INFECTIOUS SKIN DISEASES

Walid Nabil Fouad HamdAllah Mohamed MICROBIOLOGY DEPARTMENT MEDICAL RESEARCH INSTITUTE

Humans are natural hosts for many bacterial species that colonize the skin as normal flora. Staphylococcus aureus and Streptococcus pyogenes are infrequent resident flora, but they account for a wide variety of bacterial pyodermas (pus in skin infections). Predisposing factors to infection include minor trauma, preexisting skin disease, poor hygiene, and, rarely, impaired host immunity.

List of some bacterial skin infections:

1. 2. 3.

4.
5. 6. 7.

Impetigo Folliculitis, Furunculosis, and Carbunculosis Erythrasma Ecthyma Erysipelas Cellulitis Necrotizing Fasciitis

1. Impetigo

Impetigo is a common superficial skin infection usually caused by S. aureus and occasionally by S. pyogenes. Mixed infections caused by both bacteria are common and result when a primary infection is invaded by the other bacteria. Infection is highly contagious and usually treated with a topical antibiotic. Two clinical types of impetigo exist: nonbullous and bullous. Both types have a distinct appearance and cause: The nonbullous type is more common (70% of impetigo infections), and typically occurs on the face and extremities, initially with vesicles or pustules on reddened skin. The vesicles or pustules eventually rupture to leave the characteristic honeycolored (yellow-brown) crust. Bullous impetigo, almost exclusively caused by S. aureus, exhibits flaccid bullae with clear yellow fluid that rupture and leave a golden-yellow crust.

Nonbullous impetigo (S. aureus)

Bullous impetigo (S. aureus)

2. Folliculitis, Furunculosis, and Carbunculosis

Folliculitis is another very common bacterial skin infection caused by S. aureus. It is an infection in the hair follicle, which is a pretty small structure. It makes sense that this infection looks like a group of small little red bumps that can be filled with a small amount of pus. Folliculitis usually heals without scarring. Hot tub folliculitis is an infection of the hair follicles caused by the bacteria Pseudomonas aeruginosa. This bacterium is commonly found in contaminated whirlpools, hot tubs, water slides, physiotherapy pools, or even loofah sponges. Children tend to get hot tub folliculitis more often (probably because they stay in the water longer). A furuncle is an infection of the pilosebaceous unit, therefore is more extensive than a folliculitis because the infection also involves the sebaceous gland. A furuncle frequently occurs on the neck, face, armpits, and buttocks. It begins as a small, tender, red nodule that becomes painful and fluctuant. Frequently, pus will spontaneously drain, and often the furuncle will resolve on its own. A carbuncle can simply be defined as a multiple furuncles grouped together. A carbuncle usually involves the deeper layers of the skin - the subcutaneous fat. It looks like a large, red nodule that is hot and may have visible layers of pus just beneath the surface of the skin.

Folliculitis

Hot tub folliculitis

Furuncle

Carbuncle

3. Erythrasma

Erythrasma is a bacterial skin infection caused by the gram-positive bacterium Corynebacterium minutissimum. It occurs most often between the third and fourth toes, but it can also frequently be found in the groin, armpits, and under the breasts. Because of its color and location, it's often confused with a fungal infection like jock itch. Erythrasma starts as a pink to red patch with well-defined edges. This patch has a finely wrinkled appearance with a very fine scale on it. After some time, the rash fades from pink to a uniform brown color. This consistent brown color with the fine scale distinguishes it from jock itch or other fungal infections which are typically redder around the edges with thicker scaling on the edges.

Erythrasma is more common in the following populations: Overweight people, Elderly, Diabetics, People in warm, moist climates.

Erythrasma

4. Ecthyma

Ecthyma is a deep infection of the skin that resembles impetigo. S. aureus or S. pyogenes is the usual pathogen of ecthyma. The most common site of infection is the legs. Infection is characterized by thickly crusted erosions or ulcerations, which begins with vesicles and bullae. Untreated staphylococcal or streptococcal impetigo can extend more deeply, penetrating the dermis, producing a shallow crusted ulcer.
Ecthyma

5. Erysipelas

Erysipelas is a superficial infection of the skin, which typically involves the dermal lymphatic system. Erysipelas is also known as St. Anthony's fire, an accurate description of the intensity of this rash. Erysipelas is most often caused by the Group A -hemolytic Streptococcus. In a few cases, it can be caused by other types of Streptococcus or Staphylococcus bacteria. Erysipelas was previously found mainly on the face. However, now it is seen most commonly on the lower extremities. Erysipelas tends to occur in areas where the lymphatic system is obstructed. A cluster of symptoms typically precede the appearance of the rash by 4 to 48 hours. These symptoms include fever, chills, fatigue, anorexia, and vomiting. The rash then quickly appears as a bright red, hot, swollen, shiny patch that has clearly defined borders.

Erysipelas

6. Cellulitis

Cellulitis is a bacterial infection of the deeper layers of the skin, the dermis and the subcutaneous tissue. In adults and children, cellulitis is most often caused by Streptococcus and S. aureus bacteria. Sometimes Haemophilus influenzae type B can cause cellulitis in children younger than 3, but this has become less common since we've been vaccinating against this bacteria. Children often get cellulitis on the head and neck, and adults often get cellulitis on the arms or legs. Before skin changes occur, someone with cellulitis can have fever, chills, and fatigue.

The typical skin infection of cellulitis is usually erythematous (red), edematous (swollen), tender, warm to touch, and painful plaque that expands rapidly. It's often difficult to tell exactly where the border is between normal and infected skin (ill-defined borders). Red streaks coming out of the area and swollen lymph nodes can sometimes occur.
Left untreated, cellulitic skin can become bullous and necrotic, and an abscess or fasciitis, or both, can occur.

Cellulitis

7. Necrotizing Fasciitis

Necrotizing fasciitis is a rare infection of the subcutaneous tissues and fascia that eventually leads to necrosis. Predisposing factors include injuries to soft tissues, such as abdominal surgery, abrasions, surgical incisions, diabetes, alcoholism, cirrhosis, and intravenous drug abuse. S. pyogenes can be the sole pathogen responsible for necrotizing fasciitis, but most patients have a mixed infection with other aerobes (groups B and C streptococci, MRSA) and anaerobes (Clostridium spp). Infection begins with warm, tender, reddened skin and inflammation that rapidly extends horizontally and vertically. Necrotizing fasciitis commonly occurs on the extremities, abdomen, or perineum or at operative wounds.

Within 48 to 72 hours, affected skin becomes dusky, and bullae form, followed by necrosis and gangrene, often with crepitus. Without prompt treatment, fever, systemic toxicity, organ failure, and shock can occur, often followed by death.

Necrotizing fasciitis

Fungal skin infections are caused by microscopic fungus that proliferate due to ideal conditions . Fungal skin infections in humans occur on nails, skin and hair, as it sustains itself on protein keratin which is abundantly found in these areas.
Although several species of fungi are potentially pathogenic in humans, Candida (esp. Candida albicans) is the organism responsible for most fungal infections. Candida, which is normally present within the human body, is usually harmless. However, it can cause symptoms when a weakened immune system or other factors allow it to grow unabated.

Increased use of antibiotics and immunosuppressive drugs such as corticosteroids are major factors contributing to higher frequency of fungal infections. Antibiotics and immunosuppressive drugs, by disrupting normal bacterial colonization and suppressing the immune system, create an environment within the body in which fungi can thrive

1. Dermatophytosis

Dermatophytosis or ringworm infection is an infection of keratinized tissue (skin, hair, and claws) by one of the 3 genera of fungi collectively called dermatophytes Epidermophyton, Microsporum, and Trichophyton. Fungal reservoirs for these organisms include soil, animals, and infected humans. Dermatophytes feed on keratin, the material found in the outer layer of skin, hair, and nails. These fungi thrive on skin that is warm and moist, but may also survive directly on the outsides of hair shafts or in their interiors. Dermatophytosis is common in most adult people, with up to 20 percent of the population having one of these infections at any given moment. It is especially common among people who play sports, wrestling in particular. Different types of dermatophytosis include:

Tinea pedis (athlete's foot) affects the feet Tinea unguium affects the fingernails and toenails Tinea corporis affects the arms, legs, and trunk

Different types of dermatophytosis include (cont.):

Tinea cruris (jock itch) affects the groin area Tinea manuum affects the hands and palm area Tinea capitis affects the scalp Tinea barbae affects facial hair Tinea faciei (face fungus) affects the face

Tinea pedis

Tinea cruris Tinea unguium Tinea corporis Tinea capitis

2. Candidiasis

Candidiasis refers to a diverse group of infections caused by Candida albicans or by other members of the genus Candida. These organisms typically infect the skin, nails, mucous membranes, and gastrointestinal tract, but they also cause systemic disease. Infection is common in immunocompromised patients, diabetics, the elderly, and patients receiving antibiotics. Candida albicans accounts for 70% to 80% of all candidal infections. C. albicans commonly resides on skin and mucosal surfaces. Alterations in the host environment can lead to its proliferation and subsequent skin disease. List of some of the most common types of skin candidiasis:

Candidal intertrigo: A specific infection of the skin folds (axillae, groin), characterized by reddened plaques, often with satellite pustules. Thrush: An oropharyngeal candidiasis, characterized by white nonadherent plaques on the tongue and buccal mucosa.

List of some of the most common types of skin candidiasis (cont.):

Paronychia: An acute or chronic infection of the nail characterized by tender, edematous, and erythematous nail folds, often with purulent discharge (this disease is common in diabetics). Candidal vulvovaginitis: An acute inflammation of the perineum characterized by itchy, reddish, scaly skin and mucosa; creamy discharge; and peripheral pustules. (The counterpart in men is balanitis, characterized by shiny reddish plaques on the glans penis, which can affect the scrotum).

Candidal intertrigo

Paronychia Thrush

Candidal vulvovaginitis

3. Tinea versicolor

Tinea versicolor is a common opportunistic superficial infection of the skin caused by the ubiquitous yeast Malassezia furfur. Prevalence is high in hot, humid climates. Purported risk factors include oral contraceptive use, heredity, systemic corticosteroid use, Cushing's disease, immunosuppression, and malnutrition. M. furfur may filter the rays of the sun and also produces phenolic compounds that inhibit tyrosinase, which can produce hypopigmentation in many patients. Infection produces discrete and confluent, fine scaly, well-demarcated, hypopigmented or hyperpigmented plaques on the chest, back, arms, and neck. Pruritus is mild or absent.

Tinea versicolor

Viral skin infections typically cause a skin rash, sore or lesion. And these skin problems may be accompanied by other symptoms if the skin infecting virus is capable and able to spread to other parts of your body.
Viral skin infections tend to be more aggressive if your immunity is impaired, especially a problem with lymphocyte production. An example is increased incidence of skin rashes, sores and lesions in those suffering from HIV because of a weakened immune system. Three principal virus types cause the majority of viral skin infections rash, sore and lesion problems, they are: poxvirus, herpes simplex virus and human papillomavirus. There are many different types of viral skin infections, ranging from common to rare and mild to severe. Several of the commonly known viral infections that may cause rashes, sores, lesions or other skin problems are: cold sores, genital herpes, chickenpox, shingles, warts, and molluscum contagiosum.

1. Herpes Simplex

Herpes simplex virus (HSV) infection is a painful, self-limited, often recurrent dermatitis, characterized by small grouped vesicles on an erythematous base. Disease is often mucocutaneous. Infection with the herpes virus is categorized into 2 distinct disorders based on the site of infection: Oral herpes, the visible symptoms of which are colloquially called cold sores or fever blisters, is an infection of the face or mouth caused by HSV type 1. Genital herpes, known simply as herpes, is the second most common form of herpes caused by HSV type 2.

Disease follows implantation of the virus via direct contact at mucosal surfaces or on sites of abraded skin. After primary infection, the virus travels to the adjacent dorsal ganglia, where it remains dormant unless it is reactivated by psychological or physical stress, illness, trauma, menses, or sunlight.

Oral Herpes (HSV-1)

Genital Herpes (HSV-2)

2. Chickenpox

Chickenpox is a highly contagious disease caused by primary infection with the varicellazoster virus, a member of the herpesvirus family. The same virus also causes herpes zoster shingles in adults. Chickenpox usually starts with vesicular skin rash mainly on the body and head rather than at the periphery and becomes itchy, raw pockmarks, which mostly heal without scarring. Most cases of chickenpox occur in children younger than 10. The disease is usually mild, although serious complications sometimes occur. Most children with chickenpox have the following symptoms before the rash appears: Fever, Headache, and Stomach ache. The chickenpox rash occurs about 10 to 21 days after coming into contact with someone who had the disease. The average child develops 250 to 500 small, itchy, fluid-filled blisters over red spots on the skin.

Chickenpox

3. Herpes Zoster

Herpes zoster (shingles) is an acute, painful dermatitis that affects approximately 10% to 20% of adults, often in the presence of immunosuppression. It is caused by the varicella zoster virus (VZV), and characterized by a painful skin rash with blisters in a limited area on one side of the body, often in a stripe. The initial infection with VZV causes the acute (short-lived) illness chickenpox which generally occurs in children and young people. Once an episode of chickenpox has resolved, the virus is not eliminated from the body but can go on to cause shinglesan illness with very different symptomsoften many years after the initial infection. During the course of varicella, the virus travels from the skin and mucosal surfaces to the sensory ganglia, where it lies dormant for a patient's lifetime. Reactivation often follows immunosuppression, emotional stress, trauma, and irradiation or surgical manipulation of the spine, producing a dermatomal dermatitis.

Herpes Zoster (Shingles)

4. Warts

Warts are common and benign epithelial growths caused by human papillomavirus (HPV). Warts affect approximately 10% of the population. Anogenital warts are a sexually transmitted infection, and partners can transfer the virus with high efficiency. Immunosuppressed patients are at increased risk for developing persistent HPV infection. HPV infection follows inoculation of the virus into the epidermis through direct contact, usually facilitated by a break in the skin. After inoculation, a wart usually appears within 2 to 9 months. The rough surface of a wart can disrupt adjacent skin and enable inoculation of virus into adjacent sites, leading to the development and spread of new warts. The common wart is the most common type: It is a hyperkeratotic, flesh-colored papule or plaque studded with small black dots (thrombosed capillaries). Other types of warts include flat warts (verruca plana), plantar warts, and condyloma acuminatum (venereal warts).

Plantar Warts

Common Warts

Flat Warts

Venereal Warts

5. Molluscum Contagiosum

Molluscum contagiosum is a viral skin infection that causes raised, pearl-like papules or nodules on the skin. It is caused by a DNA poxvirus called the molluscum contagiosum virus (MCV), a member of the poxvirus family. The disease is a common infection in children and occurs when a child comes into direct contact with a lesion. It is frequently seen on the face, neck, armpit, arms, and hands but may occur anywhere on the body except the palms and soles. The virus can spread through contact with contaminated objects, such as towels, clothing, or toys.

Molluscum Contagiosum