Bacterial skin

diseases
Department of Dermatology
University of Medical
Sciences in Poznan

Bacterial flora of the skin

Resident

flora

numerous in moist, hairy areas rich in sebaceous glands

organisms are found in clusters in stratum corneum and hair
follicles
a mixture of micrococcai and diphtheroids
Staphylococcus epidermidis predominates on the surface and
anaerobic diphteroids (Propionibacterium acne) deep in the hair
follicle

Transient

and temporary flora

Resident flora

S. epidermidis

Aerobic

organisms in general
Cocci (ball-shaped bacteria)
Bacilli (rod-shaped bacteria)

Corynebacterium

TRANSIENT AND
TEMPORARY FLORA
STAPHYLOCOCCUS AUREUS
- nose and perianal region of some
individuals can be spread to the skin

ENTEROBACTERIACAE
- part of the normal gut flora
- Can be spread to the skin by the hands

PSEUDOMONACAE
- present in the environment
- moist places

INTACT EPIDERMAL BARRIER

pH

(5,4-5,9 on the free skin, like forehead,

higher in the axillae and groin)
WATER AND FAT CONTENT OF THE
STRATUM CORNEUM
SKIN TEMPERATURE
INTEGRITY OF NORMAL FLORA

Erysipelas
Acute erythematous, rapidly spreading skin
infection, usually associated with
systemic symptoms
Cause: Streptococus pyogenes (occasionally
other streptococci)
Formerly: common, feared and fatal
disease!
(St. Anthonys fire)

Etiology
Presence of a defect in skin barrier function
Associated with HSV infection, interdigital
tinea pedis, leg ulcer
Other even minor injury
30% of patients have Streptococcus pyogenes in
their nares
Lymphatic obstruction as a second cofactor

STREPTOCOCCI THEMSELVES
CAUSE FURTHER
LYMPHATIC DAMAGE,
CREATING A VICIOUS CIRCLE,
FACILITATING RECURRENCE!

CLINICAL FINDINGS
Warm,

painful erythema
Rapidly spreads peripherally
Always sharp border to the adjacent
normal skin
tongue like irregular extentions are
common

Common sites
Cheeks

Legs
Edematous

arm following mastectomy

and lymph node dissection

Most patients are febrile and may have

chills.

Erysipelas variants
Blisters

Hemorrhagic

blisters (legs)= erysipelas

vesiculosum et bullosum
Necrosis= erysipelas gangraenosum

Complications

Myo-

peri- and endocarditis

Glomerulonephritis
Cavernous sinus thrombosis
Now uncommon but infants,
immunosuppressed patients and the
elderly deserve special attention!

Therapy
Systemic:

penicillin i.v. In case

of allergy: oral erythromycin (2
weeks)
Topical: dressings with ichthyol
or boric acid or aluminium
acetotartrate (Altacet)

Folliculitis
Inflammation of the hair follicle usually
clinically manifested as distinct papules
and pustules

Types of folliculitis
Infectious

Inflammatory

mechanical

Bacterial
Fungal
Viral
Parasitic
Folliculitis decalvans
Eosinophilic folliculitis
Chronic irritative
Acne nectroticans

Staphylococcal folliculitis
Infection

of the terminal hair- almost

exclusively a disease of men
Women: axilla, groins. Legs
Scalp folliculitis: men

Typical lesion: inflamed papule or pustule on the

hair line (acne necrotica), face, axillas,
buttocks or pubic hairs; painful and pruritic
with erythematous periphery.
Widespread infection: fever, lymphadenopathy
Therapy: antibiotics (temporary improvement, but
relapses are common)
Topical: antibiotic drying solutions or lotions.

FURUNCLE (BOIL)
Deep inflammatory nodule with central pus,
developing from a bacterial hair follicle
infection.
Cause: Staphylococcus aureus.
May be associated with:
Poor hygiene
Immunosuppressive therapy

Risk factors (furuncle)

Corticosteroid therapy
Diabetes mellitus
HIV/AIDS
Wasting illnesses
Also: patients with atopic dermatitis who
have a heavy skin carriage of S. aureus
and minor defects in their skin are
present.

Common location
Nape
Face
Axillae
Buttocks
Arms
Legs
Nasal vestibulum
External ear canal

Furuncle
Small yellow creamy pustulered nodule
with a central yellow plug. Painful,
tense and often associated with local
edema, lymphangitis, fever,
lymphadenopathy
Especially dangerous furuncles: involving
the mid-face (cavernous sinus
thrombosis)

Therapy
Penicillinase-resistant

penicillins or

cephalosporins
In an immunocompromised patient:
hospital and i.v. Therapy!
Topical: ointment based on ichthyol,
povidone-iodine solutions.
Surgical: controversial

FURUNCULOSIS: multiple recurrent

furuncles
CARBUNCLE: worst form of furuncle
with coalescence of lesions and marked
inflammation

Impetigo
Common superficial skin inflammation,
chracterized by small blisters, that
rapidly rupture and evolve into honey
coloured crust.
Cause: Staphylococcus aureus
Streptococci gr A

Impetigo
Most common among children and quite
contagious
Often several children (classmates) will
present simultaneously
The infection may be transferred via wash
clothes and towels

Impetigo
Face
Mouth
Nose
Neck
Hands
Outlook: good, with a prompt response to
treatment

Impetigo
Feared complications: development of
glomerulonephritis (4%)
Therapy: topical: mupirocin ointment,
bacitracin ointment, clioquinol ointment,
crust may be removed by wet compresses.
Systemic: penicillinase-resistant
penicillins, cephalosporins, erythromycin

Erythrasma
Bacterial infection of intertriginous areas
usually with asymptomatic, red-brownish
macules.
Cause: Corynebacterium minutissimum

Erythrasma
20% of population infected
Most patients: older men
Intertriginous sites
Hyperhydrosis
Obesity
Diabetes mellitus

Most common sites-intertriginous

Groin
Axilla
Gluteal cleft
Inframammary folds
Umbillicus
Toe web spaces

Erythrasma
The best way to make the diagnosis

Woods lamp examination

Corynebacteria
porphyrins
coral red fluorescencet

Course: erythrasma is both chronic and

frequently recurrent, despite therapy.
Therapy: a short course of systemic
erythromycin is the easiest method
Topical: imidazole creams ( for 1 week then
weekly for prophylaxis), erythromycin
(solution)

Eliminate predisposing factors

Obesity

Sweating

and maceration

Frequent washing with antibacterial soaps

Monitoring of therapy with Wood light
examination

Viral diseases
Dermatology Department
University of Medical Sciences in Pozna

Cutaneous lesions caused by viruses

Either reflect a direct skin infection by an
epidermotropic virus (verrucae, molluscum
contagiosum)
May be a reflection of a widespread viral
infection (measles, chicken pox)

Warts (verrucae)
Cutaneous tumors caused by epidermotropic
viruses which tend to spontaneously regress, but
may rarely progress into cutaneous
malignancies
Cause: HUMAN PAPILLOMA VIRUS (HPV)

HPV transfer
HUMANS-HUMANS
ANIMALS-HUMANS
HUMANS-ANIMALS (?)
Incubation time: weeks to years
Autoinoculation is a rule:
inoculation with organisms already present in or on
the body

Detection of HPV
Direct immunofluorescence- comercially
available but not sensitive or specific
Serologic tests: research tool for a limited
number of HPV
PCR: able to identify very small amounts of virus
sometimes too sensitive!

Common wart
(verruca vulgaris)

Nature of the warts

Fingers and back of the hands: papular warts

Eyelids: long, thin, filiform warts

Beard area: flat and filiform warts (often large

numbers spraed through shaving)

Scalp: large, exophytic
Palms: smooth and sharply bordered

Soles
Flat and often grow
into the skin like a thorn

spread like a tile

mosaic

 Periungual region: very common, usually along

the lateral nail fold

Nail bed: very uncommon; present as painful
discoroured spots or nodules

Immunosuppressed patients:
Congenital immunodeficiences, HIV/AIDS,
chemotherapy
Warts are:
Widespread
Almost uncontrollable

Course and prognosis

Most tend to resolve spontaneously

Scarring as a result of therapy

Before dissapearance may become inflamed

(host immune response is active)

Plantar warts
Probably the most contagious of warts

Spread wherever large numbers of people go

barefoot (swimming pools, gymnasiums)

Plantar warts
Solitary: most typical location : over metacarpal

heads, may sometimes resemble a corn, or a

clavus
Mosaic warts: multiple warts that coalesce
together resembling a mosaic floor; tend to be
flat and asymptomatic but very difficult to treat

Plane warts
Small, flat papules, often slightly

hyperpigmented and most commonly found on

the face
Typically seen in children and young adults
Frequently dissapear spontaneously with diffuse
inflammation

Genital warts
Condylomata acuminata
Flat genital warts
Giant genital warts

Condylomata acuminata
Highly contagious

Major public health problem

SEVERAL TYPES OF HPV FOUND IN THE

GENITAL REGION (HPV-16, HPV-18) APPEAR
TO BE ONCOGENIC!

Tiny red papule coalesce together produce a

cauliflower-like picture
Typical locations:
Women: labia minora, vagina
Men: coronal sulcus, glans, urethral meatus
Perianal region

Pearly penile papules-normal!

Giant genital warts (Buschke and

Lwenstein 1925)
Large destructive tumors

Perianal, under the foreskin

At some point they become squamous cell

carcinoma (verrucous type)

A large, persistent penile or perianal wart,
especially if appears clinically destructive
biopsied or excised!

Therapy of warts
Multiplicity of warts underscores the fact that no
one regimen is highly effective.
Treatment should be designed to avoid scarring
and should not be terribly aggressive or painful.
The method depends on the location, number, size,
as well as previous therapeutic attempts.

Cryotherapy
Liquid nitrogen: probably most widely used

method
Applied either with a spray applicator, cottontipped swabs or metal sounds
Need to freeze hard enough to produce a blisterHPV themselves are not damaged by the cold
temperature

Surgery
Curette, scalpel, electrosurgical device

Best suired for a small number of warts on

glabrous skin

Lasers
CO2 laser

HPV particles are potentailly infectious!

Well suited for periungual warts: less bleeding,

facilitate removal of part or all the nail

Keratolytic agents
Often in conjunction with cryotherapy

Salicylic acid: solutions, flexible collodion,

plasters, gel patches

Lactic acid
Trichloroacetic acid

Cytostatic agents
Podophyllin: inhibitor of the mitotic cytoskeleton

derived from the may apple (Podohyllum

peltatum); best suited for mucosal surfaces
1% podophyllotoxin: more standarized
podophyllin mixture: FDA approve for treatment
of genital warts

Immunologic therapy
Warts are sometimes cleared by cell mediated

immunity
Interferons: intralesional injection, often
combined with mechanical debulking, topical gel
also available
Imiquimod 5% cream: approved for external
anogenital warts

HPV VACCINES
Cervac (Glaxo): HPV 16 and 18
Gardasil (Merck): HPV 16, 18, 6,

Gardasil, the investigational vaccine

against HPV, significantly reduced the
combined incidence of persistent HPV 6, 11,
16, or 18 infection and related diseases,
including new cervical pre-cancers and
genital warts compared to placebo in a Phase
II study published for the first time in The
Lancet Oncology.
"The level of protection in this study against
infection with these four HPV types, including
pre-cancerous lesions, was significant," said
the study's lead investigator, Luisa Villa, PhD,
head of the Virology Group at the Ludwig
Institute for Cancer Research, So Paulo
branch.

HERPES VIRUSES
HERPES SIMPLEX VIRUSES
VARICELLA ZOSTER VIRUS

Herpes viruses
Herpes simplex virus 1 (HSV1)

Herpes simplex virus 2 (HSV2)

Varicella zoster virus

Epstein-Barr virus
Human herpes virus 6

Human herpes virus 7

Human herpes virus 8

HSVs cause a wide range of

disorders
In newborns: sepsis, encephalitis

In young children: primary herpetic stomatitis

In older individuals: recurrent oral and genital

infections
In elderly and immunosuppressed patients:
disseminated infections

TRIGGERS
FEVER

TRAUMA
SUNLIGHT

STRESS

CLINICALLY
GROUPED BLISTERS OR EROSIONS

HERPETIFORM ARRANGEMENT

HSV
HSV1

HSV2

LIPS
ORAL MUCOSA
HEAD
NECK

GENITALIA

Laboratory findings
Tzanck smear:examined for the typical

multinucleated giant cells (HSV causes epithelial

cells to fuse together)- simple but gives definitive
diagnosis
Electron microscopy: identifies viral bodies
PCR: HSV can be identified from any tissue or
fluid

 Immunofluorescent examination: tissue

examined with antibodies against HSV-1, HSV-2

Viral culture: takes up to 48h and may not yield
organisms if the source is not fresh
Serologic tests: epidemiological interest

Therapy
The mainstay: acyclovir: purine nucleoside
analogue, which interferes with viral DNA
synthesis
Cream, gel, tablets, intravenous form
Used to treat: initial infections, recurrences, may be
used for many months to supress infections
Safe drug

According to the U.S. Centers for Disease Control and Prevention,

45 million people in the United States ages 12 and older, or 1 out of
5 of the total adolescent and adult population, are infected with
HSV-2.

Eczema herpeticum
Generalized HSV infection in patients with atopic
dermatitis and other widespread skin diseases.
Result of an autoinoculation (labial HSV) or
heteroinoculation from an infected contact

Clinical findings
Fever

Malaise
Tight feeling skin

Treatment
Acyclovir and its relatives

Intravenous therapy preferred

Hospitalization needed

Antibiotics for secindary bacterial infections

Wet soaks zinc lotion

VARICELLA ZOSTER VIRUS

 THE SAME VIRUS CAUSES VARICELLA IN

CHILDREN (PRIMARY INFECTION) AND

ZOSTER (SECONDARY INFECTION)
PATIENTS WITH ZOSTER CAN INFECT
NONEXPOSED CHILDREN AND
IMMUNOSUPPRESSED PATIENTS, CREATING
VARICELLA

Varicella is extremely common!

In most countries, 90-95% of the
population has had the infection by
15 years of age!

FIRST INFECTIONimmunity virus remains

behind in neural ganglia with age or
immunosuppression, unknown trigger factors
reactivate the virusinvolves a single sensory
nerve and its dermatome

Varicella (chickenpox)
Initial infection with VZV in an unprotected host.
Spread by droplets (windpox)
Reifection and a second clinical attack of varicella
is unheard of in normal individuals

 Incubation period: 2 weeks

Fever, malaise
Widespread blisters typically on an

erythematous base
Scalp typically affected
Lesions in many stages: macules, blisters,
erosions, crust

Therapy
Oral acyclovir reduces the severity of varicella

Antibiotics
Zinc oxide lotion

ZOSTER

 SECOND INFECTION WITH vzv USUALLY IN

ADULTS AND LIMITED TO A DERMATOME

Primarily a disease of elderly and
immunosuppressed

DERMATOMES

Varicella zoster virus remains in a neural ganglion while

the patient has general immunity to the virus.
Factors triggering the outbreak of zoster:
Trauma
Radiation therapy
Sunburn
Other infections (syphilis)
Immunosupression (HIV, leukemia, lymphoma,
chemotherapy)

Clinical findings
-

face: area of three branches of cranial nerve V

involved (forehead, mid-face and jaw line)
Trunk
Initially the patient experiences pain before skin
lesions appear

Postherpetic neuralgia
Persistent pain which may last for months to years
and which may be disabling.
Up to 30% of elderly patients develop some degree
of neuralgia.

Special variants of zoster

Oral zoster (hard palate, maxilla, tongue)

Otic zoster (tympanic membrane and ear canal)

Hemorrhagic and necrotic zoster

disseminated zoster

Therapy
Aciclovir

Topical drying agents (zinc oxide lotion or

clioquinol lotion)
Antibiotics (doxycycline)
Postherpetic neuralgia: antiviral agents,
psychotherapeutic agents: carbamazepine

POX VIRUSES

Moluscum contagiosum
Epidermotropic pox viruse infection producing
papular lesions with a central dell.
Common viral infection: in children spread by
casual contact; in adults: transmitted during
sexual intercourse.

Clinical findings
Small flesh-colored papules with a central

depresion (hollow, dell)

Lesions may be grouped together
Inguinal, axillary, neck region
Eyelids: troublesome site!
Adults: genital region

Therapy
Curettage after local anaesthesia (EMLA) or

general anaesthesia if lesions are multiple in a

small child
Lesions can be opened with a needle or forceps
Iodine paint