Bacterial infections of Skin

Dr Sudha Agrawal BPKIHS, Dharan

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DEFENSES

Dry

Acidic (pH 5.4)

Temperature less than 37oC

Lysozyme and lipids

Skin-associated lymphoid tissue (SALT) Resident microflora

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Skin and infection

Entry

Multiplication

Skin (pores, hair follicles) Wounds (scratches, cuts, burns) Insect & animal bites

Extracellular Intracellular (??)

Diseases

Damage

Localized infections with local and/or systemic effect Systemic infections

Toxin Host immune response

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Normal flora of skin

Classification:

1. Resident flora: grow on skin & relatively

stable in no. and composition at particular sites 2. Transient flora: lie on skin surface without attachment, unable to multiply & disappear within short time 3. Transient or temporary residents
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Normal Skin Flora

Major bacterial groups

Coryneforms (Gram +ve, pleomorphic rods) Corynebacterium (Aerobic & lipophilic) Brevibacterium (Aerobic & non-lipophilic) Propinobacterium (Anaerobic)

Contd
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Staphylococci (Gram +ve cocci, aerobs) S. epidermidis, S. hominis, S.hemolyticus, S.saprophyticus

Minor bacterial groups

Acinetobacter (25%) Micrococci

Fungal group

Pityriasporum
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Bacterial infection of the skin (Pyoderma)

Classification of pyodermas
1.

Primary

Impetigo Ecthyma Folliculitis

Superficial Deep
* * * * Folliculitis of leg Furuncle Carbuncle Sycosis Barbae
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Cellulitis/ Erysipelas Pyonychia SSSS TSS

2.

Secondary
Secondary infection of preexisting dermatoses eg. Atopic dermatitis, Scabies

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Impetigo (contagious superficial infection)

Non-bullous Bullous

1. Cause - Streptococcal (Group A) Staph. aureus - Staph. aureus (Phage Groups II) 2. Pre-school and young school age All ages 3. Very thin walled vesicle on an erythematus Bullae of base 1-2cm 4. Transient Persist for 2-3 day 5. Yellowish-brownish crusts (thick) Thin, flat, brownish crust
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Contd

6. Irregular peripheral extension without Central healing with healing peripheral extension 7. Regional adenitis 8. Constitutional symptoms present 9. Face (around the nose, mouth & limbs) anywhere 10. Palms & sole spared 11.MM, very rare Rare Absent occur May involved May involved
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Predisposing factors

Malnutrition Diabetes Immuno-compromise status

Complications

PSGN (strep M-type 49) Scarlet fever Urticaria Erythema mutiforme

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Ecthyma

Streptococcal & staph

Common in children
Small bullae or pustules on erythematous base Formation of adherent dry crusts Beneath which ulcer present Indurated base

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Heals with scar and pigmentation

Buttocks, thighs and legs, commonly affected
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Folliculitis

Superficial folliculitis
Infection

of hair follicles caused by staph. aureus

Commonly

Children
Scalp

& limb painful

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Rarely Heals
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in a week

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Deep Folliculitis

Deep folliculitis of leg

Chronic
Staph.

aureus

Hair

follicles of leg

Multiple

Atrophic

scar
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Furuncle (Boil)

Acute

Staph. aureus
Small, follicular noduler -- Pustule-necrotic--discharge pus

Painful Constitutional symptoms

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Heals with scar

Age: Adult
Site: Neck, Wrist, Waist, Buttocks, Face

Complication

Cavernous Sinus thrombosis, (upper lip & check) Septicemia (malnutrition)

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Carbuncle

Extensive infection of a group of contagious follicles Staph. aureus Middle or old age Predisposing factors

Diabetes Malnutrition Severe generalized dermatoses During prolonged steroid therapy

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Painful, hard lump Suppuration begins after 5-7 days Pus discharge from multiple follicular orificies Necrosis of intervening skin Large deep ulcer

Constitutional symptoms
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Sycosis barbae

Beard region

Pustules surrounded by erythema

Males

After puberty
After trauma Upper lip and chin Staph. aureus
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Cellulitis

Inflammation of loose connective tissue

Streptococcal (Group A)
Acute/sub-acute/chronic

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Erythematous, edematous, swelling

Pain/tenderness Constitutional upset
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Pyonychia

Acute

Erythematous swelling of proximal and lateral

nail fold

Painful

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Staphylococcal scalded skin synotrane (Ritters Disease)

Exotoxin of staph (Phage Group II) Acantholysis Occult staph. upper respiratory tract infection or purulent conjunctivitis

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Infants and children Tender red skin

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Contd

Denuded skin Heals 7 - 14 day Dont grow staph. from blister fluid

Complication 2%
Cellulitis Pneumonia

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Prognosis : Rule
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Principles of therapy of pyoderma

Good personal hygiene Management of predisposing factors Local

Attend

to traumas, Pressure, Sweating, Bites Treat pre-existing dermatosis Investigate carrier sites: Nose, Axilla, Perineum

Systemic
Treatment

of disease like DM Nutritional deficiency Immunodeficiency

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Principles of therapy of pyoderma

Local therapy
Cleaning

with soap-water and weak

KMN04 solution
Removal

of crusts with KMN04 soluation of antibacterial cream

Application

Systemic therapy
Antibiotics
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Recurrent staphylococcal infection

Persistent nasal carriage Abnormal neutrophitic chumotaxis Deficient intracellular killing Immunodeficient status D.M.

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T/t of staph. carriage elimination

Nasal & perineal care Rifampicin 600 mg/d 7-10 days Clindamycin 150 mg/d 3 months Topical mupirocin Replacement of microflora with a less pathogenic stains of S. aureus (strain 502)
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S. aureus produces skin infection

I. Direct infection of skin and adjuscent tissues
a. b. c. d. e. f. Impetigo Ecthyma Folliculitis Furunculosis Carbuncle Sycosis Eczema infection

II. Secondary infection

III.Cutaneous disease due to effect of bacterial toxin

a. b.
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Staphylococcal scalded skin syndrome Toxic shock syndrome

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-hemolytic streptococcus produces skin infection

I. Direct infection of skin or subcutaneous

a. b. c. d. e. f. g. Impetigo (non bullous) Ecthyma Erysipelas Cellulitis Vulvovaginitis Blistering distal dactylitis Necrotizing fascitis Eczema infection
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II. Secondary infection

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III. Tissue damage from circulating toxin

Scarlet fever

IV. Skin lesion attributed to allergic hypersensitivity to streptococcal antigens

E. Nodosum Vasculitis

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V. Skin disease provocated or influenced by streptococcal infection (mechanism uncertain)

Guttate psoriasis

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Consider the following in relation to bacterial infection of skin a.

Cellulitis is the inflammation of subcutaneous tissue as well as dermis caused by Streptococcus.

b. Bullous impetigo is caused by streptococci c. d. In erysipelas, inflammation is limited to dermis and upper part of subcutaneous tissue. Furunculosis is caused by Streptococcus

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Learning objectives of bacterial infections of skin

1. Define Pyoderma and classify it. 2. List the normal flora of skin 3. Define impetigo. List the differentiating features of bullous and non-bullous impetigo. 4. Describe the C/F, investigations of impetigo. Outline the management of impetigo.

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Learning objectives of bacterial infections of skin

1. Define folliculitis, classify it and describe the management of it. 2. Describe the C/F, investigations and management of ecthyma/ cellulites/ erysipelas/ furuncle/ carbuncle/ SSSS 3. List the skin infection produced by Bhemolytic streptococci. 4. List the skin infection produced by staphylococci.

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Thank you

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