Folliculitis Common Cutaneous • Inflammation of hair follicle(s) Bacterial Infections • Symptoms: Often pruritic (itchy) 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 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 antibiotics – 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 • Mupirocin 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, pharynx • Chlorhexidine 4% bodywash qd x 1 week Hidradenitis 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 Cyst • 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 ***Impetigo*** • Superficial skin infection • Contagious In kids, generalized eczema often doesn’t • Bullous and non-bullous forms clear until the impetigo is cleared • Causes: Staphylococcus 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! 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 • Infection of dermis 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 (erythema), 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 Pyoderma 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 Lyme Disease • 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: meningitis; 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 Syphilis: Treponema pallidum • Primary Syphilis: 18-21 days after infection (spirochete) – (cf: RPR + at 5-6 weeks after infection; FTA-Abs + earlier) • Primary: chancre • 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 erythema multiforme) •Test for HIV – Papulosquamous (like pityriasis rosea) • Report to NYSDOH – Mucous patch in mucosal surfaces • Benzathine Penicillin G - 2.4 million units – IM – Condyloma latum (NOT viral warts) –1o and 2o – one dose • Latent: no rash –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 Dermatophytes • Organisms: Trichophyton rubrum 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: tinea manuum – Hair/Scalp: tinea capitis – Face: tinea facialis – Beard: tinea barbae – Body: tinea corporis – Groin: tinea cruris – Nail: tinea unguium Tinea unguium Bowen’s Disease (vs. onychomycosis) • Aka Squamous Cell Carcinoma in situ • Tinea unguium refers to dermatophyte infection – What is in situ should excite you! of the nail • Solitary scaly plaques usually are not psoriasis – 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 pathology (most sensitive) • Monitoring? Baseline (monthly is excessive) • Pre-treatment confirmation of fungus (KOH, culture, or pathology) • Rare side effects: neutropenia, lupus • 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% • Fluconazole: > 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;