) • North America 10.6 (4.2-26.7) • Northeastern Mediterranean 15.8 (7.0-35.6) • South America 31.2 (10.0-97.6) • East Asia 36.5 (16.2-82.0) • Oceania and Pacific Islands 43.0 (15.5-119.4) • Sub-Saharan Africa 46.3 (17.3-123.6) • North Africa and Middle East 59.0 (25.1-138.9) Stenhem M et al. Emerg Inf Dis 2010;16:189-196 Abscess management • « Ubi pus, Ibi evacuata » Still true since Hippocrate Am J Med 1876; 6: 226 In case of recurrent S.aureus SSTI, the followings can be proposed: • Education • Mupirocin • Antiseptic wash • None of them • All of them Staphylococcal decolonisation in pts with recurrent SSTI: effective? Ref N= S.aureus FU Tt vs P(or E) P = Raz MSSa34 12 m M monthly 0.002 Ellis 134 CA-MRSa 4 m M /5 days 0.76 Gordon 92 27%-MRSa 6-8 m M monthly NS Fritz 300 68%MRSa 6 m E + M (5 d) 0.4 M: mupirocin; E: education; E + M + Chl 0.51 P: Placebo; Chl: Chlorhexidine BB: Bleach baths E + M + BB 0.02 Simar AE. Lancet 2011; 11: 952-962 Decolonization for prevention of recurrent CA-MRSA infections • California, private practice, 31 pts enrolled • Mean age : 40 y; 58% Female; 86% healthy • Mean Nb of episodes < 6 mths = 5 (2-30) • 10 d regimen:nasal mupirocin 2/d, body wash hexachlorophene/d + AB (cycl; tmp/smx) • Mean Infection rate = 0.03 inf/month > 6 mths (FU period) vs 0.84 inf/mth < 6 mths intervention (P < 0.0001) Miller LG et al. Antimicrob Ag Chemoth 2012; 56: 1085-86 Infections cutanées bactériennes • Streptocoques et staphylocoques sont responsables d’infections plus ou moins sévères selon le terrain et la profondeur de l’atteinte cutanée • Streptococcus pyogenes: toujours sensible aux pénicillines (G,A,…), résistance aux macrolides rendant aléatoire le traitement par les antibiotiques du groupe MLSK • Staphylococcus aureus: toujours plus résistant, notamment diffusion mondiale progressive des SARM an ville; pristinamycine (MLSK) efficace Larva migrans cutanée ankylostomienne (larbish) • Même si tout ce qui court sous la peau ne relève pas de la larva migrans cutanée ankylostomienne (HrCLM) • HrCLM reste la cause la + fréquente de dermatite rampante exception faite de quelques pays (Japon….) Boracay, Philippines LMC ankylostomienne c° voyageurs Ref (1) (2) (3) Patients 60 67 64 Nationalité Canada France France > Retour 45 % 51 % 55 % Délai/Retour 5j (0-30) 8j (0-28) 16j (1-120) (1) Davies et al. Arch Dermatol 1993;129:588-591 (2) Caumes et al.
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