Superficial Pyodermas Are Common4

Home , Abscess, Cellulitis, Epidermoid cyst, Folliculitis, Impetigo, Pyoderma

Bethany KH Lewis, MD MPH Clinical Assistant Professor University of Utah Department of Dermatology I HAVE NO CONFLICTS OF INTEREST TO DECLARE Today’s agenda

• Skin microbiome review • Clinical presentations of pyodermas – Impetigo – Folliculitis – Cellulitis • Treatment guidelines Pyoderma

• “Pyo” – pus • “Derma” – skin

• Pyoderma – skin infection forming pus, or bacterial skin infection

• Primary causative agents: Staph aureus and Strep pyogenes Skin microbiome1,2

• One billion organisms per cm2 of skin • Colonization starts at birth, diversifies w/ age

• Bacterial species vary by site – Sebaceous/follicle – Propionibacterium, Staphylococcus – Body folds – Corynebacterium > Staphylococcus

• Inflammatory diseases have been a/w altered microbiomes – Atopic dermatitis, rosacea, acne Homeostasis disruption pyodermas2

1. Balance between skin and microorganisms – Environmental trauma • i.e. shaving, wounds, other – Underlying skin barrier issues • i.e. atopic dermatitis – Predisposing conditions • i.e. immunosuppression, diabetes 2. Disturbance of microorganism milieu – Staph aureus overgrowth • i.e. homogenization 2/2 exposure – Decrease in diversity Superficial pyodermas are common4

• Impetigo 0.3% • Cellulitis 2.2% Classification of pyodermas

Folliculitis

Impetigo

Cellulitis Bacterial Infections Epidermis Impetigo

Dermis Cellulitis

Appendages Folliculitis

Slide modified from and courtesy of Scott Florell, MD FOLLICULITIS Not all folliculitis is bacterial folliculitis5 Majocchi’s granuloma

DDX includes : • “Hot tub” – Pseudomonas • Herpes simplex • T. rubrum, Candida, Pityrosporum • Drugs or occupational Eosinophilic folliculitis – Topical or PO steroids, lithium – Chloracne • Nutritional deficiency • Eosinophilic Bacterial folliculitis5,7

Diagnosis Treatment • Bacterial swab for Gram • Anti-Staph medications: stain and culture – Topical antibiotics • KOH to evaluate for yeast or • Clinda/erythromycin lotion or solution fungus • Mupirocin ointment • HSV PCR or DFA – Antimicrobial washes • Benzoyl peroxide 10% wash – If extensive involvement, 5-10 day course PO ABX When the hair follicle is more extensively involved7

Furuncle/Carbuncle/Abscess • Diagnosis: – Try to differentiate from inflamed epidermoid cyst • Treatment: – Incision & drainage – Culture & sensitivity – Empiric TMP/SMX or doxycycline – Defined MSSA: dicloxacillin or cephalexin – Defined MRSA: TMPSMX Compare & Contrast

Inflamed EIC Furuncle/Abscess Decontamination procedures

• Intranasal mupirocin BID x 5 days • Daily chlorhexidine washes vs. dilute bleach baths • Daily decontamination of personal items Bacterial Infections Epidermis Impetigo

Dermis Cellulitis

Appendages Folliculitis

Slide modified from and courtesy of Scott Florell, MD IMPETIGO Impetigo

• Superficial epidermal infection, predominantly Staphylococcus Impetigo

• Thin-walled vesicles/pustules, easily rupture & crust with a “honey” color • Exposed areas: face, hands, neck, extremities Impetigo7

• Diagnosis: • Treatment: – Consider a wound – Topical antibacterial culture to differentiate • Mupirocin Staph vs. Strep – +/- systemic antibiotic if: – Typically this is MSSA • extensive involvement • outbreak situation • glomerulonephritis- causing S. pyogenes strain • 7 d. PO cephalexin or dicloxacillin Bacterial Infections Epidermis Impetigo

Dermis Cellulitis

Appendages Folliculitis

Slide modified from and courtesy of Scott Florell, MD CELLULITIS Cellulitis

• Bacterial infection of dermis & subcutaneous tissue • Often occurs near areas of skin breakdown – Risk factors: • Venous stasis/edema • Toe web infections • Eczema • Legs > digits > other exposed sites Cellulitis

• Routine blood or wound cultures not routinely recommended • 5 days anti-Strep antibiotic for routine cases Treatment guidelines for cellulitis7

• Mild: without focus of purulence – PO peni/dicloxacillin, cephalosporin, clindamycin • Moderate: with systemic signs of infection – IV penicillin, ceftriaxone, cefazolin, clindamycin • Severe: failed orals, immunocomp, sepsis – Empiric vancomycin + piperacillin/tazobactam – Emergent C&S and possible debridement References

1. Weyrich, LS et al. The skin microbiome: Associations between altered microbial communities and disease. Australasian Journal of Dermatology 2015; 56: 268-74. 2. Schommer, NN & Gallo, RL. Structure and function of the human skin microbiome. Trends in Microbiology 2013; 21(12). 3. Chen, YE & Tsao, H. The skin microbiome: current perspectives and future challenges. JAAD 2013; 69: 143-55. 4. Stulberg, DL, Penrod, MA, & Blatny, RA. Common bacterial skin infections. Am Fam Physician Jul 2002; 66(1): 119-125. 5. Luelmo-Aquilar, J & Santandreu, M. Folliculitis: recognition and management. Am J Clin Dermatol 2004; 5(5): 301-310. 6. Baron, EJ et al. A guide to the utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). CID 2013; 57: 485-8. 7. Stevens, DL et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. CID 2014; 59: 147-159. 8. Korownyk, C & Allan, GM. Evidence-based approach to abscess management. Can Fam Physician 2007; 53: 1680-84. 9. Bernard, P. Management of common bacterial infections of the skin. Curr Opin Infect Dis 2008; 21: 122-8. 10. Birnie, AJ et al. Interventions to reduce Staphylococcus aureus in the management of atopic eczema 2008. The Cochrane Collaboration, Issue 3.