SKIN NORMAL FLORA

PRESENTER-DR.U.BRAHMAIAH
MODERATOR-DR.UDAY KUMAR
DR.K.BHUMESH KUMARI
PROFESSOR-DR.GEETHAKIRAN
PROFESSOR AND HOD-DR.UDAY KUMAR

Normal Flora

Definition
Normal flora is
the mixture of
microorganisms
(bacteria
and
fungi) that are
regularly found
at
any
anatomical site
of human body
like:

The majority of skin microorganisms are found in

the most superficial layers of the epidermis and
the upper parts of the hair follicles

Resident flora
Acquired rapidly during & after birth
Reflects age of person
Reflects nutrition of person

Reflects sex of person

1.
.
.
.

.
.
.
.
3.
.

90% is S. epidermidis; S. aureus, may be in moist areas

A diverse microbial flora =>

Human body Area: the skin and mucous membranes
Time: shortly after birth until death
Number: 1014 bacteria =>1013 host cells
2. Normal flora may:
a. Aid the host
b. Harm the host (in sometimes)
c. Exist as commensals (no effect to the host)
Viruses and parasites => NOT normal microbial flora
Most investigators consider that they are not commensals and
do not aid the host.

Some of the common flora on

skin are:
Bacteria:
Staphylococcus aureus
folliculitis, boils, etc.
Staphylococcus epidermis
- Impetigo, Abscess
Staphylococcus warneri Endocarditis, UTI

Propionibacteri
um acnes
Acne vulgaris
Pseudomonas
aeroginosa Folliculitus

Fungal colonies:
Candida albicans - Candidiasis

Factors Influencing Normal Flora

1.

Local Environment (pH, temperature, redox potential, O2, H2O,

and nutrient levels).

2.

Diet

3.

Age

4.

Health condition (immune activity)

5.

Antibiotics,..etc

In a healthy human,
the internal tissues
such as:
blood
brain
muscle
cerbrospinal fluid
(csf.)
are normally free
of microorganisms.

Origin of Normal Flora

Healthy fetus, in utero, is essentially free of MOs

Infant exposed immediately to MOs when passing through

mothers vaginal tract and then to MOs in environment

Within few hours, oral and nasopharyngeal flora of neonate

established

Within one day, resident flora of lower intestinal tract

established

Density of normal flora in

Humans

Distribution of bacterial flora,sweat

glands and sebaceous glands at 6 sites

Site

Bacterial flora(no/cm2)

Sweat glands (no/cm2)

Sebaceous glands
(no/cm2)

Scalp

1.46106

80-200

400-900

Cheek

(5-10) 105

270

400-900

Axilla

(5-10) 106

200

Not significant

Back

300 106

64

Large

Palm

600

400-620

Absent

Sole

Large colony

400-620

Absent

Human adult has 2 square meters of skin

Overall, a hostile environment toward bacteria
Eccrine (simple sweat) glands
. release Nacl solution : hyperosmotic surface

Apocrine glands : sweat & nutrients,secrete lactic acid pH3-5

Sebaceous glands : a/w hair follicles
. secrete lipids ,bacteria convert it into unsaturated fatty acids which have
antimicrobial activity and strong odor

MOs that normally live on or in any part of the body with out
causing disease

Two basic types of NF:

Resident NF normally GROW on/in indicated body site,

presence fixed in body

Transient NF only TEMPORARILY PRESENT on/in indicated

body site, usually dont become firmly attached but simply die
within hours

Transient microbes: in contact with environment

Resident microbes
Areas of high moisture content

. Axilla, groin, toe webs, perineum, scalp

Superficial layers of the epidermis, upper parts of hair follicles,

sebaceous glands

Staph epidermidis; Staph aureus; Corynebacteria

(Propionibacterium acnes); Streptococci; Clostridium spp.
(perineum and upper thighs)

Role of Normal Flora

Immunostimulation

a) They produce antibodies which may

contribute to host defenses.
b) Some of these antibodies may
react with normal tissue components.
May

be source of opportunistic infections

e.g : In Patients with impaired defense Mechanism

cross

 Protection

from External Invaders

a) Because of the normal flora occupy bodys epithelial
surfaces,they are able to prevent other bacteria by blocking
receptors
b) competing for essential nutrients
c) producing anti-bacteria substances
e.g : Fatty acids, peroxides , Bacteriocins.
Nutrition
Some of the normal intestinal flora
e.g. E. coli & Bacteroids produce Vitamin K in the gut which is
available for use by host.

Skin: 3 main micro environments

Axilla, perineum, toe webs
Hands, face and trunk
Upper arms and legs

S. epidermidis
Major inhabitant making up more than 90% of the flora

S. aureus
Nose, perineum, vulva skin
Occurrence in nasal passages varies with age being greatest in newborns, less in

adults

Neither profuse sweating nor washing significantly modifies normal

skin flora
Soap or disinfectant (hexachlorophene) diminish microbial
population
. Soap - 30 second scrubbing

. Soap: physically removes organisms

. Disinfectants: bactericidal

But NF rapidly replenished from sebaceous and sweat glands

Key organisms to learn in skin

Staphylococcus epidermidis (coagulase-negative

staphylococci);

Propionibacterium sp.,

Corynebacterium sp.

Staphylococcus
epidermidis
Staphylococcus aureus
C+, clusters
Staphylococcus aureus,
a predominant
normal microflora of
skin

Propionibacterium acnes
B+, anaerobic
Diphteroids (club shaped)
Candida albicans

Streptococcus
species
C+, pairs, chains

Corynebacterium
B+, aerobic
Diphtheroids

Human benefits from normal

flora

Prevention of colonization by more pathogenic species (colonization

resistance).
Competition for receptors (tropism)
Competition for nutrients (interference)
Direct antagonism through bacteriocins, toxic chemical byproducts

Example of protective effect

Normal mouse - requires ~106 Salmonella to become infected
Germ free mouse - infectious dose is ~10 Salmonella

Hair Follicles

inhabited by anaerobes (Propionibacterium sp)

in their deeper parts and nearer the surface aerobic
cocci,Malassezia species of yeasts.

Propionibacteria are anaerobic, Grampositive, rod-shaped

organisms,

. acnes, and P. granulosum

widespread, follicles that have large sebaceous glands over the face
and upper trunk.

both been associated with acne lesions

The third species, P. avidum, is found in moist sites, particularly the

axillae and groins. Its pathogenic potential unclear

Propionibacterium species require the increased skin lipid levels

of puberty before becoming established

Present at very low levels before the onset of puberty.

Propionibacterium acnes & Gram-positive cocci are capable of
hydrolysing lipids of sebum to produce free fatty acids

The acidic milieu which results inhibits the growth of other

organisms such as Streptococcus pyogenes

Normal flora of Axilla

supports a very high level of bacterial colonization

mostly staphylococci, micrococci and coryneforms

Propionibacterium acnes is usually present and

P. avidum is often found

Why are armpits smelly?

1.

Anaerobic bacteria in the pit

use sebum from sweat glands
to produce short chain fatty
acids

2.

The sweat and sebum

produced by the pit is naturally
aromatic

3.

Use of deodorants with

antibacterial substances, inhibit
growth of G(+), may lead to
growth of G(-) MOs and
infection

Nail flora
Apergillus
Penicillium
Cladosporium
Mucor

Normal flora of Toe clefts

In shoe wearers, 4 toe cleft is often hyperhydrated and

the skin macerated.

large number of bacteria present

The toe web is an important site for Brevibacterium

species, and not surprisingly Acinetobacter species are often isolated,

as are Alkaligenes species.

In the elderly and in tropical Climates coliforms and other organisms

of the intestinal flora may be present

genitalia
Coagulase negative staphyloccoci
Micrococcoci
Coliforms
enteroccocci

Perineum & Groin

Coagulase negative staphyloccoci
Micrococcoci

Normal flora of Umbilicus

The umbilicus of the newborn is frequently colonized by

Staphylococcus aureus shortly after birth

The umbilicus of the newborn may also be colonized by

Streptococcus pyogenes, and look normal

The organisms can readily spread from infant to infant in a hospital

nursery.

Searches for the source of infection in a maternity unit should

always include umbilical swabs from the babies.

Normal flora - Conjunctiva

Variety of bacteria: low numbers present

High moisture
Blinking mechanically removes bacteria
Lachrymal secretions include lysozyme
Staph epidermidis and Propoinibacterium acnes dominate
Staph aureus, Haemophilus sp. and Neisseria sp.
occasionally found

Normal Flora of the Human Oral

Cavity
Oral bacteria include:
1. Viridans streptococci
2. Lactobacilli
3. Staphylococci (S. aureus and S.
epidermidis)
4. Corynebacterium sp.
5. Bacteroides sp.
6. Streptococcus sanguis (dental
plaque)
7. Streptococcus mutans (dental
plaque)
8. Actinomyces sp.

Normal Flora of the Respiratory

Tract
A) The nares (nostrils)
1. Staphylococcus epidermidis
2. Corynebacterium
3. Staphylococcus aureus
4. Neisseria sp.
5. Haemophilus sp
6. Streptococcus pneumoniae

B) The upper respiratory tract

(nasopharynx).
1. Non-hemolytic streptococci
2. Alpha-hemolytic streptococci
3. Neisseria sp.
4. Streptococcus pneumoniae
5. Streptococcus pyogenes
6. Hemophilus influenzae
7. Neisseria meningitidis

C) The lower respiratory tract (trachea,

bronchi, and pulmonary tissues):
Usually sterile.
The individual may become susceptible to
infection by pathogens descending from the
nasopharynx e.g.
H. influenzae
S. pneumoniae).

Methods of sampling

Simple qualitative studies by swabbing

The number of organisms is increased by the duration of rubbing,

pressure exerted and moistening the swab

The best quantitative estimates of the total bacterial flora are

determined by applying an open-ended cylinder of known cross
sectional area to the skin, introducing a small, known volume of
suitable liquid vehicle and scrubbing the surface of the skin to
free the organisms

Full-thickness skin-biopsy material should

be the best sample
Disposal of organisms can be studied
quantitatively by air sampling techniques
using either settle plates or an impaction
sampler
PCR

Isolation Media
use of ordinary blood
serum agar for aerobic organisms
solid Brewers thioglycolate medium
without indicator
1% Tween 80 indicator for
Propionibacterium
acnes

Variables affecting normal

microflora - Genetics

Racial differences have been demonstrated in the nasal

carriage of S. aureus in children

white individuals being more likely carriers than black

individuals

Bacterial flora develops in orderly succession from birth to stable

adult flora : Example : mouth microflora
Infant - mouth sterile at birth
Rapidly develops flora, primarily from mother
. Strep salivarius (on tongue); lactobacilli
. Changes with eruption of teeth(Strep sanguis; mutans)
. Ecologic system develops- micro environments of anaerobic and

aerobic flora

Gender - Examples

Presence of different mucosal surfaces (esp. genitourinary)

Hormonal effects on flora in females - e.g. change in vaginal flora

with onset of puberty

Stress - Examples

Alterations in bowel flora recognized with severe stress

There is evidence that males carry higher numbers of

bacteria, aerobic organisms than females

Men are more likely to be disseminators of Staphylococcus

aureus than females

Variables affecting normal microflora

- Nutrition and diet of host

Examples : Infant feeding

. Breast-fed infants - GI flora is predominantly Bifidobacterium

sp. (anaerobic gram positive bacillus)

. Bottle-fed infants - GI flora more closely resembles that of

adults (enteric gram negative bacilli, mixed anaerobes, staph)

Adult diets

. Predominant species found in colonic flora differs among

vegetarians, fish eaters, and omnivores

FACTORS RESPONSIBLE FOR DISCOURAGING

MICROBIAL COLONIZATION ON SKIN
1.

DRYNESS:

Dry surface is inhibitory to microbial growth.

Some regions of the skin are moist than others, e.g. The
axillary region, toe webs and the perineum( skin at the lower
end of the trunk between the thighs.)
These regions has higher number of normal flora organisms
than the drier area of skin.

2.

Low Ph:
Skin has a normal pH between 3 and 5 and it is higher in
moist regions.
This low pH is due to the lactic acid or other organic acids
produced by normal skin microorganisms such as
staphylococci. This factor discourages the growth of other
organisms.

3.

Inhibitory Substances:
Sweat glands secrete lyzozyme that destroys bacterial cell
walls.
Sebaceous glands secrete complex lipids which may be
partially degraded by Propionibacterium acnes, that results in
long chained unsaturated fatty acids e.g. Oleic acid. This fatty
acids are highly toxic to other bacteria.

Normal flora may act as opportunistic

pathogens

Especially in hosts rendered susceptible

by:

1. Immuno-suppression (AIDS & SCID)

2. Radiation therapy & Chemotherapy

3. Perforated mucous membranes

4. Rheumatic heart diseaseetc.

THANK YOU