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Home , Elephantiasis nostras, Skin infection

Objectives

• 1. To implement a management strategy for MRSA Common Cutaneous eradication. • 2. To recognize the common presentations of cutaneous Bacterial . • 3. To identify cutaneous manifestations of cocksackie virus . • 4. To manage effectively.

Eosinophilic Folliculitis (HIV)

• of hair follicle(s) • Symptoms: Often pruritic (itchy)

Pseudomonas folliculitis

Treatment of Folliculitis Folliculitis: Causes • Bacterial – culture pustule • : – topical clindamycin or oral cephalexin / doxycycline – Gram positives (Staph): most common – shower and change shirt after exercise – Gram negatives: Pseudomonas – “hot tub” folliculitis – keep dry; loose clothing • Fungal: Pityrosporum aka Malassezia • Fungal: topical antifungals (e.g., ) • HIV: eosinophilic folliculitis (not bacterial) • Eosinophilic folliculitis • Renal Failure: perforating folliculitis (not – Phototherapy bacterial) – Treat the HIV Infectious or Inflammatory? Infectious!

21 year old female with controlled Furunculosis Crohn’s disease and history of • Incise and Drain hidradenitis suppuritiva presents stating • Swab culture • Assume MRSA she has recurrent flares of her HS • Empiric oral antibiotics – Bactrim DS 1 po bid x 10 days – Doxycycline 100mg po bid x 10 days – Augmentin / Cephalexin / Clindamycin if want to roll the dice with close follow-up • Mupirocin ointment – To wounds tid – To nares (bid x 5days) • Bleach bath – 1/3 cup bleach to tub biw-tiw • Wash fomites – bedding, worn clothes, bath towels (don’t reuse)

MRSA MRSA Eradication

• Swab nares  mupirocin ointment bid x 5 days • GI noted Crohn’s was controlled but increased infliximab – Swab axillae, perineum, pharynx intensity, but that was not controlling recurrent “flares” • Chlorhexidine 4% bodywash qd x 1 week • 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) • Oral antibiotics x 14 days: Bactrim, Doxycycline, depends on sensitivities • THIS WAS INFLIXIMAB-RELATED FURUNCULOSIS • Swab partners FROM MRSA COLONIZATION • Hand sanitizer frequently – D/C infliximab • Bleach wipes to surfaces (doorknobs, faucet handles) – Anti-MRSA regimen • Towels use once then wash; paper towels when possible – Patient is better  Infectious or Inflammatory? Inflammatory!

Hidradenitis suppuritiva

Perhaps Pathognomonic: Hidradenitis Suppuritiva Double-Headed Comedone in Hidradenitis Suppuritiva • Intralesional triamcinolone 10mg/cc • Culture – sometimes is superinfected • Short courses of antibiotics to cool it down – doxycycline or cephalexin • Laser hair removal • TNF-blockers – infliximab or adalimumab • AS BRIDGE TO SURGERY – Excision (best for axillae) – Marsupialization (when cannot excise)

Infectious or Inflammatory? Inflammatory! Inflamed Acute

• Incision and Drainage – Characteristic odor • Swab culture (sometimes superinfected, esp. if pus) • Empiric antibiotics controversial • Intralesional triamcinolone 5-10mg/cc around to the inflamed area • Excision when “cooled off”

Impetigo Bullous

Note collarettes of scale from unroofed bullae

Impetiginized eczema ***Impetigo*** • Superficial • Contagious In kids, generalized • Bullous and non-bullous forms eczema often doesn’t • Causes: , streptococci (often colonize clear until the nose) impetigo is cleared • Superinfects any defect in skin (eczema, bite, etc.) • Appearance: honey-colored crust • Treatment: mupirocin = best; tid!!!; may require oral antibiotics • Sequelae: post-streptococcal glomerulonephritis; rheumatic fever SSSS Staphylococcal Scalded Skin Syndrome:

exofoliative toxin cleaves Dsg 1

Staphylococcal Scalded Skin Syndrome SSSS

SSSS Antibiotics or Diuretics?

• 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 Diuretics!

This is stasis (from liver failure). Think cellulitis if:

Often bilateral. • Unilateral • Has 3 of 4 of: Therapy: • Tumor • Leg elevation • Rubor • Diuretics • Dolor • Compression • Calor

Cellulitis Cellulitis • Infection of and subcutis (i.e., fat), usually bacterial, due to break in skin (e.g., tinea pedis in a 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/edema) • Sequelae: fibrosis of lymphatics  and recurrent cellulitis

Recurrent cellulitis  Cellulitis Therapy verruciformis • Healthy adult: antibiotics po • Comorbidity: diabetes, venous stasis, HIV – Need i.v. antibiotics – Careful about switching to p.o. too soon – Sometimes needs two weeks of i.v. abx – Leg elevation  less edema  better distribution of drug to target • Trace border to monitor improvement This lesion of the lower shin evolved over three Gangrenosum

weeks. Violaceous border

Pyoderma Gangrenosum Pyoderma Gangrenosum • Can present with superinfection (cellulitis) – Swab culture • Treat infection and inflammation at same time – Topical mupirocin (empirically) • Association: Inflammatory Bowel Disease, Myeloma – Oral or i.v. antibiotics (Staph >> Pseudomonas) • Pathergy: Tissue damage disproportionate to inciting • Intralesional triamcinolone 10mg/cc q1-2weeks trauma • Cyclosporine 5mg/kg or Infliximab 5mg/kg – DO NOT DEBRIDE SURGICALLY!!!

Pyoderma Gangrenosum Pyoderma Gangrenosum – classic punched out ulcers granulating after therapy, probably few neutrophils (no infection)

Rarely Bilateral or Multifocal

• Surgical emergency • early and aggressive debridement • i.v. broad-spectrum antibiotics • tissue culture

Pseudomonas superinfection from chronic moisture/draining

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: meningitis; septic shock; sharply angulated slate-gray purpura signaling disseminated intravascular coagulation (DIC) • Therapy: droplet/contact isolation; blood culture; penicillin G • Prophylaxis of contacts: rifampin, ciprofloxacin

Spirochetal Diseases: Ixodes scapularis (formerly dammini) (deer tick) • Cause: Borrelia burgdorferi (spirochete) via bite of Ixodes (deer tick) – Tick must be attached > 18 hours for transmission • Three stages – 1) erythema chronicum migrans – 2) carditis (AV block) and neuritis (Bell’s palsy) – 3) arthritis male nymph • Therapy: doxycycline or amoxicillin for 1o • Prophylaxis female – Doxycycline 200mg po once within 72h of tick bite – Insect repellent if outdoors (DEET = N,N-diethyl-m-toluamide) adult Features of Syphilis 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: Treponema pallidum (spirochete) Secondary Syphilis – Palms • Primary: – painless, indurated • Secondary: the great imitator – Palms/soles (like ) – Papulosquamous (like ) – Mucous patch in mucosal surfaces – Condyloma latum (NOT viral ) • Latent: no • Tertiary: gumma (rubbery, ulcerated nodule), CNS (tabes dorsalis – posterior column demyelination) • Congenital: TORCH infection, many signs

Secondary syphilis mimicking a morbilliform drug rash Secondary Syphilis - Papulosquamous Tertiary Syphilitic Gumma Secondary Syphilis – Mucous Patch

Dermatophytes • Organisms: Trichophyton rubrum most common; Microsporum canis and T. tonsurans also common • Name of infection corresponds with anatomic location • Symptoms: pruritic – Foot: tinea pedis • Diagnosis: via KOH (potassium hydroxide) and/or culture – Hand: tinea manuum – Hair/Scalp: – Face: tinea facialis – Beard: tinea barbae – Body: – Groin: – : tinea unguium

Tinea corporis (“ring worm”) or Excise? • Nothing to do with worms Excise Bowen’s Disease

(well, just not econazole) • Aka Squamous Cell Carcinoma in situ – What is in situ should excite you! • Solitary scaly plaques usually are not – Rule out SCC in situ

• Excision is favored – esp. for locations prone to metastasis (i.e., lip, ear, genitalia, scars, > 2cm) • Imiquimod is an alternative daily x 1 month – If red, weeping reaction it means it is working; no reaction means failure • Radiation therapy for poor surgical candidates

Black-dot Tinea Capitis Kerion

Look closely to see black dots where hairs 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., candida, molds, or dermatophytes) • Therapy: Nail lacquers don’t work! B) After 3 months of Differential Diagnosis: terbinafine… Psoriasis Subungual Onycholysis hyperkeratosis

before after

KOH: hyphae Diagnosis

• KOH • Culture – helpful to prove dermatophyte • Nail clipping to pathology (most sensitive)

Epithelial scales are out of focus deliberately

Oral Terbinafine Topical Therapy: • Stigma/fear: liver damage Ciclopirox 8% lacquer • Justified: in hepatitis patients, alcoholics • Some say good for maintenance of a clear nail • Actual data: 2.5 cases/100,000 persons/month [Gupta et al. J Drugs Dermatol. 2005;4(3):302-8.] • Thin nails with disease (fingers > toes) • Monitoring? Baseline (monthly is excessive) • In conjunction with urea, in theory • Pre-treatment confirmation of fungus (KOH, culture, • How to use: apply daily, coat over coat, x 1 week; or pathology) acetone removal weekly • Rare side effects: neutropenia, • Cost: 6 months of therapy (time) and money • Drug interactions – CYP450 2D6 but not a problem in over 25,000 patients [Hall et al. Arch Dermatol. 1997; 133(10):1213-9]. When to see results Effectiveness of Therapy

• Fingernail grows 0.1mm/day (i.e., 5 months) • Terbinafine orally x 3 months: 40-80% cure, 15% relapse (per terbinafine Package Insert) • Toenail grows more slowly (i.e., 8-12 months)

• Ciclopirox lacquer x 48 weeks: 5.5-8.5% cure • Three month course of terbinafine shows clearing at base (90d x 0.05mm/d = 4.5mm) • No lunula involvement; need adjunctive debridement • May need 4th and 5th month (if less than expected evidence of clearing) – Is this clinically relevant statistical significance? – Does it LAQUE effectiveness?

Other orals Tinea pedis • More side effects and/or drug interactions and/or less activity BUT can be effective • Types: moccasin; interdigital • Itraconazole: Heart failure; drug interactions (CYT P450 3A4  QT prolongation); • Differential diagnosis: psoriasis, eczema hepatotoxicity • Fluconazole: > liver toxicity; drug interactions: warfarin, phenytoin, cyclosporin • Ketoconazole: > liver toxicity; drug interactions (CYP450 3A4)

Interdigital Tinea Pedis Moccasin Tinea Pedis One hand, Two feet: Psoriasis Tinea manuum and pedis (it’s not tinea pedis!)

No scale indicating sparing of one hand

Scale indicating infection

Dermatophyte: Antifungal Therapy Terbinafine 250mg p.o. • Topical: for limited area (i.e., groin, small area on body) and tinea capitis (shampoo, adjunctive) Type of Tinea Duration of Therapy • Oral: tinea unguium, tinea manuum, tinea capitis Pedis/corporis/cruris/manum Two-four weeks (definitive), extenisve tinea corporis Unguium - fingernails Six weeks Capitis/barbae Six weeks • Topically, terbinafine is most effective, but any topical will do. Unguium - toenails Twelve weeks • Orally, terbinafine is most effective (except for Microsporum).

What is the dose of fluconazole to treat this infection if it extends into the esophagus? cf. Oral Hairy (EBV)

A. 150mg po qd x one dose  Vaginal B. & C. 100-200mg po qd x 1-2 weeks  Oropharyngeal candidiasis D. 200-400mg po qd x 2-3 weeks  Esophageal candidiasis E. 800mg po once, then 400mg qd x 3 weeks  Candidemia Candidal Intertrigo Inverse Psoriasis

It’s neither Candida nor dermatophyte!!! Swab culture helps determine if yeast vs. bacterial vs. sterile inflammatory

Candidal Angular Chelitis Candidal Paronychia

Candida Chronic between nail inflammation plate and of proximal proximal nail nail fold fold

Pityriasis versicolor Pityrosporum orbiculare Candidemia (aka Malassezia furfur) Look closely for the fine scale.

Candidal sepsis in a neutropenic patient. hypopigmentation

KOH: Tinea versicolor Primary Virus Infection (misnomer! It’s not a dermatophyte.) Spaghetti And Meatballs

Labial Herpes • Viral shedding occurs in normal-appearing skin

Erythematous base • Diagnosis: crop of – Tzanck smear (multinucleated giant cells) vesicles • Not distinguish HSV from VZV – Direct Fluorescent Antibody: sequentially incubate slide with smeared vesicle in fluorescent anti-HSV & anti-VZV antibodies – Viral culture

Atopic Dermatitis of Face Multinucleated giant cell

Xerosis indicates poor barrier with susceptibility to viral infection (see next slide) 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 palate, • Any VZV in immunocompromised host – treat as tongue, buccal mucosa) disseminated • Sequelae: rare aseptic meningitis, myocarditis, paralysis • Avoid unvaccinated pregnant females • Spread: oral-oral or fecal-oral; incubation 3-6 days

Hand-Foot-and-Mouth Disease

Vesicles and erosions Photos courtesy of Dr. Mark Lebwohl

Herpangina Coxsackie A6 severe disease

• Cause: coxsackie A types and echoviruses • Symptoms: dysphagia, fever, sore throat • 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.

Mulluscum Incision contagiosum Traction behind blade = GOOD in

Extraction with comedone extractor Pityriasis Rosea

• 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 collarette Herald Pityriasis rosea of scale Pityriasis Rosea patch

Verruca Vulgaris Why Paring Alone Does Not Work • Thrombosed capillaries • Absent dermatoglyphics • Verrucous surface

HPV-infected keratinocytes remain at the base

Therapy for Verruca Vulgaris Cantharidin Painless Painful • Paring (but involves a blade) • Shave removal • Back of a wooden cotton tip applicator  one drop • Imiquimod • Paring (if aggressive) – Daily under duct tape • Cryotherapy • Cover for 8 hours with 3M Blenderm tape, then wash off • 5-Fluorouracil bid – 30 seconds, 2 – 3 cycles • May hurt later (but doctor isn’t “the bad guy”) • Cantharidin • Pulse dye laser • AVOID: eyes, mucous membranes, genitals – Two to three sessions – 0.45msec pulse, 8-30 J/cm2, – IN OFFICE ONLY 3-5mm spot size • Manufacterer: Dormer Laboratories Inc (brand is Cantharone • Duct tape alone • Electrodesiccation and or Cantharone Plus) curettage • Salicylic acid plasters – 40% – From Canada • Intralesional bleomycin • Cimetidine 300mg po tid – Has 31% salicylic acid (adult) or 10mg/kg • Candida antigen injections • Decrease 6-MP/azathioprine Pediculus humanus var. capitis

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

Louse

Unhatched nit - brown Cure Rates of Lice Products in U.S. Topical Agent Cure Rate Malathion 98% Spinosad 86% Benzyl alcohol 75% Ivermectin 74% Permethrin 40%

DO NOT USE LINDANE = NEUROTOXIN!

Pediculosis Capitis Last case… • Can live off scalp for 55 hours  fomites to bag for 3 days • 89 year old male, PMH BPH, hypertension, venous stasis, recent hip and neck fracture s/p fall, comes from rehab • Treat once and repeat in 7 days facility to inpatient service for work up of change in mental • Check family members & close contacts (friends) status. He complains of itch.

Look to the wrist burrow Scabetic papulovesicles Disease Spectrum

• Scabies in child – palms/soles (vesicles); face • Scabies in adult – trunk (red ) • Crusted scabies – scale with tons of mites

•From: http://images.google.com/imgres?imgurl=http://www.studentbmj.com/issues/05/06/education/images/view_2.jpg&imgre furl=http://www.studentbmj.com/issues/05/06/education/228.php&h=204&w=200&sz=8&hl=en&start=1&tbnid=tVLH p0UZ4OnUBM:&tbnh=105&tbnw=103&prev=/images%3Fq%3Dscabies%2Bvesicles%26ndsp%3D20%26svnum%3D 10%26hl%3Den%26ie%3DUTF-8%26oe%3DISO-8859-1%26safe%3Doff%26sa%3DN

Scabetic papules Crusted or “Norwegian” scabies

• Mite density in crust > 1000 mites/cm2 • Can be localized or generalized

Crusted Scabies Localized Crusted Scabies

Courtesy of Dr. Robert Phelps, Department of Dermatopathology, The Mount Sinai Medical Center Generalized Crusted Scabies Scabies • Cause: Sarcoptes scabiei var. hominis • Itchy patient with red papules  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; From: Callen JP, – clip fingernails et al, eds. Color Atlas of – Treat contacts Dermatolog, 2nd Ed. W.B. • Crusted (Norwegian) Scabies: thousands of mites in Saunders the scale; immunocompromised or neurologic disorder; Company, Philadelphia. may require a third cycle of therapy 2000. * ivermectin orally is off-label for scabies

Thank you for your attention!

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