Folliculitis. Common Cutaneous Bacterial Infections. Eosinophilic Folliculitis (HIV) Folliculitis: Causes. Treatment of Folliculitis

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1 Folliculitis Common Cutaneous Bacterial Infections Inflammation of hair follicle(s) Symptoms: Often pruritic (itchy) Pseudomonas folliculitis Eosinophilic Folliculitis (HIV) Folliculitis: Causes Bacteria: Gram positives (Staph): most common Gram negatives: Pseudomonas hot tub folliculitis Fungal: Pityrosporum aka Malassezia HIV: eosinophilic folliculitis (not bacterial) Renal Failure: perforating folliculitis (not bacterial) Treatment of Folliculitis Bacterial culture pustule topical clindamycin or oral cephalexin / doxycycline shower and change shirt after exercise keep skin dry; loose clothing Fungal: topical antifungals (e.g., ketoconazole) Eosinophilic folliculitis Phototherapy Treat the HIV 21 year old female with controlled Crohn s disease and history of hidradenitis suppuritiva presents stating she has recurrent flares of her HS

2 MRSA GI noted Crohn s was controlled but increased infliximab intensity, but that was not controlling recurrent flares I & D MRSA on three occasions THIS WAS INFLIXIMAB-RELATED FURUNCULOSIS FROM MRSA COLONIZATION D/C infliximab Anti-MRSA regimen Patient is better MRSA Eradication Swab nares mupirocin ointment bid x 5 days Swab axillae, perineum, pharynx Chlorhexidine 4% bodywash qd x 1 week 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 Pointing abscess (furuncle) --pointing requires I & D-- Acute Paronychia Furuncle Treatment Impetigo Incise & Drain (I & D) Culture pus Warm soaks Antibiotics e.g., cephalexin orally AND mupirocin topically If recurrent, suspect nasal carriage of Staph aureus swab culture and mupirocin to nares b.i.d. x 5 days q month

3 Bullous impetigo Note collarettes of scale from unroofed bullae ***Impetigo*** Superficial skin infection Contagious Bullous and non-bullous forms 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 Impetiginized eczema In kids, generalized eczema often doesn t clear until the impetigo is cleared Staphylococcal Scalded Skin Syndrome: exofoliative toxin cleaves Dsg 1 SSSS Staphylococcal Scalded Skin Syndrome

4 SSSS SSSS 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 Cellulitis Stasis Dermatitis 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 verruciformis

5 Cellulitis Therapy 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 Necrotizing Fasciitis Surgical emergency early and aggressive debridement i.v. broad-spectrum antibiotics tissue culture 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: Lyme Disease 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 Therapy: doxycycline or amoxicillin Prophylaxis Doxycycline 200mg po once at time of tick bite Vaccine in endemic areas Insect repellent if outdoors (DEET = N,N-diethyl-mtoluamide) male Ixodes scapularis (formerly dammini) (deer tick) female nymph adult

6 Right Bell s Palsy (or bad Botox? :O) Features of Syphilis Primary Syphilis: 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 Benzathine Penicillin G million units IM 1 o and 2 o one dose 3 o 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) 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 Palms Secondary syphilis mimicking a morbilliform drug rash Secondary Syphilis - Papulosquamous

7 Secondary Syphilis Mucous Patch Secondary Syphilis - Condyloma Latum Moist, verrucous plaques Tertiary Syphilitic Gumma Dermatophytes Organisms: Trichophyton rubrum most common; Microsporum canis and T. tonsurans also common Name of infection corresponds with anatomic location Foot: tinea pedis Hand: tinea manuum Hair/Scalp: tinea capitis Face: tinea facialis Beard: tinea barbae Body: tinea corporis Groin: tinea cruris Nail: tinea unguium Dermatophytes Symptoms: pruritic Diagnosis: via KOH (potassium hydroxide) and/or culture Tinea corporis ( ring worm ) Nothing to do with worms

8 Black-dot Tinea Capitis Kerion Look closely to see black dots where hairs broke off near the scalp Tinea unguium (vs. onychomycosis) Tinea Unguium 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! Tinea pedis Moccasin Tinea Pedis Types: moccasin; interdigital Differential diagnosis: psoriasis, eczema

9 Interdigital Tinea Pedis One hand, Two feet: Tinea manuum and pedis No scale indicating sparing of one hand Scale indicating infection Tinea cruris ( jock itch ) Spares the scrotum; no satellite lesions (vs. candidal intertrigo affects scrotum) Dermatophyte: Antifungal Therapy Topical: for limited area (i.e., groin, small area on body) and tinea capitis (shampoo, adjunctive) 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). Terbinafine 250mg p.o. Type of Tinea Duration of Therapy Pedis/corporis/cruris/manum Two-four weeks Unguium - fingernails Six weeks Capitis/barbae Six weeks Unguium - toenails Twelve weeks What is the dose of fluconazole to treat this infection if it extends into the esophagus? A. 150mg po qd x one dose Vaginal candidiasis B. & C mg po qd x 1-2 weeks Oropharyngeal candidiasis D mg po qd x 2-3 weeks Esophageal candidiasis E. 800mg po once, then 400mg qd x 3 weeks Candidemia

10 cf. Oral Hairy Leukoplakia (EBV) Candidal Intertrigo Candidal Diaper Dermatitis Candidal Angular Chelitis Pearl: If recurrent after topical clotrimazole, use nystatin 100,000 unit/ml p.o. 2mL (peds) or 5mL (adults) qid x 3-5 days Candidal Paronychia Candidemia Chronic inflammation of proximal nail fold Candida between nail plate and proximal nail fold Candidal sepsis in a neutropenic patient.

11 Pityriasis versicolor Pityrosporum orbiculare (aka Malassezia furfur) Look closely for the fine scale. KOH: Tinea versicolor (misnomer! It s not a dermatophyte.) Spaghetti And Meatballs hypopigmentation hyperpigmentation Primary Herpes Simplex Virus Infection Labial Herpes Erythematous base crop of vesicles Genital Herpes The crop of vesicles often becomes a crop of erosions with scalloped border. Still with an erythematous base. Herpes Simplex Virus Viral shedding occurs in normal-appearing skin Diagnosis: Tzanck smear (multinucleated giant cells) Not distinguish HSV from VZV Direct Fluorescent Antibody: sequentially incubate slide with smeared vesicle in fluorescent anti-hsv & anti-vzv antibodies Viral culture

12 Multinucleated giant cell Atopic Dermatitis of Face Xerosis indicates poor barrier with susceptibility to viral infection (see next slide) Eczema Herpeticum Eczema Herpeticum Herpes Associated Erythema Multiforme Disseminated HSV

13 Herpes Zoster (Shingles) Disseminated VZV Primary dermatome Stops at midline Disseminated lesions Shingles: When to isolate a patient Normal health but shingles cover it up Disseminated VZV contact and droplet Any VZV in immunocompromised host treat as disseminated Avoid unvaccinated pregnant females Hand-Foot-and-Mouth Disease Cause: coxsackievirus A6, A16 & enterovirus 71 Exanthem: oval/linear, gray vesicles on palms, soles Enanthem: painful oral erosions with red halo (hard palate, tongue, buccal mucosa) Sequelae: rare aseptic meningitis, myocarditis, paralysis Spread: oral-oral or fecal-oral; incubation 3-6 days Hand-Foot-and-Mouth Disease Herpangina Vesicles and erosions Photos courtesy of Dr. Mark Lebwohl

14 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 Photo from: Ventarola D, Bordone L, Sliverberg N. Update on hand-foot-and-mouth disease. Clin Dermatol May-Jun;33(3): Molluscum contagiosum 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 papule Therapy: self-limited; curettage scar; cantharidin (not genital); incision and comedone extractor works best for me Molluscum contagiosum Mulluscum contagiosum in atopic dermatitis

15 Incision Traction behind blade = GOOD Extraction with comedone extractor Pityriasis Rosea collarette of scale Pityriasis Rosea Herald patch 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 Pityriasis rosea Verruca Vulgaris Thrombosed capillaries Absent dermatoglyphics Verrucous surface

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

17 Pediculosis Capitis Can live off scalp for 55 hours fomites to bag for 3 days Treat once and repeat in 7 days Check family members & close contacts (friends) Scabies Look to the wrist 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; clip fingernails 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 Thank you for your attention! For more derm lectures, procedural videos, and more, check out: