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Folliculitis

Folliculitis

Common Cutaneous • of follicle(s) Bacterial • Symptoms: Often pruritic (itchy)

Pseudomonas folliculitis

Eosinophilic Folliculitis (HIV) Folliculitis: Causes

• : – Gram positives (Staph): most common – Gram negatives: Pseudomonas – “hot tub” folliculitis • Fungal: Pityrosporum aka • HIV: eosinophilic folliculitis (not bacterial) • Renal Failure: perforating folliculitis (not bacterial)

Treatment of Folliculitis 21 year old female with controlled Crohn’s disease and history of • Bacterial suppuritiva presents stating – culture pustule she has recurrent flares of her HS – topical or oral cephalexin / – shower and change shirt after exercise – keep dry; loose • Fungal: topical (e.g., ) • Eosinophilic folliculitis – Phototherapy – Treat the HIV MRSA MRSA Eradication

• Swab nares  ointment bid x 5 days • GI noted Crohn’s was controlled but increased – Swab axillae, perineum, infliximab intensity, but that was not controlling • Chlorhexidine 4% bodywash qd x 1 week recurrent “flares” • Chlorhexidine mouthwash qd x 1 week; soak toothbrush (or disposable) •I & D  MRSA on three occasions • Bleach bath: 1/3 cup to tub, soak x 10 min tiw x 1 week, then prn (perhaps weekly) • THIS WAS INFLIXIMAB-RELATED • Oral x 14 days: Bactrim, Doxycycline, depends FURUNCULOSIS FROM MRSA COLONIZATION on sensitivities – D/C infliximab • Swab partners – Anti-MRSA regimen • Hand sanitizer frequently – Patient is better  • Bleach wipes to surfaces (doorknobs, faucet handles) • Towels use once then wash; paper towels when possible

Pointing (furuncle) --pointing requires I & D-- Acute

Furuncle Treatment

• Incise & Drain (I & D)  Culture • Warm soaks • Antibiotics – e.g., cephalexin orally AND mupirocin topically • If recurrent, suspect nasal carriage of Staph aureus  swab culture and mupirocin to nares b.i.d. x 5 days q month Bullous ***Impetigo*** impetigo • Superficial skin • Contagious • Bullous and non-bullous forms • Causes: aureus, streptococci (often colonize nose) Note collarettes • Superinfects any defect in skin (eczema, arthropod of scale from bite, etc.) unroofed bullae • Appearance: honey-colored crust • Treatment: mupirocin = best; tid!!!; may require oral antibiotics • Sequelae: post-streptococcal glomerulonephritis; rheumatic

Impetiginized eczema

Staphylococcal In kids, generalized Scalded Skin eczema often doesn’t clear until the Syndrome: impetigo is cleared exofoliative toxin cleaves Dsg 1

SSSS Staphylococcal Scalded Skin Syndrome SSSS SSSS

• Infants (3% mortality) and adults with chronic renal insufficiency (50-100% mortality) • Exfoliative toxin ET-A and ET-B • Fever, skin tenderness, peri-oral furrows, exfoliation at flexures • Pan-culture • Therapy: I.V. antibiotics

Stasis

Recurrent cellulitis  Cellulitis • Infection of and subcutis (i.e., fat), usually bacterial, due to break in skin (e.g., tinea pedis in a verruciformis diabetic) • Cause: Staph aureus and Group A strep most common; but, can be any organism. – Culture not of use unless ulcerated • Signs: rubor (), dolor (pain), calor (heat), tumor (swelling/) • Sequelae: fibrosis of lymphatics  and recurrent cellulitis Cellulitis Therapy

• Healthy adult: antibiotics po • Surgical emergency • early and aggressive • Comorbidity: , venous stasis, HIV – Need i.v. antibiotics • i.v. broad-spectrum – Careful about switching to p.o. too soon antibiotics – Sometimes needs two weeks of i.v. abx • tissue culture – Leg elevation  less edema  better distribution of drug to target • Trace border to monitor improvement

Meningococcemia: DIC Meningococcemia

• Derm Emergency (notify State Dept. of Health) • Cause: Neisseria meningitidis (lives in nasopharynx) (Gram negative diplococci) • Prodrome: mild upper respiratory infection • Signs: ; septic shock; sharply angulated slate-gray purpura signaling disseminated intravascular coagulation (DIC) • Therapy: droplet/contact isolation; ; G • Prophylaxis of contacts: rifampin, ciprofloxacin

Spirochetal Diseases: Ixodes scapularis (formerly dammini) (deer tick) • Cause: burgdorferi (spirochete) via bite of Ixodes (deer tick) – Tick must be attached > 18 hours for • Three stages – 1) erythema chronicum migrans – 2) carditis (AV block) and neuritis (Bell’s palsy) – 3) male nymph • Therapy: doxycycline or amoxicillin • Prophylaxis female – Doxycycline 200mg po once at time of tick bite – in endemic areas adult – Insect repellent if outdoors (DEET = N,N-diethyl-m- toluamide) Features of Right Bell’s Palsy • Primary Syphilis: 18-21 days after infection (or bad Botox? :O) – (cf: RPR + at 5-6 weeks after infection; FTA-Abs + earlier) • Secondary Syphilis: 6 weeks - 4 months after infection • Tertiary Syphilis: 3-5 years after infection Therapy: •Test for HIV • Report to NYSDOH • Benzathine Penicillin G - 2.4 million units – IM –1o and 2o – one dose –3o – 3 doses one week apart – BEWARE!!! Not Bicillin (penicillin G benzathine and penicillin G procaine) • Need probenecid to maintain blood levels of PCN G procaine • Doxycycline 100mg po bid x 2 weeks

Syphilis: pallidum (spirochete) Secondary Syphilis – Palms • Primary: – painless, indurated • Secondary: – Palms/soles (like ) – Papulosquamous (like ) – Mucous patch in mucosal surfaces – Condyloma latum (NOT viral ) • Latent: no • Tertiary: (rubbery, ulcerated nodule), CNS ( – posterior column demyelination) • Congenital: TORCH infection, many signs

Secondary syphilis mimicking a morbilliform drug rash Secondary Syphilis - Papulosquamous Secondary Syphilis – Secondary Mucous Patch Syphilis - Condyloma Latum

• Moist, verrucous plaques

Tertiary Syphilitic Gumma

• Organisms: rubrum most common; and T. tonsurans also common • Name of infection corresponds with anatomic location – Foot: tinea pedis – Hand: – Hair/Scalp: – Face: tinea facialis – Beard: – Body: – Groin: – : tinea unguium

Tinea corporis (“ring worm”) Dermatophytes • Nothing to do with worms • Symptoms: pruritic • Diagnosis: via KOH (potassium hydroxide) and/or culture Black-dot Tinea Capitis

Look closely to see black dots where broke off near the scalp

Tinea unguium Tinea Unguium (vs. )

• Tinea unguium refers to infection of the nail • Onychomycosis is any fungal infection of the nail (i.e., , , or dermatophytes) • Therapy: Nail lacquers don’t work!

Tinea pedis Moccasin Tinea Pedis

• Types: moccasin; interdigital

• : , eczema Interdigital Tinea Pedis One hand, Two feet: Tinea manuum and pedis

No scale indicating sparing of one hand

Scale indicating infection

Tinea cruris (“jock ”) Dermatophyte: Therapy • Spares the ; no satellite • (vs. candidal intertrigo affects scrotum) • Topical: for limited area (i.e., groin, small area on body) and tinea capitis (shampoo, adjunctive)

• Oral: tinea unguium, tinea manuum, tinea capitis (definitive), extenisve tinea corporis

• Topically, is most effective, but any topical will do. • Orally, terbinafine is most effective (except for Microsporum).

What is the dose of to treat this infection if it Terbinafine 250mg p.o. extends into the esophagus?

Type of Tinea Duration of A. 150mg po qd x one dose Therapy  Vaginal Pedis/corporis/cruris/manum Two-four weeks B. & C. 100-200mg po qd x 1-2 weeks Unguium - fingernails Six weeks  Oropharyngeal candidiasis Capitis/barbae Six weeks D. 200-400mg po qd x 2-3 weeks Unguium - toenails Twelve weeks  E. 800mg po once, then 400mg qd x 3 weeks  Candidemia Candidal Intertrigo cf. Oral Hairy (EBV)

Candidal Diaper Dermatitis Candidal Angular Chelitis

Pearl: If recurrent after topical clotrimazole, use nystatin 100,000 unit/mL p.o. 2mL (peds) or 5mL (adults) qid x 3-5 days

Candidal Paronychia Candidemia

Candida Chronic between nail inflammation plate and of proximal proximal nail nail fold fold Candidal in a neutropenic patient. Pityriasis versicolor Pityrosporum orbiculare KOH: (aka ) (misnomer! It’s not a dermatophyte.) Look closely for the fine scale. Spaghetti And Meatballs

hypopigmentation

Labial Herpes Primary Infection

Erythematous base crop of vesicles

Herpes Simplex Virus • Viral shedding occurs in normal-appearing skin

The crop of vesicles • Diagnosis: often becomes a crop of erosions with – Tzanck smear (multinucleated giant cells) scalloped border. • Not distinguish HSV from VZV – Direct Fluorescent : sequentially Still with an incubate slide with smeared vesicle in erythematous base. fluorescent anti-HSV & anti-VZV – Viral culture of Face Multinucleated giant

Xerosis indicates poor barrier with susceptibility to viral infection (see next slide)

Eczema Herpeticum Eczema Herpeticum

Disseminated HSV Herpes Associated Erythema Multiforme Herpes Zoster () Disseminated VZV

Primary dermatome Stops at midline

Disseminated lesions

Shingles: Hand-Foot-and-Mouth Disease When to isolate a patient • Normal health but shingles – cover it up • Cause: A6, A16 & enterovirus 71 • Disseminated VZV – contact and droplet • : oval/linear, gray vesicles on palms, soles • Enanthem: painful oral erosions with red halo (hard • Any VZV in immunocompromised – treat as palate, tongue, buccal mucosa) disseminated • Sequelae: rare , myocarditis, • Avoid unvaccinated pregnant females paralysis • Spread: oral-oral or fecal-oral; incubation 3-6 days

Hand-Foot-and-Mouth Disease Herpangina

Vesicles and erosions Photos courtesy of Dr. Mark Lebwohl Herpangina Coxsackie A6 severe disease

• Cause: coxsackie A types and echoviruses • Symptoms: dysphagia, fever, • Enanthem: yellow/white vesicles in throat, tonsils, uvula, soft palate with intense red halo

Eczema Coxsackium: viral rash in areas of eczema

• Cause: poxvirus • Transmission: direct contact – Sexually transmitted disease in adults – Seen in children, often with atopic diathesis (i.e., tendency to dry skin with poor barrier) • Appearance: umbilicated • Therapy: self-limited; curettage  scar; cantharidin (not genital); incision and comedone extractor works best for me Photo from: Ventarola D, Bordone L, Sliverberg N. Update on hand-foot-and-mouth disease. Clin Dermatol. 2015 May-Jun;33(3):340-6.

Molluscum contagiosum Mulluscum contagiosum in atopic dermatitis Incision Extraction with comedone extractor Traction behind blade = GOOD

collarette Herald Pityriasis Rosea of scale Pityriasis Rosea patch

• Cause: not known, perhaps HHV 6 or 7 • Symptoms: mild fever; pruritus • Exanthem: herald patch, then 1-2 weeks later similar oval red patches with peripheral collarette of scale in “Christmas-tree” distribution along lines of cleavage • Occurs in Spring and Fall • Spontaneous remission in 6-12 weeks • Consider ruling out syphilis

Pityriasis rosea Verruca Vulgaris

• Thrombosed capillaries • Absent dermatoglyphics • Verrucous surface Therapy for Verruca Vulgaris Why Paring Alone Does Not Work Painless Painful • Paring (but involves a blade) • Shave removal • Imiquimod • Paring (if aggressive) – Daily under duct tape • Cryotherapy • 5-Fluorouracil bid – 30 seconds, 2 – 3 cycles • Cantharidin • Pulse laser – Two to three sessions – 0.45msec pulse, 8-30 J/cm2, – IN OFFICE ONLY 3-5mm spot size • Duct tape alone • Electrodesiccation and • Salicylic acid plasters – 40% curettage • Cimetidine 300mg po tid • Intralesional bleomycin HPV-infected (adult) or 10mg/kg • Candida antigen injections keratinocytes • Decrease 6-MP/azathioprine remain at the base

Cantharidin Pediculus humanus var. capitis

• Back of a wooden cotton tip applicator  one drop • Cover for 8 hours with 3M Blenderm tape, then wash off • May hurt later (but doctor isn’t “the bad guy”) • AVOID: eyes, mucous membranes, genitals • Manufacterer: Dormer Laboratories Inc (brand is Cantharone or Cantharone Plus) – From Canada – Has 31% salicylic acid

Photo courtesy of Jere Mammino, DO Nits with embryos Hatched nit - white

Louse

Unhatched nit - brown Pediculosis Capitis • Can live off scalp for 55 hours  to bag for 3 days • Treat once and repeat in 7 days • Check family members & close contacts (friends)

Scabies Look to the wrist • Cause: Sarcoptes scabiei var. hominis • Itchy patient with red  burrows • Location: fingerwebs/wrists • Transmission: skin-skin contact; hospital bedding; mites live > 2 days off skin!!! • Treatment: – permethrin 5% cream once, repeat in 4 days; – ivermectin* 200mcg/kg po once, repeat in 4 dayas; – clip fingernails • Crusted (Norwegian) Scabies: thousands of mites in the scale; immunocompromised or neurologic disorder; may require a third cycle of therapy * ivermectin orally is off-label for scabies

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