[NORMAL] Infectious Dermatology 1

Dermatological

Infections & Infestations

Mariecon O. Escuadro, MD

Diplomate, Philippine Dermtological Society

Superficial

Bacterial Skin Infections

1. Impetigo Contagiosa 2. Bullous Impetigo

3. Folliculitis

4. Furuncle & Carbuncle 5. Ecthyma

6. Cellulitis 7. Erysipelas 8. Erythrasma

Impetigo Contagiosa

• Etiology:

– Staphylococcus aureus: 50-70%

– Streptococcus pyogenes or mixed

• Group A Strep- usual

• Group B Strep- newborn • Group C, G Strep-rare

Impetigo Contagiosa

• Common sources:

– Adults

• Barbershops, parlors, meat packing plants, swimming pools, infected children

– Children

• Pets, dirty fingernails, daycare, crowded housing and other infected children

Impetigo Contagiosa

• Clinical Presentation

– Age group: early childhood most common

– Sites: exposed areas (face, hands, neck &

extremities)

– Lesions: starts as 2 mm erythematous

macules-thin-walled vesicles or

bullae-pustules, which rupture: seropurulent

discharge-dries up:

honey-colored/golden-yellow crusts.

Impetigo Contagiosa

• Complications

– Acute Glomerulonephritis (

)

• Incidence: 10-15% with Nephritogenic strains • Prognosis: excellent in children, not as good in

Bullous Impetigo

• Etiology

– Phage type 71 coagulase positive

Staphylococcus aureus

Bullous Impetigo

• Clinical Presentation

– Age groups:

– newborn (4th_&10th _day)

– children

– Sites:

– Face & hands

– Axilla & groin- adults in warm climates

– Lesions:

– Large fragile bullarupture: circinate, weeping or crusted lesions with varnish-like crusts (impetigo circinata)

Bullous Impetigo

• Constitutional Symptoms:

• Fever & weakness develops • Diarrhea

• Complications:

• Bacteremia • Pneumonia • Meningitis

Folliculitis

• Etiology

– Staphylococcus aureus

• Clinical Presentation

– Sites:

• Extremities and scalp

• Axillae, thighs, pubis & eyelashes • Gluteal & genital maybe STDs

– Lesions:

Furuncle & Carbuncle

• Etiology

– Break in the skin (pressure, friction, irritation,

hyperhidrosis, dermatitis, dermatophytosis or

shaving), provides portal of entry of

Staphylococcus aureus

– Autoinoculation from a carrier focus (nose or

groin)

– Predisposing factors: alcoholism, malnutrition,

blood dycrasias, disorder of neutrophil

function, iatrogenic or immunosuppression

(HIV or Diabetes)

Furuncle & Carbuncle

• Clinical Presentation

– Sites

• Nape, axilla, buttocks

– Lesions

• Furuncle/boil: acute, round, tender, circumscribed perifollicular abscess

• Carbuncle: 2 or more confluent furuncles with multiple opening, +/- purulent discharge

Furuncle & Carbuncle

• Complications

– Cavernous sinus thrombosis, meningitis &

septicemia (upper lip & nose)

• Treatment

– Warm compress

– Systemic Antibiotics

• Cloxacillin

• 1st _{gen Cephalosporin}

– Surgical: incision (acutely inflamed), incision

& drainage (fluctuant)

Ecthyma

• Etiology

– Streptococcus

– Staphylococcus aureus- IVD users & HIV

• Predisposing Factors

– Malnutrition

– Poor hygiene

– Trauma

Ecthyma

• Clinical Presentation

– Sites: shins or dorsal feet

– Lesions: vesicle or vesicopustules- increase

in size-thickly crusted. Removal of crust:

superficial, saucer shaped ulcer w/ elevated

edges & raw base

• (+) scarring

Cellulitis

• Suppurative inflammation of the subcutaneous

tissue

• Etiology:

– Staphylococcus aureus

– Steptococcus pyogenes

• Predisposing Factors:

– Breaks in the skin

– Tinea pedis- most common portal of entry

– Others: hematologic malignancy, diabetes

Cellulitis

• Clinical Presentation:

– Lesions: mild local erythema & tenderness

associated with malaise & chilly sensation. +/-

fever & chills

– Erythema spreadswarmth, swelling &

tenderness, +/- pitting on pressure

– Occasionally: vesicles appear, rupture &

discharge purulent material

Cellulitis

• Complications

– Gangrene, metastaic abscess & sepsis in

children & immunocompromised

• Treatment

Erysipelas

• Aka St. Anthony’s Fire

• Etiology:

– Grp A Beta hemolytic Strep-supfl dermal

lymphatics

– Strep C or G-occasional

– Grp B Strep- newborns, abdominal or perineal

erysipelas in post partum women

Erysipelas

• Predisposing Factors

– Break in the skin barrier

– Operative wounds

– Fissures in the nares, auditory meatus, under

the earlobes, on the anus, penis, between or

under the toes (little toe)

– Accidental scalp wounds

– Chronic leg ulcers

Erysipelas

• Clinical Presentation

– Sites: face & legs

– Prodrome: malaise, chills, high grade fever,

headache, vomiting & joint pains

– Lesions: intensely erythematous (scarlet),

warm, swollen, brawny, well-demarcated

plaque w/ characteristic raised indurated

border

• +/- vesicles/bullae w/ seropurulent fluid • Spread; peripheral extension

Erysipelas

• Lesions, contd…

• On face: ear may become swollen & distorted; +/- delirium

• Leukocytosis (PMNLs >/= 20,000/mm3)

• Complications:

• Septicemia

• Deep Cellulitis

Erysipelas

• Treatment

– Systemic: at least 10 days, rapid improvement

in 24-48 hours

– Penicillin V – IV Penicillin – Erythromycin

Cellulitis & Erysipelas

Cellulitis

Erysipelas

Staphylococcus or Streptococcus

Grp A Streptococcus Subcutaneous Tissue Superficial Dermal

lymphatics

Poorly demarcated Well-demarcated with characteristic raised indurated border

Erythrasma

• Etiology

– Corynebacterium minutissimum

– Extensive: diabetes or debilitating diseases

• Clinical Presentation

– Sites: intertriginous areas (axilla, genitocrural

crease & the webs between the 4

& 5

toes>

3

& 4

toes; intergluteal cleft, perianal skin,

inframammary area & nails)

Erythrasma

• Clinical Presentation, contd…

– Lesions:

• asymptomatic except for groin lesions which may present with burning & pruritus

• Sharply delineated, dry, brown, slightly scaling patches

• (+) Coral Red Fluorescence with Wood’s light

Erythrasma

• Treatment

– Localized

• Topical erythromycin/clindamycin • Topical azoles

• Topical Benzoyl Peroxide Wash or 5% gel

– Widespread

Mycobacterial Infections

1.

Hansen’s Disease

Hansen’s Disease

• Mycobacterium leprae

• Classification:

– 1. Indeterminate

– 2. Tuberculoid (TT)

– 3. Borderline Tuberculoid (BT)

– 4. Borderline (BB)

– 5. Borderline Lepromatous (BL)

6. Lepromatous (LL)

Indeterminate Leprosy

• Solitary, ill-defined hypopigmented macule

or patch

• Sensory: normal or minimally altered

(earliest: sense of cold & light touch)

• Peripheral nerves: not enlarged

• If immunity is good: resolves

spontaneously

Tuberculoid Leprosy (TT)

• Lesions are solitary, few & asymmetrical

• Lesion: large erythematous plaque w/

sharply elevated border & atrophic center

• Sensory: anesthetic or hyposthetic &

anhidrotic

• Nerve involvement: early, superficial

peripheral nerves are enlarged, tender or

both

Tuberculoid Leprosy (TT)

• Contracture of fingers (claw hand), facial

muscle paralysis & foot drop may occur

• Interosseous muscles may be atrophied:

wasting of thenar & hypothenar eminences

• Slow skin lesions evolution

• (+) Lepromin skin test, good cell-mediated

immunity

Tuberculoid Leprosy (TT)

• Histopathology

– Well defined granuloma with Langhans giant

cells, perineural infiltrates, AFB rare

Borderline Tuberculoid (BT)

• Similar to TT but smaller & more

numerous

Borderline Leprosy (BB)

• Skin lesions numerous, asymmetrical &

irregularly shaped

Borderline Lepromatous (BL)

• Lesions are numerous, symmetrical &

small

• Nerve involvement is symmetrical &

appears later

Lepromatous Leprosy (LL)

• Lesions are ill-defined, infiltrated,

numerous & symmetrical

• Nerve involvement: symmetrical, develops

slowly and at later stages

• Nerve damage: massive bacillary

infiltration w/ compression & fibrosis

• +/- hyperesthesia

Lepromatous Leprosy (LL)

• Hair: slow progressive hair loss w/ thinning

of outer thrid of eyebrow

• Progressively worsen w/o treatment

• (-) lepromin skin test, poor CMI

Lepromatous Leprosy (LL)

• Histopathology:

Hansen’s Disease

• Diagnosis

– Sensory Test- “pin-prick” or “ballpen-point” test

– Skin biopsy stained with Fite –Faraco stain

– Skin slit smears: “ Zieh-Neelsen stain

– Lepromin skin test: immunologic status

6+ >1000 bacilli/f 5+ 100-1000 4+ 10-100 3+ 1-10 2+ 1-10 in 10 OIF 1+ 1-10 in 100 OIF

Hansen’s Disease

• Diagnosis

– Lepromin skin test: immunologic status

• Fernandez reaction: 24-48 hours • Mitsuda reaction: 4 weeks

Hansen’s Disease

• Treatment

– Paucibacillary (Indeterminate & TT)

– Multibacillary (BT, BB, BL, LL)

– WHO Protocol:

• 1. Single lesion Paucibacillary

– Single dose: Rifampin 600mg, Ofloxacin 400mg & Minocycline 100mg (ROM)

• 2. Paucibacillary (Indeterminate, TT)

– Rifampin 600mg once a month x 6 months – Dapsone 100mg OD x 6 months

Hansen’s Disease

WHO Protocol:

• 3. Multibacillary (BT, BB,BL,LL)

– Rifampin 600mg and Clofazimine 300mg once a month – Dapsone 100mg and Clofazimine 50mg OD x 12 months,

or until smear negative

• 4. Special Cases

• For patients who cannot take dapsone & rifampin

– Clofazimine 50 mg , Ofloxacin 400mg & Minocycline 100mg OD x 6mos, – Ffd by: Clofazimine 50mg plus Ofloxacin 400mg OD or Minocycline 100

mg OD x 18 months

• For patients who refuse Clofazimine

– Minocycline 100mg or Ofloxacin 400mg OD x 12 mos or

– Rifampin 600mg, Ofloxacin 400mg & Minocycline 100mg once a mo x 24 months (ROM)

Hansen’s Disease

Treatment

Dapsone

effective, inexpensive & free of side effects at recommended doses side effects: Methemoglobinemia & anemia (in G6PD deficient); exfoliative dermatitis, hepatitis, neuropathy & agranulocytosis

Rifampin

side effects: red-orange urine, elevated liver enzymes & flu-like lesions

Clofazimine

Hansen’s Disease

• Reactional States

– Acute episodes characterized by remissions &

relapses for a week to a few months in a

chronic course of infection

– Neuritis is the most imptortant consideration

– Precipitating factors: infection, surgery,

physical, physiologic & mental stress,

vaccination, pregnancy, Vitamin A, iodides &

bromides

Hansen’s Disease

• Reactional States

– 1. Type 1 reaction

• Cell mediated; in BT, BB, BL

• Inflammation (swollen, erythematous & tender) of existing lesions

• No systemic symptoms; mj complication- nerve damage

• a. Reversal- w/ antibiotic tx, shift toward tuberculoid pole

• B. Downgrading- before antibiotic, shift toward lepromatous pole

Hansen’s Disease

• Reactional States

2. Type 2 reaction/Erythema nodosum

leprosum

• Circulating immune complex-mediated dse;In BL, LL

• Painful, erythematous subcutaneous & dermal nodules

• With systemic symptoms: fever, myalgia, arthralgia, anorexia & iritis

Hansen’s Disease

• Management of Reactions:

– Type 1 Reversal Mild

• Analgesics

• Chloroquine (1-2weeks)

– Type 1 Reversal Severe

• Prednisone 40-80mg OD x 5-7 days then taper for 2-6 months

• Clofazimine 300mg OD x 6 weeks

– Type 2/ ENL

• Clofazimine 300 mg OD x 6 weeks, 200mg OD x 2-6 mos & 100 mg OD x 1-2 years

• Thalidomide 400mg OD, tapered to 50-100 mg OD in 1 week (teratogenic)

Cutaneous TB

• M. tuberculosis, M. bovis

• Classification is based on the mode of

onfection & immunologic state of the host

• Diagnosis is based on clinical

manifestations, histopathologic analyisis,

demonstration of relevant mycobacteria in

tissue or in culture & host reaction

Cutaneous TB

• 1. Primary Inoculation TB/Tuberculous Chancre/ Tuberculous Primary Complex

• 2. Tuberculous Verrucosa Cutis/Warty TB • 3. Lupus Vulgaris

• 4. Scrofuloderma/TB Colliquativa Cutis

• 5. Orificial TB/TB Ulcerosa Cutis et mucosae

• 6. Others: Tuberculous Gumma, Acute Miliary TB of the skin, Sequelae of BCG inoculation

Tuberculous Chancre

• Tuberculous chancre & affected regional LN

• Children

• Sites: face, conjunctivae & oral cavity; hands &

lower extremities

• Pathogenesis (MBPB):

– Tubercle bacilli are introduced into the tissue at the site of minor wounds

– Oral lesions caused by bovine bacilli in nonpasteurized milk & after mucosal trauma or tooth extraction

Tuberculous Chancre

• Chancre (small papule, crust or erosion w/

little tendency to heal) appears 2-4 weeks

after inoculation

• Painless ulcer: shallow w/ a granular or

hemorrhagic base studded w/ miliary

abscess or covered by necrotic tissue;

undermined ragged edges & reddish blue

huemore indurated w/ thick adherent

Tuberculous Chancre

• Mucosal: painless ulcers or fungating

granulomas

• Slowly progressive, regional LAD x 3-8

weeks after infectionweeks or months:

cold abscess that perforate to surface &

form sinuses

Tuberculous Chancre

• Histopathology (Fite Stain):

• 3-6 weeks: tuberculoid appearance & caseation

• Diagnosis

– Ulcer w/ little or no tendency to heal

– Unilateral regional LAD

Tuberculous Chancre

• Course

– Untreated: 12 mos

– Hematogenous spread: bones & joints

– Calcification of regional LN

Tuberculosis Verrucosa Cutis

• Paucibacillary caused by exogenous re

infection (inoculation) in previously sensitized

individuals w/ high immunity

• Clinical Manifestations:

– Small asymptomatic papule or papulopustule w/ puple inflammatory halo

– Hyperkeratotic

– Slow growth & peripheral expansion verrucous plaque w/ irregular border; solitary

Tuberculosis Verrucosa Cutis

• Histopathology

– Pseudoepitheliomatous hyperplasia w/ marked

hyperplasia w/ marked hyperkeratosis, a dense

inflammatory infiltrate & abscess in the supfl

dermis or within the pseudoepitheliomatous

rete pegs

– Epitheloid cells & giant cells in upper & middle

dermis

Lupus Vulgaris

• Chronic, progressive form

• Moderate immunity & a high degree of

tuberculin sensitivity

• Females, 2-3x

• Pathogenesis: post primary, PB caused by

hematogenous, lymphatic or contguous

Lupus Vulgaris

• Clinical Manifestation

– Sites: nose, cheek, earlobe or scalp

– Initial lesion:

• brownish red, soft or friable macule or papule w/ a smooth or hyperkeratotic surface.

• Apple jelly color on diascopy

– Progression:

• Elevation, deeper brownish color & plaque

• Nasal or auricular cartilage: extensive destruction & disfigurement

Lupus Vulgaris

• Clinical Manifestation

– Sites: nose, cheek, earlobe or scalp

– Initial lesion:

• brownish red, soft or friable macule or papule w/ a smooth or hyperkeratotic surface.

• Apple jelly color on diascopy

– Progression:

• Elevation, deeper brownish color & plaque

• Nasal or auricular cartilage: extensive destruction & disfigurement

Lupus Vulgaris

• Diagnosis

– Softness of lesion, brownish red color & slow

evolution

– Apple jelly nodules

• Histopathology

– Typical tubercles

– Secondary changes: epidermal thinning,

atrophy or acanthosis w/ excessive

hyperkeratosis or psedoepitheliomatous

hyperplasia

Lupus Vulgaris

• Course

– Long term disorder

– Functional impairment & disfigurement

– Squamous Cell CA

Scrofulderma

• Subcutaneous TB leading to cold abscess

formation breakdown of overlying skin

• MB or PB

• Represents contiguous involvement of

skin overlying another site of infection (TB

lymphadenitis, bones & joints or

epididymitis)

Scrofulderma

• Site: parotidal, submandibular &

supraclavicular; bilateral

• Lesion: firm, subcutaneous nodule, well

defined, freely movable & asymptomatic

softens, liquefaction w/ perforation

Scrofulderma

• Histopathology:

• Massive necrosis & abscess formation in center

• Course

Orificial TB

• Rare TB of mucous membranes

• Autoinoculation

• Underlying Disease: far advanced

pulmonary, intestinal or genitourinary TB

• Clinical Manifestation:

– Small, yellowish or reddish nodules  soft

ulcer w/ typical punched-out appearance,

undermined edges & circular or irregular

border

Orificial TB

• Clinical Manifestation:

– Multiple yellowish tubercles & bleeds easily

– Edematous & inflamed

– Extremely painful: dysphagia

– Sites:

• TB of Pharynx & Larynx: tongue (tip & lateral

margins), soft & hard palate; lips (advanced cases) • TB of Genitourinary: vulva

Orificial TB

• Histopathology

– Massive, non-specific inflammatory infiltrate &

necrosis, but tubercles w/ caseation maybe

found

Superficial Fungal

Infections

Dermatophytoses

• Infects non-viable keratinized cutaneous

tissues including stratum corneum, nails &

hair

– Microsporum – Trichophyton

– Epidermophyton

• Factors that promote dermatophytoses

– Environmental

– Immunosuppression – Genetic susceptibility

Dermatophytoses

• Diagnostics

– KOH smear- septated hyphae

– Histopathology- with PAS & methenamine

silver stains exhibiting septated hyphae within

the stratum corneum

– Fungal cultures

– Wood’s lamp

Dermatophytoses

• Tinea capitis (ringworm of scalp & kerion)

• Tinea barbae (beard)

• Tinea faciei (face)

• Tinea corporis (body)

• Tinea manus (hands)

• Tinea pedis (feet)

Tinea Capitis

• Clinical Manifestations

– 1. Non Inflammatory Type

a. Black-dot b. Gray patch

– 2. Inflammatory Type

a. Kerion b. Favus

Tinea Capitis

• Non-inflammatory Type

– A. Black dot- endothrix; infected hairs broken

off at or below the surface of the scalp

– B. Gray patch- ectothrix; scaly patches with

areas of stubs of broken hair

Tinea Capitis

• Endothrix: arthrospores are formed inside the

hair shaft; no fluorescence

• T. tonsurans • T. schoenleinii • T. violaceum

• Ectothrix: hair is surrounded w/ sheath of tiny

spores; greenish fluorescence

• Microsporum species • T. verrucosum

• T. mentagrophytes • T. megnini

Tinea Capitis

• Inflammatory Type

• Begins as erythematous, scaly, papular eruptions w/ loose & broken off hairs

– A. Kerion- localized spot w/ pronounced

swelling, creating a boggy & indurated area

exuding pus

– B. Favus- concave, sulfur-yellow crust

forming around loose wiry hairs

– Hyphae & air spaces within the hairshaft – Bluish-white fluorescence

Tinea Capitis

• Treatment

– Griseofulvin x 2-4 mos or at least 2 weeks after negative microscopic and culture examinations – Terbinafine 250mg/ Tab x 2 weeks (Trichophyton)

and 4 weeks (Microsporum)

– Itraconazole 100mg/caps, 2 caps/day x 4-6 weeks – Ketoconazole 200mg/tab x 4-6 weeks

– Others: short courses of systemic steroids for

inflammatory type; Selenium sulfide Shampoo or Ketoconazole Shampoo left for 5 mins 3x a week

Tinea Barbae

• Clinical Manifestations-

usually on the neck

&/or beard area

– 1. Deep Type

Tinea Barbae

• 1. Deep Type

• Develops slowly

• Does not usually involve the upper lip except the mustache

• Produces nodular thickenings & kerion-like swellings, which are confluent & form diffuse boggy infiltrations w/ abscesses

• Overlying skin is inflamed • Hairs are loose or absent

• Pus may be expressed through the remaining follicular openings

Tinea Barbae

• 1. Superficial, crusted Type

• Mild pustular folliculitis

– With broken off hairs – Without broken off hairs

• Hairs are loose, dry, brittle & when

extracted, the bulb appears intact

Tinea Barbae

• Treatment

– Micronized or Ultramicronized Griseofulvin

500-1000mg/ day x 4-6 weeks

– Terbinafine 250mg/ Tab x 2 weeks

(Trichophyton) and 4 weeks (Microsporum)

– Itraconazole 100mg/caps, 2 caps/day x 4-6

weeks

Tinea Barbae

• Treatment

– Topical Antifungals: miconazole, clotrimazole,

oxiconazole, sulconazole, econazole,

ketoconazole, naftitine, terbinafine, ciclopirox

olamine BID x 2-4 weeks

– Affected areas washed with soap and water

– Healthy areas maybe shaved or clipped

Tinea Faciei

• Erythematous, slightly scaling patches or

plaques with indistinct borders & with

Tinea Faciei

• Treatment

– Topical Antifungals: miconazole, clotrimazole,

oxiconazole, sulconazole, econazole,

ketoconazole, naftitine, terbinafine, ciclopirox

olamine BID x 2-4 weeks

– Oral Antifungals:

• Micronized or Ultramicronized Griseofulvin 500-1000mg/ day x 4-6 weeks

• Terbinafine 250mg/ Tab x 2 weeks (Trichophyton) and 4 weeks (Microsporum)

• Itraconazole 100mg/caps, 2 caps/day x 4-6 weeks • Ketoconazole 200mg/tab x 4-6 weeks

Tinea Corporis

• Sites: neck, upper & lower extremities and

trunk

• Characterized by one or more circular,

sharply circumscribed, slightly

erythematous, dry, scaly plaques w/

central clearing

• Borders are usually elevated & more

inflames & scaly than the central part

Tinea Corporis

• Lesions may widen to form rings,

sometimes making concentric rings or

rings of intricate patterns (Tinea imbricata)

• Disseminated patches of both dry

(macular) & moist (vesicular) types of

Tinea circinata

Tinea Corporis

• Treatment

– For Extensive lesions

• Micronized or Ultramicronized Griseofulvin 370-750mg/ day x 4-6 weeks

• Terbinafine 250mg/ Tab x 2 weeks • Itraconazole 200mg/day x 1 week

• Fluconazole 150mg/tab once a week x 4 weeks

– For Localized lesions

• Topical Antifungals: miconazole, clotrimazole, oxiconazole, sulconazole, econazole, ketoconazole, naftitine, terbinafine, ciclopirox olamine BID x 2-4 weeks

Tinea Cruris

• Aka “Jock Itch”

• Sites: upper & inner surfaces of the thighs

• Begins as a small erythematous and scaling or

vesicular & crusted patch that spreads

peripherally & partly clears in the center

• Curved with well-defined border particularly on

its lower edge

• Border: vesicles, pustules or papules

• Extends: downward- thighs &

backwards-perineum or anus

Tinea Cruris

• Treatment

– Same as Tinea Corporis

– Reduce perspiration and enhance

evaporation on crural area

– Area should be kept dry by wearing loose

underclothing and trousers, application of

plain talcum powder or antifungal powder

Tinea Pedis

• Aka “Athelete’s Foot”

• Most common dermatophytosis

• Consists of maceration, slight scaling &

occasional vesiculation & fissures between

& under the toes

• Most common site: third toe web

• If untreated: ulcerative, exudative process

affecting web spaces or entire sole

Tinea Pedis

• Types:

– 1. Non-inflammatory

• Dull erythema & pronounced scaling (moccasin or

sandal appearance)

– 2. Inflammatory

• Acute vesicular or bullous eruption

• Vesicles contain clear tenacious fluid w/ glycerin consistency which dries up leaving yellowish

brown crusts

Tinea Pedis

• Treatment

– Reduce perspiration and enhance

evaporation on the interdigital areas

– Toe webs & soles should be dried

immediately after bathing

– Use antiseptic powder on the feet after

bathing ( eg Tinactin powder or Zeasorb

Medicated Powder)

– Plain tlac, cornstarch or rice powder maybe

dusted to the socks & shoes to keep feet dry

Tinea Pedis

• Treatment

– Severe Tinea Pedis

• Micronized or Ultramicronized Griseofulvin 370-750mg/ day x 4-6 weeks

• Terbinafine 250mg/ Tab x 2 weeks • Itraconazole 200mg/day x 1 week

• Fluconazole 150mg/tab once a week x 4 weeks • *** With severe maceration: One part Aluminum

Acetate to 20 parts of water as dressing

• ***Secondary Infections: Oral or Topical

Tinea Pedis

• Treatment

– Localized Tinea Pedis

• Topical Antifungals: miconazole, clotrimazole, oxiconazole, sulconazole, econazole,

ketoconazole, naftitine, terbinafine, ciclopirox olamine BID x 2-4 weeks

• Keratolytic Agents (eg Salicylic Acid, Lactic Acid Lotions) for areas protected by thick layers of underlying skin

Tinea Manum

• Dry, scaling, erythematous or may be

verrucous

Tinea Manum

• Treatment

– Severe Tinea Manum

• Micronized or Ultramicronized Griseofulvin 370-750mg/ day x 4-6 weeks

• Terbinafine 250mg/ Tab x 2 weeks • Itraconazole 200mg/day x 1 week

• Fluconazole 150mg/tab once a week x 4 weeks • *** With severe maceration: One part Aluminum

Acetate to 20 parts of water as dressing

• ***Secondary Infections: Oral or Topical

Tinea Manum

• Treatment

– Localized Tinea Manum

• Topical Antifungals: miconazole, clotrimazole, oxiconazole, sulconazole, econazole,

ketoconazole, naftitine, terbinafine, ciclopirox olamine BID x 2-4 weeks

• Keratolytic Agents (eg Salicylic Acid, Lactic Acid Lotions) for areas protected by thick layers of underlying skin

Onychomycosis

• Types

– 1. Distal Subungal Onychomycosis

– 2. Superficial White Onychomycosis

– 3. Proximal Subungal Onychomycosis

– 4. Candidal Onychomycosis

Distal Subungal Onychomycosis

• Involves the distal nail bed & hyponychium

w/ sec involvement of the underside of

nailplate

• Whitish-yellowish discoloration starting at

the distal corner of the nail & involves the

junction of the nail & its bed and becomes

brown-black in color

• Later: opaque, thickened, friable & raised

by underlying hyperkeratotic nail bed

Superficial White Onychomycosis

• Aka Leukonychia Trichophytica

• Invasion of the toenail plate on the surface

producing chalky white nail plate

Proximal Subungal Onychomycosis

• Involves the proximal nail fold

• White spot appears from beneath the PNF

which gradually fills the lunula & moving

distally

Candidal Onychomycosis

• Aka Total Dystrophic Onychomycosis

• Involves the whole nail plate

• Fingernails>toenails

• Begins under the lateral & proximal nail

fold & the adjacent cuticle is pink, swollen

& tender on pressure\

• Neighboring nail becomes dark, ridged &

separated from the nail bed

Candidal Onychomycosis

• Later: total onycholysis

• Nail plate doe not become white, yellow or

friable

• Seen in chronic mucocutaneous

candidiasis

Onychomycosis Therapy

• Terbinafine 250mg/day x 6 weeks for fingernails

and 12 weeks for toenails

• Itraconazole Pulse Treatment: 200mg BID for 1

week of each month for 2 months for fingernails

and 3 months for toenails

• Fluconazole 150-300mg once a week x 6-12

months

• Griseofulvin 350mg TID with meals x 4-6 months

for fingernails and 10-18 months for toenails

Dermatophytid

• “Id reaction” to the fungal antigen

especially the inflammatory types

• Diagnosis depends on presence of fungal

infection at site different from the lesion

– Pruritic vesicles on the hand & sides of fingers-most

common site esp of Tinea Pedis

– Acute widespread eruption usually follicular, lichenoid

& scaly papules on the trunk esp of Tinea Capitis

– Erysipelas-like dermatophytid on the shin esp of toe

web tinea

Pityriasis/Tinea Versicolor

• Etiology:

– Malassezia furfur or Pityrosporum orbiculare

• Short thick fungal hyphae &spores (“spaghetti & meatballs”)

• Clinical Manifestation

– Yellowish or brownish macules in pale skin or hypopigmented macules in dark skin

– Coalesce to form patches

– Delicate scaling (“grattinage”)

Pityriasis/Tinea Versicolor

• Clinical Manifestation, contd…

– Sites of Predilection

• Sternal region & sides of chest • Abdomen

• Back • Pubis • Neck

• Intertriginous areas

– *** Hypopigmentation- fungus compels production of abnormally small melanosomes which are not

Pityriasis/Tinea Versicolor

• Diagnosis

– Wood’s Lamp: yellowish or brownish

fluorescence

– Skin Scarping w/ 10% KOH: spaghetti &

meatballs

Pityriasis/Tinea Versicolor

• Treatment

– 1. Topicals

• Imidazoles- Ketoconazole Shampoo • Selenium Sulfide Shampoos

• Ciclopirox Olamine Shampoo • Zinc Pyrithione Shampoo

• Sulfur Preparations

• Propylene Glycol lotions • Benzoyl Peroxide

Pityriasis/Tinea Versicolor

• Treatment

– 2. Oral

• Ketoconazole 200 mg/day x 10 days • Fluconazole 400mg single dose

• Itraconazole 200mg x 5-7 days

• *** hypopigmentation will take time to resolve and is not a sign of treatment failure

Candidiasis

• Aka candidosis, moniliasis, thrush or

oidiomycosis

• Etiology: Candida albicans

• Features:

– Normal inhabitant at various sites (skin, nails, mucous membranes & viscera), until there is some change in the state of the area then it becomes a pathogen

– Areas: perianal and inguinal folds, interdigital, nail folds & axillae

• *** warmth, moisture & maceration permit the organism to thrive

Candidiasis

• Types:

– 6. Congenital Cutaneous Candidiasis – 7. Perianal Candidiasis

– 8. Candidal Paronychia

Oral Candidiasis

• Newborn/ Infant

– Grayish white membranous plaques w/ reddish base on mucous membrane of mouth

– Angles of the mouth

• Adults

– Buccal mucosa and tongue

– Papillae of tongue atrophied w/ smooth, glazed and bright red surface

– *** elderly, debilitated & malnourished – *** often 1st _{manifestation of HIV}

Oral Candidiasis

• Treatment

– Clotrimazole troches

– Fluconazole 100-200mg/day x 5-10 days

– Itraconazole 200 mg OD x 5-10 days

Perleche/Angular Cheilitis

• Maceration w/ transverse fissuring of the oral commisures

• Early lesions: ill-defined, grayish white thickened areas w/ slight erythema of mucous membrane at oral

commisure

• More developed lesions: bluish white ot mother of pearl color, contiguous w/ a wedge shaped erythematous

scaling dermatitis of skin portion of commisure fissure, maceration & crust formation

Perleche/Angular Cheilitis

• Also seen in Riboflavin deficiency & in

malocclusion caused by ill-fitting dentures

• Can be bilateral

Candidal vulvovaginitis

• Labia: erythematous, moist & macerated

• Cervix: hyperemic, swollen & eroded with

small vesicles on the surface

• Sx: severe pruritus, irriattion, extreme

burning

Candidal vulvovaginitis

• Pregnancy, In diabetes or secondary to

broad spectrum antibiotic therapy

• Frequent recurrences

Candidal vulvovaginitis

• Treatment

– Fluconazole 150mg single dose or 100mg/day

x 5-7days

– Itraconazole

– Topical Antifungals

Candidal Intertrigo

• Arises between folds of genital, in groins

or armpits, between buttocks, under large

pendulous breasts, over hanging

abdominal folds or umbilicus

• Pinkish intertriginous moist patches

surrounded by a thin, overhanging fringe

of macerated epidermis (“collarette of

scale”)

Pseudo Diaper Rash

• Perianal region spread over entire area

enhanced by maceration produced by wet

diapers

• Scaly macules & vesicles w/ maceration:

pruritus, burning & extreme discomfort

• Erythematous desquamating “satellite” or

“daughter” lesions scattered along edges

Congenital Cutaneous

Candidiasis

• Infection of an infant during passage

through a birth canal infected with C.

albicans

• Erythematous macules progress to thin

walled pustules, that rupture, dry &

desquamate

• Lesions are widespread, involving even

the nailfolds.

Perianal Candidiasis

• (+) pruritus ani

• Erythema, oozing & maceration

• Svere pruritus & burning

• Maybe precipitated by oral antibiotic tx

• Treatment:

– Imidazoles

– Topical corticosteroids

– Antipruritic meds

Candidal Paronychia

• Chronic inflammation of nailfold produces

discharge of pus

• Involves all nail plate

• Cushion-like thickening of paronychial

tissue

• Slow erosion of lateral NF

• Gradual thickening & brownish

discoloration of nailplate

Candidal Paronychia

• Sual: dishwashers & diabetics

• Treatment

– Oral Fluconazole weekly

– Itraconazole in pulse doses

– Anticandidal lotions

– *** continued for 2-3months to prevent

Chronic Mucocutaneous

Candidiasis

• Chronic but superficial

• Before age of 6

• Oral Lesions: diffuse perleche & lip

fissures

• Nail: thickened & dystrophic, (+)

paronychia

• Skin: hyperkeratotic, horn-like or

granulomatous lesions

Chronic Mucocutaneous

Candidiasis

• Adult onset: heralds the occyrence of

Thymoma

Viral Infections with

Purely Cutaneous Involvement

• Molluscum contagiosum

• Verruca/Wart

Molluscum contagiosum

• Etiologic Agent:

– Molluscum contagiosum virus (poxvirus)

• Epidemiology:

– MCV 1: general population

– MCV 2: 60% among HIV patients

– 3 groups: young children, sexually active

adults & immunosuppressed patients (HIV)

– Direct skin to skin contact

Molluscum contagiosum

• Clinical Presentation

– Lesions:

• smoothed surface, firm, dome-shaped, pearly papules

• 3-5mm in diameter (giant: 1.5cm) • Characteristic: central umbilication

Molluscum contagiosum

Children

Adults

Usually STD’s Few to >100 <20 lesions

Location: face, trunk & extremities Location: lower abdomen, upper thighs and penile shaft (men)

May occur in genitals as part of wide distribution; if restricted- sexual abuse maybe considered

Molluscum contagiosum

• Differential Diagnoses

• Wart

• Syringoma (benign sweat gland tumor on face around the eyes)

• Sebaceous hyperplasia (sebaceous gland hyperplasia in seborrheic areas of face) • Basal Cell Carcinoma (skin cancer)

Molluscum contagiosum

• Complications

– Secondary bacterial infection

– Eczematous reaction in 10% (molluscum dermatitis) – Conjunctivitis or keratitis

– Cutaneous horn (MC cornuatum)

• Histopathology

– Eosinophilic and later basophilic inclusion bodies (Molluscum bodies or Henderson-Paterson

Molluscum contagiosum

• Diagnosis

– Clinical: centrally umbilicated dome-shaped

lesion

– Diagnostics:

• Cryotherapy: umbilication appears clear against a white (frozen) background

• Shelley’s method for visualization

– Expression of pasty core lesion – Squash between 2 glass slides – Methylene blue stain

Molluscum contagiosum

• Treatment

– Surgical nicking with comedone extractor*** – Removal by curettage

– Surgical tape after bathing x 16 weeks (90% cure) – Topical Tretinoin 0.05% ODHS

– Imiquimod Cream ODHS*** – TCA 35%-100% application – 10% KOH

– Light cryotherapy

– Anthradin x 4-8 hours

Molluscum contagiosum

• Treatment, contd…

– Adults w/ genital molluscum

• Mandatory screening for STD • Screen sexual partners

• Cryotherapy

• Podophyllotoxin 0.5% cream BID x 3 days per weeks x 12 weeks

Molluscum contagiosum

• Course and Prognosis

– Spontaneous resolution in 2-4 months

Human Papillomavirus/Wart

• Etiologic Agent:

– Human Papillomavirus (HPV)

• 80 types to date

Human Papillomavirus/Wart

• Clinical Presentation:

– Verruca Vulgaris/Common Wart

– Verruca Plana/ Flat warts

– Verruca Plantaris/ Plantart wart

Verruca Vulgaris

– Most common: HPV type 2

– Less frequent: HPV type 1,4,7

– Age: 5-20 years old (15% occur after 35) – Children: 5%

– Risk Factors:

• Frequent immersion of hands in water • Meat handlers

Verruca Vulgaris

-

Spontaneous resolution

- 50% by 1 year

- 60-70% by 2 years

-

Predilection sites

- Hands (fingers & palms)

Verruca Vulgaris

Lesions

elevated, rounded papules with rough, grayish surface

tiny, black dots on surface w/ thrombosed capillaries

Verruca Plana

– Most common: HPV type 3

– Less frequent: HPV type 10, 27 & 41 – Children & young adults

– Lesions:

• 2-4mm flat topped papules, slightly erythematous or brown on pale skin & hyperpigmented on darker skin

• Generally multiple

• Grouped on face (forehead, cheeks, nose, perioral), neck, dorsa of hands, wrists or knees

Verruca Plantaris

– Most common: HPV type 1 – Less frequent: HPV type 2, 4

– Appear at pressure points on ball of foot esp midmetatarsal area

– Soft pulpy cores are surrounded by firm, horny ring – Mosaic wart: contiguous warts appearing as one

Verruca Plantaris

Myrmecia wart:

- dome shaped

- bulkier beneath the surface - HPV 1

Verruca Plantaris

Ridged wart:

-

- slightly elevated, skin-colored, 3-5mm papules - non weight bearing areas

Plantar verrucous cysts:

-

-1.5-2cm epithelium lined cysts on plantar area -weight bearing areas

Condyloma Acuminata

• Common sexually transmitted disease

among sexually active young adults

• Infection rate: 50%

• Lifetime risk: 80%

• Subclinical and latent infections-

recurrences & transmission

Condyloma Acuminata

• Benign Genital Warts: HPV 6 & 11

Human Papillomavirus/Wart

• Differential Diagnosis:

– Molluscum contagiosum-umbilicated surface

– Syringoma- benign sweat gland tumor of the face – Seborrheic Keratoses-stuck-on hyperkeratotic,

pigmented papules & plaques

– Acrochordon-skin tag; skin-colored, soft exophytic papule

– Callus & corn-maintained skin lines, absent thrombosed capillaries/black dots

Human Papillomavirus/Wart

• Treatment

– Few lesions

• Light cryotherapy

• Topical Salicylic Acid • Electrodessication

– More extensive

• Topical Tretinoin 30-100% OD-BID • 5 Fluorouracil cream 5% BID

Human Papillomavirus/Wart

• Treatment

– Refractory

• Pulse dye laser before electrodessication (reduced risk of scarring)

– Genital

• Podophyllin 25% in tincture of benzoin weekly, washed off 4-8 hours later.

• Trichloroacetic acid 35-85% weekly or biweekly. Safe in in pregnancy.

• Cryotherapy w/ liquid nitrogen every 1-3 weeks, 1 or 2 freeze-thaw cycles. Safe in pregnancy.

• Electrofulguration or electrocauterization • Minor surgical removal

With Systemic Involvement

• Varicella/Chickenpox

• Herpes Zoster/Shingles

• Herpes Simplex

• Measles/Rubeola

• Rubella/German Measles

Varicella

• Etiology

– Primary infection of VZV

• Epidemiology

– 90%- children <10 years in temperate

countries; adults & adolescents in tropical

– Summer months

Varicella

• Pathogenesis

– Aerosol or direct contact

– Inoculation of respiratory mucosa replication in

regional nodes (innate defenses)  primary viremia: replication in liver & spleen & RESSecondary

Viremia: mononuclear cells transport virus to skin & mucous membranes (fever & malaise) Virus

released into respiratory secretions replication in epidermal cells

Varicella

• Clinical Characteristics

– Incubation Period: 10-21 days

– Transmission: direct contact & respiratory

route

– Infectious: 4 days before & 5 days after

exanthem

– Prodrome: low grade fever, malaise &

headache

Varicella

• Differential Diagnosis

– Drug eruption (drug intake, monomorphous)

– Allergic Contact Dermatitis (symmetrical, localized) – Blistering diseases- Dermatitis Herpetiformis & Linear

IgA dermatoses

• Diagnostics

– Tzank smear- multinucleated giant cells

Varicella

Congenital

Neonatal

Immuno

compromised

-hypoplastic limbs,

cutaneous scars, ocular & CNS diseases

-extremely severe & even fatal

-necrotic & ulceration

-maternal infections: 20 weeks AOG

-in utero- zoster

postnatally during 1st ₂

years of life

-maternal infections: 5 days before & 2 days after delivery

Varicella

• Treatment

– Antiviral Therapy (Aciclovir, Valaciclovir &

Famciclovir)

• Within 24 hours of appearance of eruption • Acyclovir 800mg 5x a day x 7days

• Valacyclovir 1 gm TID x 5days

– Immunocompromised

• Mild: Aciclovir 800 mg 5x/D x 7-10 days

• Severe: Aciclovir 10mkdose IV q8 x 7 days or longer

• Acyclovir resistant: Foscarnet 40mkdose IV q8 until healed

Varicella

• Treatment

– Antiviral Therapy (Aciclovir, Valaciclovir &

Famciclovir)

• Within 24 hours of appearance of eruption • Acyclovir 800mg 5x a day x 7days

• Valacyclovir 1 gm TID x 5days

– Immunocompromised

• Mild: Aciclovir 800 mg 5x/D x 7-10 days

• Severe: Aciclovir 10mkdose IV q8 x 7 days or longer

• Acyclovir resistant: Foscarnet 40mkdose IV q8 until healed

Varicella

• Treatment, contd…

– Supportive: topical antipruritic lotions, oatmeal baths & cool light clothing

– Antibiotics- secondary bacterial infections

• Complications

– Secondary bacterial infection w/ Staph or Strep – Cerebellar ataxia & encephalitis

– Asymptomatic myocarditis & hepatitis – Reye’s syndrome- Aspirin is CI

Herpes Zoster

• Etiology:

– Varicella Zoster Virus Secondary infection

• Latency in DRG replicates & travels down sensory nerve into skin

• Epidemiology:

– Increases with age, sun exposure, smoking,

trauma, stress & immunocompromised states

Herpes Zoster

• Classically occurs unilaterally within the

distribution of cranial or spinal sensory

nerve

• Dermatomes:

Herpes Zoster

• Clinical Presentation

– Eruption is preceded by pain over affected areas – Papules & plaques of erythema in dermatome,

followed by blisters within hours

– Lesions maybe hemorrhagic, necrotic or bullous – Duration: depends on age, severity of eruption &

underlying immunosuppression ( 2-3 weeks in younger & up to 6 weeks in elderly)

Herpes Zoster

Pregnancy Disseminated Ophthalmic

-Antivirals: risk-benefit ratio

-> 20 lesions outside the affected dermatome

-Ophthalmic division of CNV

-Acyclovir has been commonly given during pregnancy without direct effect to the fetus

-in old & debilitated -Hutchinson’s Sign: vesicles on side & tip of the nose (external

division of nasociliary nerve w/ involvement of eyeball)

-Usually localized to the skin & does not affect the fetus -fever, protration, headache, signs of meningeal irritation or viral meningitis - Ocular involvement: uveitis (92%) & keratitis (50%)

Herpes Zoster

• Diagnosis

– Histopathology: intraepidermal vesicles, balloon cells which are degenerated cells of spinous layer, marked intercellular & intracellular edema

• Treatment

– Supportive

:

• Bedrest- prevention of neuralgia in middle aged & elderly

Herpes Zoster

• Treatment, contd…

– Antiviral Therapy

• Cornerstone in management, reduces zoster-associated pain

• Intitiated within 3-4 days

– Acyclovir 800mg 5x/day x 7days – Valacyclovir 1 gm TID x 7 days – Famciclovir 500 mg TID x 7days

Herpes Zoster

• Complications

– Ramsay-Hunt Syndrome: facial & auditory nerves

• Herpetic inflammation of geniculate ganglion • Zoster of external ear or tympanic membrane

• Herpes auricularis, facial paralysis & auditory symptoms

– Post herpetic Neuralgia; zoster associated pain until 1 month from resolution of lesions

• Major complication of zoster • Age or severity dependent • Treatment:

– Tricyclic Antidepressants-1st _line

– Anticonvulsants: phenothiazines & carbamazepine 200-400mg OD – Gabapentin in escalating doses up to 3200mg OD

Herpes Simplex

• Etiology

– Orolabial: HSV Type 1

– Genita; : HSV Type 2

• Epidemiology

– One of the most prevalent STI worldwide

– 80% are seropositive for HSV-1

Herpes Simplex

• Clinical Presentation

– Orolabial Herpes

– Herpetic Whitlow

– Genital Herpes

– Intrauterine & Neonatal Herpes***

– Eczema Herpeticum

Orolabial Herpes

• High fever, regional lymphadenopathy & malaise

• “Cold sore” or “fever blister”

• Grouped blisters on erythematous base

involving the lips near vermillion border

• Trigger for recurrence: UV exposure

Herpetic Whitlow

• Infection of the pulp of the fingertip

• Bimodal:

– Children: < 10 years old – Adults: 20-40 years old

• Tenderness & erythema, of lateral nail fold

followed by formation of deep seated blisterd

24-48 hours after

Genital Herpes

• Spread by skin to skin contact usually during

sexual activity

• Incubation period: 5 days

• Primary Infection

– Grouped blisters & erosions in vagina, rectum or penis w/ continued devt of new lesions over 7-14 days

– Bilaterally symmetrical w/ bilaterally enlarged inguinal LN

Genital Herpes

• Recurrence

– Prodrome; burning, itching or tingling

– Papules in 24 hoursvesicles in another 24 hours erosions in 24-36 hours and heals in 2-3 days

– Milder than 1st _{due to antibodies}

– Common site: upper buttocks

– Heals without scarring unless secondarily infected – Chronic suppressive therapy- reduces asymtomatic