sign in sign up
<<
Home , Chancre, Epidermoid cyst, Folliculitis

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

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 • Fungal: Pityrosporum aka • Fungal: topical antifungals (e.g., ketoconazole) • HIV: eosinophilic folliculitis (not bacterial) • Eosinophilic folliculitis • Renal Failure: perforating folliculitis (not – Phototherapy bacterial) – Treat the HIV

MRSA Furunculosis • Incise and Drain • GI noted Crohn’s was controlled but increased • Swab culture infliximab intensity, but that was not controlling • Assume MRSA recurrent “flares” • Empiric oral – Bactrim DS 1 po bid x 10 days •I & D  MRSA on three occasions – Doxycycline 100mg po bid x 10 days – Augmentin / Cephalexin / Clindamycin if want to roll the dice with close follow-up • THIS WAS INFLIXIMAB-RELATED • ointment FURUNCULOSIS FROM MRSA COLONIZATION – To wounds tid – D/C infliximab – To nares (bid x 5days) • Bleach bath – 1/3 cup bleach to tub biw-tiw – Anti-MRSA regimen • Wash fomites – bedding, worn clothes, bath towels – Patient is better  (don’t reuse) MRSA Eradication Perhaps Pathognomonic: • Swab nares  mupirocin ointment bid x 5 days Double-Headed Comedone in – Swab axillae, perineum, • Chlorhexidine 4% bodywash qd x 1 week Suppuritiva • Chlorhexidine mouthwash qd x 1 week; soak toothbrush (or disposable) • 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 • Swab partners • Hand sanitizer frequently • Bleach wipes to surfaces (doorknobs, faucet handles) • Towels use once then wash; paper towels when possible

Hidradenitis Suppuritiva Inflamed Epidermoid

• Intralesional triamcinolone 10mg/cc • Incision and Drainage • Culture – sometimes is superinfected – Characteristic odor • Short courses of antibiotics to cool it down – doxycycline or cephalexin • Swab culture (sometimes superinfected, • Laser hair removal esp. if pus) • TNF-blockers – infliximab or adalimumab • Empiric antibiotics controversial • AS BRIDGE TO SURGERY • Intralesional triamcinolone 5-10mg/cc – Excision (best for axillae) – Marsupialization (when cannot excise) around to the inflamed area • Excision when “cooled off”

Impetiginized eczema ****** • Superficial • Contagious In kids, generalized eczema often doesn’t • Bullous and non-bullous forms clear until the impetigo is cleared • Causes: aureus, streptococci (often colonize nose) • Superinfects any defect in skin (eczema, arthropod bite, etc.) • Appearance: honey-colored crust • Treatment: mupirocin = best; tid!!!; may require oral antibiotics • Sequelae: post-streptococcal glomerulonephritis; rheumatic fever SSSS Staphylococcal Scalded Skin • Infants (3% mortality) and adults with chronic Syndrome: renal insufficiency (50-100% mortality) • Exfoliative toxin ET-A and ET-B • Fever, skin tenderness, peri-oral furrows, exofoliative toxin exfoliation at flexures cleaves Dsg 1 • Pan-culture • Therapy: I.V. antibiotics

Diuretics!

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

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

Cellulitis • Infection of and subcutis (i.e., fat), usually Cellulitis Therapy bacterial, due to break in skin (e.g., tinea pedis in a diabetic) • Healthy adult: antibiotics po • Cause: Staph aureus and Group A strep most common; but, can be any organism. • Comorbidity: diabetes, venous stasis, HIV – Culture not of use unless ulcerated – Need i.v. antibiotics • Signs: rubor (), dolor (pain), calor – Careful about switching to p.o. too soon (heat), tumor (swelling/edema) – Sometimes needs two weeks of i.v. abx • Sequelae: fibrosis of lymphatics  lymphedema and recurrent cellulitis – Leg elevation  less edema  better distribution of drug to target • Trace border to monitor improvement Gangrenosum Pyoderma Gangrenosum • Can present with superinfection (cellulitis) – Swab culture • Treat infection and inflammation at same – Topical mupirocin (empirically) time – Oral or i.v. antibiotics (Staph >> Pseudomonas) • Association: Inflammatory Bowel Disease, • Intralesional triamcinolone 10mg/cc q1-2weeks Myeloma • Cyclosporine 5mg/kg or Infliximab 5mg/kg • Pathergy: Tissue damage disproportionate to inciting trauma – DO NOT DEBRIDE SURGICALLY!!!

Spirochetal Diseases: Meningococcemia • Cause: Borrelia burgdorferi (spirochete) via bite • Derm Emergency (notify State Dept. of Health) of Ixodes (deer tick) • Cause: Neisseria meningitidis (lives in – Tick must be attached > 18 hours for transmission nasopharynx) (Gram negative diplococci) • Three stages • Prodrome: mild upper respiratory infection – 1) erythema chronicum migrans • Signs: ; septic shock; – 2) carditis (AV block) and neuritis (Bell’s palsy) sharply angulated slate-gray purpura signaling – 3) arthritis disseminated intravascular coagulation (DIC) • Therapy: doxycycline or amoxicillin for 1o • Therapy: droplet/contact isolation; blood culture; • Prophylaxis penicillin G – Doxycycline 200mg po once within 72h of tick bite • Prophylaxis of contacts: rifampin, ciprofloxacin – Insect repellent if outdoors (DEET = N,N-diethyl-m- toluamide)

Features of Syphilis: • Primary Syphilis: 18-21 days after infection (spirochete) – (cf: RPR + at 5-6 weeks after infection; FTA-Abs + earlier) • Primary: • Secondary Syphilis: 6 weeks - 4 months after infection – painless, indurated • Tertiary Syphilis: 3-5 years after infection • Secondary: the great imitator Therapy: – Palms/soles (like ) •Test for HIV – Papulosquamous (like ) • Report to NYSDOH – Mucous patch in mucosal surfaces • Benzathine Penicillin G - 2.4 million units – IM – Condyloma latum (NOT viral ) –1o and 2o – one dose • Latent: no –3o – 3 doses one week apart • Tertiary: gumma (rubbery, ulcerated nodule), – BEWARE!!! Not Bicillin (penicillin G benzathine and penicillin G procaine) CNS (tabes dorsalis – posterior column • Need probenecid to maintain blood levels of PCN G procaine demyelination) • Doxycycline 100mg po bid x 2 weeks • Congenital: TORCH infection, many signs Dermatophytes • Organisms: most common; Microsporum canis and T. tonsurans also common • Name of infection corresponds with anatomic • Symptoms: pruritic location • Diagnosis: via KOH (potassium hydroxide) – Foot: tinea pedis and/or culture – Hand: – Hair/: – Face: tinea facialis – Beard: – Body: – Groin: – : tinea unguium

Tinea unguium Bowen’s Disease (vs. )

• Aka in situ • Tinea unguium refers to infection – What is in situ should excite you! of the nail • Solitary scaly plaques usually are not – Rule out SCC in situ • Onychomycosis is any fungal infection of the nail (i.e., candida, molds, or dermatophytes) • Excision is favored • Therapy: Nail lacquers don’t work! – 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

Oral Terbinafine Diagnosis • Stigma/fear: liver damage • Justified: in hepatitis patients, alcoholics • KOH • Actual data: 2.5 cases/100,000 persons/month • Culture – helpful to prove dermatophyte [Gupta et al. J Drugs Dermatol. 2005;4(3):302-8.] • Nail clipping to (most sensitive) • Monitoring? Baseline (monthly is excessive) • Pre-treatment confirmation of (KOH, culture, or pathology) • Rare side effects: neutropenia, • Drug interactions – CYP450 2D6 but not a problem in over 25,000 patients [Hall et al. Arch Dermatol. 1997; 133(10):1213-9]. Topical Therapy: Ciclopirox 8% lacquer When to see results • Some say good for maintenance of a clear nail • Fingernail grows 0.1mm/day (i.e., 5 • Thin nails with disease (fingers > toes) months) • In conjunction with urea, in theory • Toenail grows more slowly (i.e., 8-12 • How to use: apply daily, coat over coat, x 1 months) week; acetone removal weekly • Cost: 6 months of therapy (time) and money • Three month course of terbinafine shows clearing at base (90d x 0.05mm/d = 4.5mm) • May need 4th and 5th month (if less than expected evidence of clearing)

Effectiveness of Therapy Other orals • More side effects and/or drug interactions • Terbinafine orally x 3 months: 40-80% and/or less activity BUT can be effective cure, 15% relapse (per terbinafine Package • Itraconazole: Heart failure; drug interactions Insert) (CYT P450 3A4  QT prolongation); hepatotoxicity • Ciclopirox lacquer x 48 weeks: 5.5-8.5% • : > liver toxicity; drug cure interactions: warfarin, phenytoin, cyclosporin • No lunula involvement; need adjunctive • Ketoconazole: > liver toxicity; drug debridement interactions (CYP450 3A4) – Is this clinically relevant statistical iifi ?

Dermatophyte: Tinea pedis Antifungal Therapy • Topical: for limited area (i.e., groin, small area • Types: moccasin; interdigital on body) and tinea capitis (shampoo, adjunctive)

• Differential diagnosis: psoriasis, eczema • Oral: tinea unguium, tinea manuum, tinea capitis (definitive), extenisve tinea corporis

• Topically, terbinafine is most effective, but any topical will do. • Orally, terbinafine is most effective (except for Microsporum). Virus Terbinafine 250mg p.o. • Viral shedding occurs in normal-appearing skin Type of Tinea Duration of Therapy Pedis/corporis/cruris/manum Two-four weeks • Diagnosis: – Tzanck smear (multinucleated giant cells) Unguium - fingernails Six weeks • Not distinguish HSV from VZV Capitis/barbae Six weeks – Direct Fluorescent Antibody: sequentially Unguium - toenails Twelve weeks incubate slide with smeared vesicle in fluorescent anti-HSV & anti-VZV antibodies – Viral culture

Shingles: Hand-Foot-and-Mouth Disease When to isolate a patient • Normal health but – 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 host – palate, tongue, buccal mucosa) treat as disseminated • Sequelae: rare aseptic meningitis, myocarditis, • Avoid unvaccinated pregnant females paralysis • Spread: oral-oral or fecal-oral; incubation 3-6 days

Herpangina

• Cause: coxsackie A types and echoviruses • Cause: poxvirus • Symptoms: dysphagia, fever, sore throat • Transmission: direct contact • Enanthem: yellow/white vesicles in throat, – Sexually transmitted disease in adults – Seen in children, often with atopic diathesis tonsils, uvula, soft palate with intense red (i.e., tendency to dry skin with poor barrier) halo • Appearance: umbilicated • Therapy: self-limited; curettage  scar; cantharidin (not genital); incision and comedone extractor works best for me Therapy for Verruca Vulgaris Pityriasis Rosea Painless Painful • Paring (but involves a blade) • Shave removal • Cause: not known, perhaps HHV 6 or 7 • Imiquimod • Paring (if aggressive) • Symptoms: mild fever; pruritus – Daily under duct tape • Cryotherapy • Exanthem: herald patch, then 1-2 weeks later • 5-Fluorouracil bid – 30 seconds, 2 – 3 cycles similar oval red patches with peripheral collarette • Cantharidin • Pulse dye laser of scale in “Christmas-tree” distribution along – Two to three sessions – 0.45msec pulse, 8-30 J/cm2, lines of cleavage – IN OFFICE ONLY 3-5mm spot size • Electrodesiccation and • Occurs in Spring and Fall • Duct tape alone • Salicylic acid plasters – 40% curettage • Spontaneous remission in 6-12 weeks • Cimetidine 300mg po tid • Intralesional bleomycin • Consider ruling out syphilis (adult) or 10mg/kg • Candida antigen injections • Decrease 6-MP/azathioprine

Cure Rates of Lice Products in Cantharidin U.S. • Back of a wooden cotton tip applicator  one drop Topical Agent Cure Rate • Cover for 8 hours with 3M Blenderm tape, then wash off Malathion 98% • May hurt later (but doctor isn’t “the bad guy”) Spinosad 86% • AVOID: eyes, mucous membranes, genitals • Manufacterer: Dormer Laboratories Inc (brand is Benzyl alcohol 75% Cantharone or Cantharone Plus) – From Canada Ivermectin 74% – Has 31% salicylic acid 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, • Treat once and repeat in 7 days venous stasis, recent hip and neck fracture • Check family members & close contacts (friends) s/p fall, comes from rehab facility to inpatient service for work up of change in mental status. He complains of . Crusted or “Norwegian” Disease Spectrum • Mite density in crust > 1000 mites/cm2 • Scabies in child – palms/soles (vesicles); face • Can be localized or generalized • Scabies in adult – trunk (red ) • Crusted scabies – scale with tons of mites

Scabies • Cause: Sarcoptes scabiei var. hominis • Itchy patient with red papules  burrows Thank you for your attention! • Location: fingerwebs/wrists • Transmission: skin-skin contact; hospital bedding; • For more derm lectures, procedural videos, mites live > 2 days off skin!!! and more, check out: • Treatment: – permethrin 5% cream once, repeat in 4 days; – ivermectin* 200mcg/kg po once, repeat in 4 dayas; http://bit.ly/dermedu – clip fingernails – Treat contacts • 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