Objectives • 1. To implement a management strategy for MRSA Common Cutaneous eradication. • 2. To recognize the common presentations of cutaneous Bacterial Infections syphilis. • 3. To identify cutaneous manifestations of cocksackie virus infection. • 4. To manage tinea versicolor effectively. Eosinophilic Folliculitis Folliculitis (HIV) • Inflammation of hair follicle(s) • Symptoms: Often pruritic (itchy) Pseudomonas folliculitis Treatment of Folliculitis Folliculitis: Causes • Bacterial – culture pustule • Bacteria: – topical clindamycin or oral cephalexin / doxycycline – Gram positives (Staph): most common – shower and change shirt after exercise – Gram negatives: Pseudomonas – “hot tub” folliculitis – keep skin dry; loose clothing • Fungal: Pityrosporum aka Malassezia • Fungal: topical antifungals (e.g., ketoconazole) • 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 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 Epidermoid Cyst Acute Paronychia • 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 impetigo Note collarettes of scale from unroofed bullae Impetiginized eczema ***Impetigo*** • Superficial skin infection • Contagious In kids, generalized • Bullous and non-bullous forms eczema often doesn’t • Causes: Staphylococcus aureus, streptococci (often colonize clear until the nose) impetigo is cleared • 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 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! Cellulitis This is stasis dermatitis (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 dermis 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 (erythema), dolor (pain), calor (heat), tumor (swelling/edema) • Sequelae: fibrosis of lymphatics lymphedema and recurrent cellulitis Recurrent cellulitis Elephantiasis nostras 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 Pyoderma 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 Meningococcemia: DIC Pseudomonas superinfection from chronic moisture/draining Spirochetal Diseases: Meningococcemia Lyme Disease • Cause: Borrelia burgdorferi (spirochete) via bite of Ixodes • Derm Emergency (notify State Dept. of Health) (deer tick) • Cause: Neisseria meningitidis (lives in nasopharynx) (Gram – Tick must be attached > 18 hours for transmission negative diplococci) • Three stages • Prodrome: mild upper respiratory infection – 1) erythema chronicum migrans • Signs: meningitis; septic shock; sharply angulated slate-gray – 2) carditis (AV block) and neuritis (Bell’s palsy) purpura signaling disseminated intravascular coagulation (DIC) – 3) arthritis • Therapy: droplet/contact isolation; blood culture; penicillin G • Therapy: doxycycline or amoxicillin for 1o • Prophylaxis of contacts: rifampin, ciprofloxacin • Prophylaxis – Doxycycline 200mg po once within 72h of tick bite – Insect repellent if outdoors (DEET = N,N-diethyl-m-toluamide) Ixodes scapularis (formerly Features of Syphilis dammini) (deer tick) • Primary Syphilis: 18-21 days after infection – (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 male nymph • Benzathine Penicillin G - 2.4 million units – IM –1o and 2o – one dose female –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 adult • Doxycycline 100mg po bid x 2 weeks Syphilis: Treponema pallidum (spirochete) Secondary Syphilis – Palms • Primary: chancre – painless, indurated • Secondary: the great imitator – Palms/soles (like erythema multiforme) – Papulosquamous (like pityriasis rosea) – Mucous patch in mucosal surfaces – Condyloma latum (NOT viral warts) • Latent: no rash • 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 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: tinea capitis – Face: tinea facialis – Beard: tinea barbae – Body: tinea corporis – Groin: tinea cruris – Nail: tinea unguium Tinea corporis (“ring worm”) Econazole 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 psoriasis – 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. onychomycosis) • Tinea unguium refers to dermatophyte 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