MINISTRY OF HEALTH OF UKRAINE Higher medical educational institution of Ukraine "Ukrainian medical stomatological academy"

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1 MINISTRY OF HEALTH OF UKRAINE Higher medical educational institution of Ukraine "Ukrainian medical stomatological academy" Approved On the meeting chair Of Pediatric Surgical Stomatology and Propaedeutics Surgical Stomatology The Head of the Department prof. Ткаchеnко P.I. 20 Educational discipline Module 2 Content module 4 Theme lesson GUIDELINES Individual work of students During preparation for Practical classes Course 3 Faculty Stomatological Surgical stomatology Inflammatory diseases in maxillofacial region. Nonodontogenous inflammatory diseases in maxillofacial region Furuncles, carbuncles and erysipelas of head. Etiology, pathogeny, classification, clinic, diagnostics, medical treatment. Poltava 2016

2 1. Actuality of the topic: Skin infections are very common occurrences throughout life. Some infections are self-limiting and resolve on their own, but many others require medical attention. Bacterial skin infections technically have specific names based on their origin and extent, but even in the medical community we often lump these technical terms into the common term "boil" or "abscess". This article will clarify the technical terms we use to describe the diagnosis of specific bacterial infections caused mainly by the bacteria, Staphylococcus aureus. 2. The objectives of the studies: Etiology, pathogens, pathological anatomy, classification, features of a clinical course, methods of diagnostics furuncles, carbuncles and erysipelas of head. To be able: to establish the diagnosis of furuncles, carbuncles and erysipelas of head. 3. Basic knowledge, skills, skills necessary for study topics (interdisciplinary integration). Name of previous courses These skills Microbiology Agents who produce above named diseases, their property. Pathological anatomy An etiology, pathogens, of furuncles, carbuncles and erysipelas of maxillofacial region. Pathophysiology A pathogenesis of above named diseases. Histology Topography and anatomy of skin Propedeutics of a surgical Methods examination of patients stomatology 4. Tasks for independent work in preparation for the classes A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson: Term A boil, also called a furuncle Erysipelas Definition is a deep folliculitis, infection of the hair follicle is an acute streptococcus bacterial infection[2] of the upper dermis and superficial lymphatics Theoretical questions to lesson: 1. Give definition of furuncle, carbuncle. 2. The etiology and pathogen of furuncle. 3. Classification of furuncles, carbuncles. 4. Clinic of furuncle. 5. Complex medical treatment of furuncle. 6. Medical treatment of carbuncle. 7. Possible complications of furuncles, carbuncles. 8. The etiology and pathogen of erysipelas. 9. Classification of erysipelas. 10. Clinical motion of erysipelas. 11. Diagnostics is that differential diagnostics of erysipelas. 12. Medical treatment and prophylaxis of erysipelas Practical works (tasks) are performed in class: To take possession of technique of realization observation of the patients with furuncle, carbuncle and erysipelas. To make a treatment planning of furuncle, carbuncle and erysipelas. To acquire technique of carrying out observation of patient with furuncle, carbuncle and erysipelas.

3 To make the plan of examine of the patient with furuncle, carbuncle and erysipelas. To make the plan of local treatment of patients with furuncle, carbuncle and erysipelas. 5. Theme contents: A furuncle is an infection of a hair follicle. Folliculitis Folliculitis is an infection that is localized to the hair follicle. A folliculitis looks like small, yellow pustules that are confined to the hair follicle. Factors that can lead to the development of a folliculitis include: - Trauma; - Chronic friction; - Occlusive clothing; - Occlusive chemicals; - Excessive sweating; - Exposure to water; Pictures of Folliculitis: - Folliculitis on the scalp; - Folliculitis on the leg; - Hot Tub Folliculitis. A special case of folliculitis that is not caused by S. aureus is hot tub folliculitis. This selflimited infection is caused by Pseudomonas aeruginosa contracted from hot tubs, whirlpools, and pools with inadequate chlorine levels. Treatment of Folliculitis. Mild cases of folliculitis and small furuncles may heal on their own with good hygiene and wound care. Furuncle Causes A furuncle (boil) is a skin infection involving pilosebaceous unit an entire hair follicle and nearby skin tissue. Infection also involves the sebaceous gland. Is more extensive than a folliculitis. Factors that contribute to the development of furuncles include: - Obesity; - Blood disorders; - Taking oral steroid medications; - Diabetes. Furuncles are very common. They are caused by staphylococcus bacteria, which are normally found on the skin surface. Damage to the hair follicle allows these bacteria to enter deeper into the tissues of the follicle and the subcutaneous tissue. Furuncles may occur in the hair follicles anywhere on the body, but they are most common on the face, neck, armpit, buttocks, and thighs. Furuncles are generally caused by Staphylococcus aureus, but they may be caused by other bacteria or fungi. They may begin as a tender, red nodule but ultimately feel like a water-filled balloon. A furuncle may drain spontaneously, producing pus. More often the patient or someone else opens the furuncle. Furuncles can be single or multiple. Some people have recurrent bouts with abscesses and little success at preventing them. Furuncles can be very painful if they occur in areas like the ear canal or nose. A health care provider should treat furuncles of the nose. Furuncles that develop close together may expand and join, causing a condition called carbunculosis. Symptoms: The lesions themselves are the primary symptoms: Small firm tender red nodule in skin (early); Fluctuant nodule (later);

4 Located with hair follicles; Tender, mildly to moderately painful; May be single or multiple; Usually pea-sized, but may be as large as a golf ball; Swollen; Pink or red; May grow rapidly; May develop white or yellow centers (pustules); May weep, ooze, crust; May join together or spread to other skin areas; Increasing pain as pus and dead tissue fills the area; Decreasing pain as the area drains; Skin redness or inflammation around the lesion. Less common symptoms include the following: Fever; Fatigue; General discomfort, uneasiness, or malaise. Note: Itching (pruritus) of the skin may occur before the lesion develops. Exams and Tests Diagnosis is primarily based on the appearance of the skin. Skin or mucosal biopsy culture may show staphylococcus or other bacteria. Treatment Furuncles may heal on their own after an initial period of itching and mild pain. More often, they progress to pustules that increase in discomfort as pus collects. They finally burst, drain, and then heal spontaneously. Furuncles usually must drain before they will heal. This most often occurs in less than 2 weeks. Boils that persist longer than 2 weeks, recur, are located on the spine or the middle of the face, or that are accompanied by fever or other symptoms require treatment by a health care provider because of the risk of complications from the spread of infection. Warm moist compresses encourage furuncles to drain, which speeds healing. Gently soak the area with a warm, moist cloth several times each day. Deep or large lesions may need to be drained surgically by the health care provider. Never squeeze a boil or attempt to lance it at home because this can spread the infection and make it worse. Meticulous hygiene is vital to prevent the spread of infection. Draining lesions should be cleaned frequently. The hands should be washed thoroughly after touching a boil. Do not re-use or share washcloths or towels. Clothing, washcloths, towels, and sheets or other items that contact infected areas should be washed in very hot (preferably boiling) water. Dressings should be changed frequently and discarded in a manner that contains the drainage, such as by placing them in a bag that can be closed tightly before discarding. Antibacterial soaps and topical antibiotics are of little benefit once a furuncle has formed. Systemic antibiotics may help to control infection in those with repeated furuncles. Prognosis. Full recovery is expected. Some people may experience many repeated episodes. Possible Complications: Spread of infection to other parts of the body or skin surfaces; Abscess formation; Sepsis (general internal infection); Abscess of kidneys or other internal organs; Osteomyelitis; Endocarditis; Brain infection;

5 Brain abscess; Spinal cord infection; Spinal cord abscess; Permanent scarring. When to Contact a Medical Professional Call for an appointment with your health care provider if furuncles develop and do not heal with home treatment within one week. Call for an appointment with your provider if furuncles recur or are located on the face or spine. Call for an appointment with your provider if boils are accompanied by fever, red streaks extending from the boil, large fluid collections around the boil, or other symptoms. Prevention: Good attention to hygiene. Antibacterial soaps. Antiseptic washes. Carbuncle A carbuncle can simply be defined as an extension of a furuncle to multiple follicles. A carbuncle usually involves the deeper layers of the skin - the subcutaneous fat. It looks like a large, red nodule that is indurated and may be fluctuant or have visible layers of pus just beneath the surface of the skin. Carbuncles often occur on the nape of the neck, the back, or the thighs and cause a fever and fatigue. Carbuncles rarely heal on their own and require immediate medical attention. Treatment Carbuncles More extensive furuncles and all carbuncles need to be treated with antibiotics such as dicloxacillin or cephalexin. If pus or induration are present, in addition to antibiotics, a procedure called incision and drainage (I&D) should be performed to drain the pus and allow the lesion to heal from the inside out. Carbuncles Caused by Methacillin Resistant Staphylococcus Aureus (MRSA) In the past several years there has been a sharp increase in the incidence of infections caused by a special strain of S. aureus that is resistant to the normal penicillin-based treatment. Until very recently, MRSA was an uncommon bacterial strain that occurred in nursing homes and other long-term care facilities. But with the overuse of antibiotics for conditions that don't require antibiotics, MRSA infections are common in certain regions of the United States. These infections often occur spontaneously in the groin, buttock, and upper thigh region. Currently there are antibiotics that can be used to treat these infections. The most common antibiotics used are trimethoprim-sulfamethoxazole (Septra or Bactrim) and fluroquinolone antibiotics like levofloxacin (Levaquin) and moxifloxacin (Avelox) in people who are allergic to sulfa. Erysipelas Erysipelas (Greek ερυσίπελας - red skin) is a type of superficial cellulitis with dermal lymphatic involvement. Is acute streptococcus bacterial infection of the dermis, resulting in inflammation and characteristically extending into underlying fat tissue. This disease is also known as Saint Anthony's fire. Erysipelas should not be confused with erysipeloid, a skin infection caused by Erysipelothrix (see Gram-Positive Bacilli: Erysipelothricosis). Erysipelas is characterized clinically by shiny, raised, indurated, and tender plaque-like lesions with distinct margins. There is also a bullous form of erysipelas. Erysipelas is most often caused by group A (or rarely group C or G) β-hemolytic streptococci and occurs most frequently on the legs and face. However, other causes have been reported, including Staphylococcus aureus (including methicillinresistant S. aureus [MRSA]), Klebsiella pneumoniae, Haemophilus influenzae, Escherichia coli, S. warneri, Streptococcus pneumoniae, S. pyogenes, and Moraxella sp. Erysipelas of the face must be differentiated from herpes zoster, angioedema, and contact dermatitis. It is commonly

6 accompanied by high fever, chills, and malaise. Erysipelas may be recurrent and may result in chronic lymphedema. Risk factors. This disease is most common among the elderly, infants, and children. People with immune deficiency, diabetes, alcoholism, skin ulceration, fungal infections and impaired lymphatic drainage (e.g., after mastectomy, pelvic surgery, bypass grafting) are also at increased risk. Signs and symptoms. Patients typically develop symptoms including high fevers, shaking, chills, fatigue, headaches, vomiting, and general illness within 48 hours of the initial infection. The erythematous skin lesion enlarges rapidly and has a sharply demarcated raised edge. It appears as a red, swollen, warm, hardened and painful rash, similar in consistency to an orange peel. More severe infections can result in vesicles, bullae, and petechiae, with possible skin necrosis. Lymph nodes may be swollen, and lymphedema may occur. Occasionally, a red streak extending to the lymph node can be seen. The infection may occur on any part of the skin including the face, arms, fingers, legs and toes, but it tends to favor the extremities. Fat tissue is most susceptible to infection, and facial areas typically around the eyes, ears, and cheeks. Repeated infection of the extremities can lead to chronic swelling (lymphadenitis). Diagnosis. Diagnosis is by characteristic appearance; blood culture is done in toxic-appearing patients. Erysipelas can be distinguished from cellulitis by its raised advancing edges and sharp borders. Elevation of the antistreptolysin O titre occurs after around 10 days of illness. Diffuse inflammatory carcinoma of the breast may also be mistaken for erysipelas. Erysipelas must be differentiated from herpes zoster, angioedema, contact dermatitis, and diffuse inflammatory carcinoma of the breast. Treatment. Depending on the severity, treatment involves either oral or intravenous antibiotics, using penicillins, clindamycin or erythromycin. While illness symptoms resolve in a day or two, the skin may take weeks to return to normal. Treatment of choice is penicillin V 500 mg QID for 2 wk. In severe cases, penicillin G 1.2 million units IV q 6 h is indicated, which can be replaced by oral therapy after 36 to 48 h. Dicloxacillin 500 mg QID for 10 days can be used for infections with staphylococci. Erythromycin 500 mg QID for 10 days may be used in penicillin-allergic patients; however, there is growing macrolide resistance in streptococci. In infections resistant to these antibiotics, cloxacillin (a semisynthetic penicillin used to treat staphylococcal infections due to penicillinresistant organisms) or nafcillin can be used. In Europe, pristinamycin and roxithromycin have been shown to be good choices for erysipelas. If MRSA is suspected, empiric coverage should be initiated. Cold packs and analgesics may relieve local discomfort. Fungal foot infections may be an entry site for infection and may require antifungal treatment to prevent recurrence. Because of the risk of reinfection, prophylactic antibiotics are sometimes used after resolution of the initial condition. However, this approach does not always stop reinfection. Complications. Spread of infection to other areas of body through the bloodstream (bacteremia), including septic arthritis and infective endocarditis (heart valves). Septic shock. Recurrence of infection Erysipelas can recur in 18-30% of cases even after antibiotic treatment. Lymphatic damage.

7 Necrotizing fasciitis -- AKA "the flesh-eating bug." A potentially-deadly exacerbation of the infection if it spreads to deeper tissue. 6. Materials for self control: А. Assignments for self control (tables, charts, drawings, graphs) Main task Recommendations Comment To acquire procedure of examine of the patient. To carry out observation of the patient. To treatment. appoint To carry out in such sequence: 1. Interrogation of the patient (the complaint, an anamnesis of disease). 2. Survey of the patient, a palpation, a percussion, probe. During examine to reveal attributes of furuncle, carbuncle and erysipelas. To prove a choice of a method local treatment of furuncle, carbuncle and erysipelas. To pay attention to the common state of the patient, presence of pathological changes of a skin of the face. To pay attention to correctness of filling of a card of the out-patient patient. B. Self-control tests: 1. Patient has a pustule which quickly become dense, sharply sickly infiltrates with size 3 5 sm. Skin above him blue-and-red color. In a center there are three areas of necrosis round hair follicles. Lymphatic s node are increase and painful. What most credible diagnosis? A. Erysipelas. B. Actinomycosis of skins. C. Furuncle. D. Carbuncle. E. Festered (suppurated) atheroma. 2. The causative agent of erysipelas is: A. Staphylococci. B. Streptococcus. C. S. Spirochete. D. D. Fungi. E. Anaerobic microorganisms. 3. At patient C. diagnosed the abscess furuncle of upper lip. After dissection bacteriological research of exudates was performing. Culture of what exciter to the furuncle more reliable only was exposed? A. Monoculture of staphylococci. B. Monoculture of streptococcus. C. Monoculture of intestinal stick. D. Monoculture of Proteus. E. Associations of staphylococci with the protozoa. C. Tasks for self-control: Problem 1. At patient 25 years, which has inclination to the allergic reactions, suffer on diabetes mellitus, three days ago in an area angle appearance the edema, itch, appeared, hyperemia of skin as crest of flame. In course of time was swollen hyperemia spread on all face almost. In an area angle appearance vesicle in size 3 5 sm. The temperature of body increase to 39 C. Question. 1. To make Diagnose.

8 2. Name the clinical forms of this disease. 3. To make differential diagnose. 4. What medical treatment of this patient? 7. Bibliography: Basic: 1. Contemporary Oral and Maxillofacial Surgery//Larry J. Peterson, Edvard Ellis III, James R.Hupp, Myron Tucker/ 2003, MOSBY, 776 p. Additional: 1. Stulberg, Daniel and Penrod, Marc. "Caring for Common Skin Conditions: Common Bacterial Skin Infections." American Family Physician 66. (July 1, 2002): Tavelli Bert. "Infectious Diseases of the Skin." Noble: Textbook of Primary Care Medicine, 3rd ed. New York: Mosby, Wilkerson Michael. "Baterial Disaeses of the Skin." Rakel: Conn's Current Therapy, 54th ed. New York: Saunders, Methodical Instruction is composed by docent Pan kevych A.I.