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CommonSkinInfectionsDermatologyMKSAP17

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Chapter05:CommonSkinInfections
RelatedQuestions
Previous:AcneiformEruptions

CommonSkinInfections
Theskinservesasanexternalbarrierandiscolonizedwithmicroorganismsthatprovideanopportunityforinfections.Skininfectionsoftenare
categorizedbytypeofcausativemicroorganism(bacteria,fungus,virus)andbythepartoftheskininfected.

BacterialSkinInfections
RelatedQuestion
Question43
Normalskincontainsnumerousmicroorganismsthatcomprisethenaturalmicrobiome,whichhelpskeeptheskinhealthyandprotectsagainst
pathogenicorganisms.Althoughstaphylococciorstreptococciarecommonlyinvolvedinskininfections,theyarealsoapartofnaturalskinflora.
Therefore,itisimportanttoperformanappropriateculturetoconfirmthatthesemicroorganismsarethecauseofinfectionwithcomplicatedskinand
softtissueinfectionsincludingabscesses,extensiveareasofinvolvement,ornonresponsetoantibiotics.Itisimportanttoobtainculturesbefore
institutingsystemicantibioticstohelpwithappropriategrowthandappropriateantibioticstewardship.Wheneverpossible,acultureshouldbe
performedbycleaningtheskinsurfacewithalcoholandthenobtainingasamplefrompurulentmaterial,yellowcrustedmaterial,oramoistorbroken
downareaofskin.Withfolliculitisoracollectionsuchasanabscess,unroofingtheouterskinmaybenecessarytoobtainthebestsample.Thisis
especiallyimportantbecauseofincreasingresistancetoantibiotics,suchasmethicillinresistantStaphylococcusaureus(MRSA).
Bacterialinfectionsarefrequentlycategorizedbasedonthelocationandtypeofinfection:folliculitisabscesses,furuncles,orcarbunclesimpetigoand
cellulitisanderysipelas.

Folliculitis
Folliculitisisinflammationofhairfolliclescharacterizedbyerythematouspapulesandpustulesthatarecenteredaroundafollicleontheface,chest,
back,orbuttocks(Figure24).
Figure24.OpeninNewWindow

Pinkpapulesandpustulescenteredaroundhairfollicles,characteristicoffolliculitis.

Folliculitiscanbenoninfectiousorinfectious.Wheninfectious,folliculitisismostoftencausedbyStaphylococcusaureus,althoughotherbacteriacan
inducefolliculitis.TheseincludePseudomonas(hottubfolliculitis)andgramnegativefolliculitisthatsometimesoccursasacomplicationofacne
therapy.FolliculitiscanalsooccurfromfungisuchasMalasseziaorCandidaspecies,orfromviruses,includingherpesviruses.Inaddition,folliculitis
canbesecondarytononinfectiouscausesincludingacnevulgaris,eosinophilicfolliculitis(seeninpatientswithHIVinfection),orasareactionto
shavingortopicalmedications.
Althoughadiagnosisoffolliculitiscanbemadeclinically,culturecandeterminethecausativeorganismandprovideantibioticsensitivityinformation
whenthereisalackofresponsetotreatmentorwhensurroundingextensiveerythemaispresent.Biopsyalsomaybenecessarytodiagnosethe
underlyingcauseandruleoutnoninfectiouscausesoffolliculitis.
Treatmentforbacterialfolliculitisincludestopicalantibacterialagentssuchasbathswithdilutebleach,chlorhexidinewashes,orbenzoylperoxidewash
asabroadspectrumantimicrobialagent.Topicalmupirocinorclindamycinlotionalsocanbeused.Cultureisnotnecessarywhenthesetopicalagents
areused.Forseverecaseswithwidespreadinvolvementorbackgrounderythema,oralantibioticsagainstStaphylococcusaureuscanbegivenasashort
course.Ifpersistentorrecurrent,maintenancewithtopicalwashesand/orfurtherevaluationforanalternatediagnosisorforcarriersofMRSAmaybe
necessary.Decontaminationcanbeperformedaswell.Lifestylechangesincludingavoidingshavingorusingshavingcreamandasharprazorand
wearinglooseclothingtopreventfrictionalsocanbeincorporated.

KeyPoints
FolliculitisismostoftencausedbyStaphylococcusaureus,althoughotherbacteria,fungi,andherpesvirusescanalsoinducefolliculitis.
Treatmentoffolliculitisincludestopicalantibacterialagentssuchaschlorhexidine,topicalantibiotics,ororalantistaphylococcalantibiotics.

Abscesses/Furuncles/Carbuncles
Acarbuncleisasuperficialinflammatorymassconsistingofseveralinflamedhairfolliclesandmultiplesitesofdrainage.Afuruncleisaninfection
centeredonahairfolliclewithpusextendingintothedermisandformingasmallabscess.Anabscessconsistsofacollectionofneutrophilsand
purulentmaterialwithinthedermisorsubcutaneoustissue.Mostabscessesareinfectiousinorigin,althoughsterileabscessescanoccurinsome
inflammatoryconditions.Theseallpresentsimilarlywithaninflamed,tender,fluctuantdermalandsubcutaneousnoduleandassociatedwarmth
(Figure25).
Figure25.OpeninNewWindow

Theabscessischaracterizedbyapainful,inflamednodulewithsomebackgrounderythema.

Theerythemacanbeconfinedtotheimmediateareaoverridingthepurulentcollectionorcanexpandandrepresentasurroundingcellulitis.Purulent
drainagemaybeeasilyexpressed,andarimofscalecanoccasionallybeseen.Thedifferentialdiagnosisincludesaninflamedepidermalinclusionor
othercyst.Althoughinflamedcystscanhaveassociatederythema,theyoftenlackthefluctuanceobservedinabscesses.
Todiagnoseanabscess,furuncle,orcarbuncle,clinicalappearanceoftenissufficient.Incisionanddrainageofthelesionisnecessary.Culturefromthe
purulentmaterialisnecessarytoguidetherapyandestablishresistancepatterns.Forsmall,uncomplicatedabscesses,furuncles,andcarbuncles,local
therapywithincisionanddrainageandwarmcompressesmaybesufficient.Cultureisstillrecommendedwhendraininganabscessincaseantibiotics
arenecessary.Inimmunosuppressedpatientsorthosewithassociatedcellulitis,fever,systemicsymptoms,alargesize(>5cm),ormultipleabscesses,
systemicantibiotictherapyisalsorequired.Hospitalizationforinitiatingintravenousantibioticsmayberequireddependingontheclinicalfindings.
BecauseS.aureusisthemostcommonpathogeninabscesses,antistaphylococcalantibioticsaregenerallyindicatedpriortoobtainingcultureresults.
Thechoiceofantibioticsdependsonthelocalantibioticresistancepatterns.GiventheincreasedprevalenceofMRSA,antibioticseffectiveagainst
MRSA,includingtetracyclineclassantibiotics,clindamycin,andtrimethoprimsulfamethoxazole,areusedasfirstlinetherapy.
WhenpatientsarecolonizedwithMRSAorhaveclosecontactswithMRSA(suchasdaycarecenters,prisons,militarypersonnel,athletes,orpersons

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WhenpatientsarecolonizedwithMRSAorhaveclosecontactswithMRSA(suchasdaycarecenters,prisons,militarypersonnel,athletes,orpersons
whowererecentlyhospitalized),recurrentabscessescanoccur.Multiplerecurrentabscessesalsocanbeasignofsystemicimmunedisordersincluding
HIVinfectionorunderlyingdiabetesmellitus,andmaytriggerscreeningforthesedisorders.Stringenthygienepractices,suchasfrequentbathing,
keepinganysorescovered,andcleaningclothes,towels,andsurfaces,areimportant.AlthoughMRSAdecolonizationinthecommunityis
controversial,useofdilutebleachbathsorchlorhexidineandtopicalmupirocintothenaresmaybeattemptedwhenseriousrecurrentinfectionsor
repeatedinfectionsamongasmallcohortoccur.

MethicillinResistantStaphylococcusaureusinHospitalizedPatients
RelatedQuestion
Question27
Staphylococcusaureusisoneofthemostcommoncausesofhealthcareassociatedinfections,includingcatheterassociatedskinandsofttissue
infections.AnincreasingnumberoftheseinfectionsarefromMRSA.MRSAcarriespotentialforsignificantmorbidityandmortalityamonginfected
hospitalizedpatientsaswellasanincreasedrisktootherhospitalizedpatientsbecauseofitsvirulence,antibioticresistancepattern,andincreasing
prevalenceamonghospitalizedpatients,especiallyICU.
Hospitalsmandatevariedscreeningpractices,withnaresswabsbeingthemostcommonmethod,althoughdeterminingwhoneedstobescreenedis
controversial.EvidencesupportingMRSAscreeninganditsabilitytoreduceMRSAinfectionorhaveanimpactonmorbidityandmortalityislacking.
Someinstitutionsrequirescreeningofeveryadmittedpatient,whereasothersrequireitonlyforICUadmissionsorthoseadmittedwithaprior
colonizationhistory.ContactisolationprecautionsinadditiontouniversalprecautionsareoftenusedwithpatientswhoscreenpositiveforMRSA.
Decolonizationstrategiesforpatientswhoscreenpositivealsomaybeperformed,especiallyforcriticallyillpatients.Universaldecolonizationwith
twicedailyintranasalmupirocinfor5daysanddailybathingwithchlorhexidineinallICUpatientshasrecentlybeenshowntobeusefulinpreventing
moreinfections.
EmpiricantibiotictherapyagainstMRSAisoftenselectedformosthospitalizedpatientswithskinandsofttissueinfectionsuntilcultureresultsare
available.Knowledgeoflocalresistancepatternscanbehelpfulinselectinginitialtherapy.

Impetigo
RelatedQuestion
Question30
Impetigoisanacute,highlycontagious,andsuperficialskininfectioncausedbygrampositiveorganisms,specificallyS.aureusorStreptococcus
pyogenes,orboth.Itismostcommoninyoung,healthychildrenbutmayoccurinchildrenoradultsassuperinfecteddermatitis(impetiginizedlesions)
orinfectasiteofpriortraumasuchasaninsectbite.
Impetigocanbeeithernonbullousorbullousimpetigo.Nonbullousimpetigoisthemorecommontypeandoftenaffectsthefaceorextremities.It
presentsasvesicles,pustules,andsharplydemarcatedareaswithoverlyinghoneycoloredcrust(Figure26).
Figure26.OpeninNewWindow

Nonbullousimpetigoisasuperficialinfectioncharacterizedbyayellowish,crustedsurfacethatmaybecausedbystaphylococciorstreptococci.

BullousimpetigoisatoxinmediatedprocessusuallycausedbyproductionofanexfoliativetoxinbyS.aureus,whichinduceserythemaandlossofthe
superficiallayeroftheepidermis(Figure27).
Figure27.OpeninNewWindow

Clear,fluidfilledblisterswithsurroundingerythemaonthelegsofapatientwithbullousimpetigo.

Thesametoxinresponsibleforbullousimpetigocancausestaphylococcalscaldedskinsyndrome,whichresultsinerythrodermaandskinpeelingin
childrenoroccasionallyinadultswithacutekidneyinjury.
Thediagnosisofimpetigooftencanbemadebasedonclinicalpresentationhowever,cultureofthehoneycoloredcrustcanbeusedtoconfirmthe
pathologicorganismandobtainsensitivitytesting,whichisimportantwhentreatingextensivediseaseorstaphylococcalscaldedskinsyndrome.
Treatmentforimpetigoincludesbothtopicalandsystemictherapies.Topicalmupirocinoftenisfirstlinetherapy,andwasheswithchlorhexidineand
dilutedbleachbathsalsocanbeused.Formoreextensiveinfection,oralantistaphylococcalantibioticsareadministered.
Systemicinfectionfromimpetigoisuncommonhowever,ecthymaisavariantofimpetigocharacterizedbyanulcerativelesionwithanoverlying
escharthatextendsintothedermisandmaybeassociatedwithlymphadenitis.Ecthymadiffersfromcellulitisbecauseofthepresenceofanoverlying
ulcerationandescharandinvolvementofthedermis.Itisimportanttonotethatthisdiffersfromecthymagangrenosum,whichisahighlymorbid
infectioncausedbyPseudomonasaeruginosathatoccursinimmunosuppressedpatientsandcanbeassociatedwithhighmortalityrate.

Cellulitis/Erysipelas
RelatedQuestion
Question62
Cellulitisisanacute,nonnecrotizinginfectionoftheskinthatinvolvesthedeeperdermisandsubcutaneousfat,mostoftencausedbyStaphylococcus
orStreptococcusspp.Thisinfectionoftenresultsfromsuperficialbreaksortraumaintheskin.Thetraumamaybefromanobvioussource(arthropod
bite,laceration,tineapedis,onychomycosis)ormaybeamicroscopicbreakintheskinwithnovisibleincitingwound.Themostcommonlocationin
adultsisanextremity,butinchildrenincludestheheadandneck.Riskfactorsforthedevelopmentofcellulitisincludediabetesmellitus,olderage,
lymphedema,andperipheralvasculardisease.
Thediagnosisofcellulitisoftenismadebasedontheclinicalpresentationofawelldemarcatederythematousplaque.Thefourcardinalsignsare
erythema,pain,warmth,andswellingassociatedlymphadenopathycanoccur.Systemicsymptomsincludingfever,chills,andmalaisealsomaybe
present(Table13).Ausefulclinicaltoolistooutlinetheerythemawithamarkertomonitorprogressionofthelesion(Figure28).
Table13.OpeninNewWindowDifferentialDiagnosisofCellulitis
Disease

Cellulitis

ClinicalCharacteristics
Welldemarcatederythematousplaquewitherythema,pain,warmth,andswellingassociatedlymphadenopathycanoccur.Systemic
symptomsincludingfever,chills,andmalaise.Bilaterallowerextremitycellulitissuggestsanalternativediagnosis.

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Cellulitis

symptomsincludingfever,chills,andmalaise.Bilaterallowerextremitycellulitissuggestsanalternativediagnosis.

Stasis
dermatitis

Erythematous,scaly,andeczematouspatchesmostcommononthelowerextremitiesandaffectingbothlegswithassociated
hyperpigmentation.Findingscanpersistformonthstoyears.Themedialanklecanbemoreseverelyinvolved,andulcerationsare
commoninthisarea.Theerythemaalsocanbestriking,involvingtheankleandextendingtobelowtheknee.Sharpdemarcationoftenis
lesscommoninstasisdermatitis.Overlyingcellulitiscandevelopinthesettingofstasisdermatitis.

Contact
dermatitis

Pruritic,geometric,anderythematouspatcheswithsuperficialscaledifferentiatedfromcellulitisbypruritusasopposedtopain.

Panniculitis
Painful,erythematoussubcutaneous,illdefinednodulespresentbilaterally.Manypanniculitideswillresolvewithhyperpigmentation.The
(erythema
acuteonsetofpainanderythemamaybeconcerningforcellulitis,althoughdistinctsubcutaneousnoduleswouldbeunusual.
nodosum)
Deep
Pain,swelling,andassociatederythemaandwarmthinoneleg,withchangesoftenmoreprominentinthecalf.Abrightlyerythematous,
venous
welldemarcatedplaqueisnotoftenseen,althoughred,blue,orviolaceoussurfacechangescanbeseen.
thrombosis
Herpes
zoster

Groupedvesiculopustulesonanerythematouspatchorplaquelocalizedtoonearea(dermatome).Theerythemacanbewelldefined.The
presenceofgrouped,crustedvesiculopustulesorpunchedouterosionsisuncommonincellulitis.Bacterialsuperinfectioncanoccur.

Foracompletelistofpotentialentitiesonthedifferentialdiagnosisofcellulitis,pleaseseethebibliography.
Figure28.OpeninNewWindow

Cellulitisofthethigh.Thecardinalfeaturesofcellulitisincludeerythema,swelling,warmth,andpainintheaffectedarea.

Thepresentationofacutestasisdermatitismaymimiccellulitis,althoughthebilateralerythemaanddiscolorationseeninstasisdermatitiswouldbe
atypicalforcellulitis.Thedifferentialdiagnosisofcellulitisalsoincludescontactdermatitis,deepvenousthrombosis,andpanniculitis.Ifthediagnosis
isinquestion,askinbiopsycanbeperformed.Tissueculturesandbloodculturesareusuallynegativeinthesettingofcellulitis.Thesourceofinfection,
includingstasisdermatitis,trauma,abrasions,injectiondruguse,ortineapedis,shouldbeidentified.
FirstlinetherapyforcellulitiswithoutadrainingwoundorabscessisanantibioticwithcoverageagainstbothStreptococcusspp.andStaphylococcus
spp.withalactamantibioticsuchascephalexinordicloxacillin,clindamycin,oramacrolideantibioticcanbeused.A5daycourseofantibioticsisas
effectiveasa10daycourse.Ifthepatientfailstorespondtotherapy,thenexpandingcoverageforMRSAshouldbeconsideredorparenteralantibiotics
maybenecessary.Noninfectiouscausesoferythemaalsoshouldbeconsideredintreatmentfailurecases.Inpatientswithrecurrentcellulitis,lowdose
dailypenicillinalsocanhelppreventdiseaserecurrence.
Erysipelasisamoresuperficialinfectionofthelymphaticsthatoftenpresentsasaviolaceousred,edematous,welldemarcatedplaqueonthefaceor
lowerextremitiessecondarytogroupAstreptococci.Patientsareextremelyuncomfortableandoftenhavesystemicsymptomssuchasfeverand
malaise.Clinically,erysipelasmaymimicallergicairbornecontactdermatitishowever,contactdermatitiscausesmorediffuseerythema,andpatients
maybeuncomfortablebutnotsystemicallyill.Becauseerysipelasisoftenduetostreptococcalinfection,firstlinetreatmentiswithpenicillin.

KeyPoints
Cellulitisisanacute,nonnecrotizinginfectionoftheskin,presentingaswelldemarcatederythematousplaquewitherythema,pain,warmth,
swelling,andassociatedlymphadenopathy.
FirstlinetherapyforcellulitiswithoutadrainingwoundorabscessisacourseofantibioticsagainstbothStreptococcusspp.andStaphylococcus
spp.(cephalexinordicloxacillin,clindamycin,oramacrolide)a5daycourseofantibioticsisaseffectiveasa10daycourse.
Erysipelasisaninfectionoftheupperdermisandsuperficiallymphaticsthatoftenpresentsasaviolaceousred,edematous,welldemarcated
plaqueontheface.

Erythrasma
ErythrasmaisabenignconditioncausedbyasuperficialinfectionwithCorynebacteriumminutissimum.Theinfectioncanbeasymptomaticormildly
pruriticandischaracterizedbysymmetric,pinktobrownpatcheswiththinscaleandanoverlyingwrinkledappearanceandmacerationinintertriginous
areassuchastheaxillae,groin,inframammaryareas,andinterdigitalspaces(Figure29).
Figure29.OpeninNewWindow

Erythrasmapresentswithsharplydemarcated,finepinktobrownscalingpatchesthataretypicallyfoundinskinfoldareas.

ErythrasmawillfluorescetoacoralredcolorwithaWoodlampexaminationbecauseofbacterialporphyrinproduction,whichisahelpfulfeaturein
differentiatingitfromothercausesofintertrigo.Firstlinetreatmentoferythrasmaisatopicalantibacterialagentsuchaserythromycin,clarithromycin,
clindamycin,benzoylperoxide,orfusidicacid.Oralagentsincludingclarithromycinanderythromycinalsocouldbeconsideredinpatientswith
extensivedisease.

PittedKeratolysis
RelatedQuestion
Question7
Pittedkeratolysisisabenign,superficialbacterialinfectioncharacterizedbysmallpitsprimarilyontheplantaraspectsofthefeetorpalmaraspectsof
thehandsinasettingofincreasedperspiration(Figure30).ThisismostoftencausedbyKytococcussedentarius,Corynebacteriumspp.,or
Actinomycesspp.Althoughpittedkeratolysisismostlyasymptomatic,anodorandscalingcanbeassociatedwiththiscondition.Treatmentrequires
decreasingperspirationbydryingthefeetwithmechanicalmethodsorantiperspirants.Topicalclindamycinanderythromycinalsoarefirstline
antibacterialagentstocleartheinfection.
Figure30.OpeninNewWindow

Multiplesuperficialpitsontheplantarsurfaceofthefootinapatientwithkeratolysis,acharacteristicmalodorousconditioncausedbyKytococcus
sedentarius,Corynebacteriumspp.orActinomycesspp.

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SuperficialFungalInfections
SuperficialfungalinfectionsarecommonandtypicallyarecausedbydermatophytesorCandidaspp.Thedifferentiationofsuperficialinfectionsfrom
deeperorangioinvasivefungalinfectionsthatcanoccurinimmunocompromisedpatientsisimportant,asthepresentation,prognosis,andtreatmentare
dramaticallydifferent.Superficialfungalinfectionsbydermatophytesinfectonlythemostsuperficiallayersoftheskin(stratumcorneum,rarely
epidermisandhairfollicles).Angioinvasivefungalinfections,incontrast,haveapredilectionforsuperficialanddeepbloodvesselsandwillpresentas
violaceoustopurple,necroticpatchesornodules,anddeepfungalinfectionswilloftenhavebothcutaneouschanges,suchasumbilicatedorverrucous
papules,andsystemicinvolvement,oftenofthelungs.

Tinea
RelatedQuestion
Question65
Therearevariedpresentationsofdermatophyteinfections,rangingfrommildtoseveremanifestations.Tineaiscategorizedaccordingtotheareaofthe
bodythatisimpacted,anddifferenttypesofdermatophytesoftenareresponsiblefortherespectiveinfections.
Tineacapitisisinfectionofthehairfollicles,typicallyofthescalp,althougheyebrowsandeyelashescanbeinfected.Thisismostcommoninchildren
andcanpresentwithalopecicareas,brokenhairshafts,andscaling.Akerioncanresultfromatineacapitisinfectionandismanifestedbyaboggy,
edematousscalpwithoverlyingpustules(Figure31).Associatedcervicallymphadenopathyiscommonandisausefulclinicalmanifestationto
differentiatefromseborrheicdermatitisorothercausesofalopecia.Inchildren,washingordisposalofitemsincontactwiththescalp(combs,hats,
razors)isessentialtopreventreinfection.
Figure31.OpeninNewWindow

Kerionisaresultoftineacapitisinfectionofthehairfolliclesofthescalp.Itisasevere,painfulinflammationthatappearsasraised,pusfilled
abscesses.

Tineacorporisclassicallypresentsaspruritic,annularerythematouspatcheswitharimofscale(ringworm).Riskfactorsincludeclosecontactin
athletes,contactwithanimals,andimmunosuppression.Majocchigranuloma,anerythematousplaquewithoverlyingpustulesandpapules,isa
granulomatousresponsetodermatophyteinfectioninthedermisandhairfollicles(Figure32).Riskfactorsincludetopicalglucocorticoiduseand
shavingoflegsinwomen,whichcausesspreadoftheorganism.Inimmunocompromisedpatients,widespreadinvolvementwithvariedpresentations
mayoccur.
Figure32.OpeninNewWindow

Majocchigranulomapresentsasanannularplaquewitherythemathatisstuddedwithpustulesandpapulesandisareactiontoadermatophyteinfection
inthedermisandhairfollicle.

Tineacruris(jockitch)isdermatophyteinfectionoftheinguinalfolds(Figure33).Itpresentsaserythematouspatcheswitharimofscaleand
characteristicallydoesnotinvolvethescrotum,incontrasttocandidalintertrigo,whichcaninvolvethescrotum.
Figure33.OpeninNewWindow

Tineacruris,adermatophyteinfectionofthegroin,pubicregion,andthighs,manifestswithpatchesoferythemawithsharplydemarcatedserpiginous
bordersandscaleattheadvancingedges.Involvementofthescrotalskinwiththeshinyerythemaandtelangiectasiasseeninthisimagedemonstrates
thehazardsoftreatingtineawithtopicalglucocorticoids.

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Althoughtineacrurisismorecommonlyseeninmen,bothmenandwomencandevelopthisinfection.Thepresenceoftineacrurisalsonecessitates
examinationofthefeetasconcomitanttineapedisinfectionisnotuncommon.
Tineapedisisdermatophyteinfectionthatpresentswithaflakyscaleinvolvingtheplantaraspectofthefeetandextendingtothesidesinamoccasin
distribution(Figure34).Interdigitalinvolvementwithscaling,maceration,andfissuringalsoischaracteristic.Associatedonychomycosiscausedbythe
sameorganismiscommon.Tineamanuumisafungalinfectionofthehands.Twofeet,onehandtineaisacommonpresentationofconcomitanttinea
pedisandtineamanuum.Variantsofdermatophyteinfectionalsocanoccur.Bulloustineapresentswithtensebullae,oftenontheextremities,and
representsanexuberantreactiontodermatophyteinfection.Withextensiveinfections,anassociatedhypersensitivityreaction,adermatophytid
reaction,canoccurawayfromthesiteofinfection.Forexample,handdermatitisalsocanoccurinpatientswithextensivetineapedis.
Figure34.OpeninNewWindow

Erythematouspatcheswithascalingrimandassociatedonychomycosis(thickeningofthenails)isseenintineapedis.

Tineanigraisanotherdermatophyteinfectionpresentingasahyperpigmented,scalypatch,oftenonthepalmaraspectofthehands.
Diagnosisofdermatophyteinfectioncanbeperformedbyexaminationofthescale,nailplate,orhairfollicleusingapotassiumhydroxide(KOH)or
chlorazolblacksolution.Thepresenceofbranchinghyphaeisdiagnostic.Dermatophytecultureorbiopsyalsocanbeperformediftheclinical
presentationisunusual,ifconfirmationofthediagnosisisneeded,orifKOHexaminationisequivocal.
Treatmentofmostsuperficialdermatophyteinfectionsincludestopicalantifungalagentssuchasmiconazole,clotrimazole,ketoconazole,orterbinafine.
Overthecounterpreparationsarecosteffectiveoptionswithgoodefficacy.Nystatinisnoteffectiveagainstdermatophytesandshouldnotbeused.
Combinationtherapywithtopicalglucocorticoidsandantifungalcreamsshouldbeavoidedbecauseofanincreasedriskoftreatmentfailures,
developmentofskinatrophywithprolongeduse,andincreasedcostwithoutincreasedefficacy.Oralantifungaltherapywithterbinafineoranazole
antifungalagentmaybenecessaryfortreatingtineacapitis,onychomycosis,Majocchigranuloma,orextensiveinfection.Oralketoconazoleshouldnot
generallybeusedbecauseofthepotentialforseverelivertoxicityandadrenalglandsuppression.Inchildren,oralgriseofulvinfortineacapitisalsomay
beused.Tineapediswillrespondto2to4weeksoftopicalantifungaltherapy,buteffectivetreatmentofonychomycosisoftenrequires12weeksoforal
therapy.Mostinfectionswillresolvebutmayrecurandrequireretreatment.Inimmunosuppressedpatients,recognitionandtreatmentofsuperficialskin
fungalinfectionsisessential,asfungalinfectionscanleadtoepidermalbreakdownandcreateaportalofentryforinvasivepathogens.
TineaversicolorisanothersuperficialfungalinfectioncausedbyMalasseziafurfur(formerlyPityrosporum)andismostcommoninwarm,humid
environments.Itpresentsashypopigmented,hyperpigmented,orpinkpatchesthataredryandslightlyscaly.Althoughthepatchescanoccuranywhere,
theneck,upperback,andchest,withextensiontotheabdomenorextremities,arecommonlyaffected(Figure35).Theseareasoftenbecomemore
noticeableafterexposuretothesunbecausetheorganismpreventstheskinfromtanning.Thistypeofsuperficialinfectionisnotcontagious.Aformof
folliculitisalsooccurs(Malasseziafolliculitis).Diagnosiscanbemadeclinicallyhowever,yeastsporesandshorthyphaecanbeeasilyobservedwith
KOHexamination(spaghettiandmeatballsappearance).Differentialdiagnosisincludesvitiligo,postinflammatorypigmentation,seborrheic
dermatitis,andpityriasisalba.Treatmentoftineaversicolorwithtopicalantiseborrheicshampoosorlotionssuchasseleniumsulfideorketoconazole
leadstoresolutionoferythemaandscaling,butthepigmentationchangesmaypersistforlongerperiodsoftime.Recurrenceiscommon,and
retreatmentandpreventionwithtopicaltherapyoftenisnecessary.Withwidespreadinvolvement,shortcoursesoforalazoleantifungalagents(withthe
exceptionofketoconazoleasnotedearlier)maybenecessary.
Figure35.OpeninNewWindow

Small,lightbrowntopinkcoalescingmaculeswithfineoverlyingscaleontheanteriorchestcharacteristicoftineaversicolor.

KeyPoints
Diagnosisofdermatophyteinfectioncanbeperformedbyexaminationofthescale,nailplate,orhairfollicleafterpreparationwithpotassium
hydroxide(KOH)orchlorazolblacksolutionthepresenceofbranchinghyphaeisdiagnostic.
Treatmentofmostsuperficialdermatophyteinfectionsincludestopicalantifungalagentshowever,overthecounterpreparationsarecost
effectiveoptionswithgoodefficacy.

Candidiasis
Cutaneouscandidiasiscanpresentinmultipleways:intertriginousareas(Figure36),oralinvolvementasoralthrushorangularcheilitis,vulvovaginal
candidiasis(Figure37),anddisseminateddiseaseinimmunocompromised,hospitalizedpatients(seeMKSAP17InfectiousDisease).
Figure36.OpeninNewWindow

Brightredpapules,vesicles,pustules,andpatcheswithsatellitepapulesintheintertriginousareasunderthebreastscharacteristicofcandidiasis.

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Figure37.OpeninNewWindow

Acutevulvarcandidiasispresentswitherythemaandedemaofthevulvawithsatellitepapulesandpustules.Associatedinvolvementofthevaginal
mucosaischaracterizedbyadischargethatmaybethick,adherent,andcottagecheeselikeorthinandloose,indistinguishablefromthedischargeof
othertypesofvaginitis.

Cutaneouscandidiasisclinicallypresentsasbrightredpatcheswithsatellitepapulesandpustulesinintertriginousareas.Involvementofthevulvaand
scrotumiscommon.Associatedvaginalinvolvementcanbecharacterizedbyadischargethatmaybethick,adherent,andcottagecheeselikeorthin
andloose,indistinguishablefromthedischargeofothertypesofvaginitis.Riskfactorsincludechronicmoistureandhyperhidrosis,andthismaybe
morecommoninfebrile,hospitalizedpatients.Diagnosiscanbemadeclinically,andKOHexaminationshowingpseudohyphaeandsporescanalsobe
diagnostic.Reducingfrictionandmoisturewithbarrierpastesandpowderssuchaszincoxideareimportant.Treatmentwithtopicalazoleantifungal
agentsisthepreferredfirstlinetherapy.AlthoughnystatiniseffectiveagainstCandidaspp.,itisnoteffectivefordermatophyteinfection.Topical
azolesshouldalsobeusedforsuperficialfungalinfectionsinintertriginousareas.Withconcomitantvulvarandvaginalinvolvement(characterizedby
associateddischarge),cutaneouscandidiasismaybetreatedwithoralantifungalagentsortopicalandintravaginalpreparations.

ViralSkinInfections
HerpesSimplexVirus
RelatedQuestion
Question50
Thefamilyofhumanherpesvirusescausesnumerouscutaneousinfectionsincludingherpessimplexvirus1(HSV1),herpessimplexvirus2(HSV2),
andvaricellazosterviralinfections(VZVorhumanherpesvirus3[HHV3]).Becausetheyarecloselyrelated,theprimaryskinlesionsaresimilar.The
classicpresentationisagroupofpainful,smallvesiclesonanerythematousbase,transitioningtopustulesandsubsequentcrustingofthelesionsover
time(Figure38).
Figure38.OpeninNewWindow

Herpessimplexviralinfectioncharacterizedbygroupedvesicopustulesonanerythematousbasethattypicallyhaveassociatedtinglingorpain.

Becausetheviruseshaveatropismforthenervedorsalrootganglia,theymigratetothisareaafterinitialinfectionwheretheycanremainlatentand
causesubsequentreinfectionandrecurrences.Phasesofinfectionincludeprimaryinfection(whichoftenismostsevere),latentinfectionintheganglion
whenviralsheddingcanstilloccur,andviralreactivationleadingtoaclinicaloutbreak.
TheprimarylesionsofHSV1andHSV2areclinicallyindistinguishable.HSV1traditionallycausesorofaciallesions,andHSV2mostoftencauses
genitallesionshowever,bothvirusescanleadtoeitheroralorgenitallesions.Herpesinfectionoutsideoftheseareascanoccur,includinginfectionon
thefingersofchildren(herpeticwhitlow)orinexposedskinasaresultofskintoskincontact,suchasincontactsportslikewrestling(herpes
gladiatorum).Diffuseinfectioncanoccurinthesettingofanunderlyingskindisease,suchaseczema(eczemaherpeticum).Thevirusesarehighly
contagious,andtransmissionisbydirectcontactofsalivaryorgenitalsecretions.Asymptomaticviralsheddingcanoccur.Outbreakscanbetriggered
bystress,feverorotherinfection,andultravioletlightexposure.Associatedmanifestationsalsocanoccur,includingerythemamultiforme.
Primaryoralherpessimplexvirusinfection(herpesgingivostomatitis)canpresentasamildorasymptomaticinfectionorcanbeseverewithfever,
malaise,lymphadenopathy,andwidespreadpainfulvesiclesanderosionsonthecutaneousandmucosallipsandgingiva(Figure39).Secondary
infectionwithCandidaalsocanoccur.Recurrentherpeslabialisoftencausesprodromalpainandstinging,followedbysolitarylesionsonthevermilion
border(coldsores).
Figure39.OpeninNewWindow

Primaryherpessimplexvirusonthesidesofthemouth.

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Mostprimarygenitalherpesinfectionsareasymptomatic,withupto70%to80%ofseropositivepersonshavingnorecollectionofinitialinfection.
Severeinitialpresentationsalsocanoccurwithfever,malaise,tenderlymphadenopathy,andpainfulerosionsthatcanbesecondarilyinfectedandlead
toaninabilitytourinateordefecate.Recurrentgenitalherpesissimilartooralherpeswithaprodrome,followedbygroupedvesiclesonan
erythematousbase,erosions,andcrusting.Involvementofthegenitalsandbuttockscanoccur.Immunocompromisedpatientscanhavesevere
presentationsofbothoralandgenitalherpes,includingpersistentverrucousnonhealingulcers.
Thedifferentialdiagnosisofgenitalulcersisimportantbecauseothersexuallytransmittedinfectionsmustbeconsidered(includingsyphilis,chancroid,
granulomainguinale,lymphogranulomavenereum).HSVisthemostcommoncauseofpainfulgenitalulcers,althoughchancroidalsocausespainful
ulcers.Otherinfectionsoftencausenonpainfululcerations(seeMKSAP17InfectiousDisease).Withanysexuallytransmittedinfection,HIVtesting
alsoisimportant.
DiagnosisofHSVcanbemadeclinically,butseveraltestsalsoareavailable.AlthoughtheTzancksmearwastraditionallyusedtoconfirmthepresence
ofaHIV,difficultieswithreliableinterpretationanditsinabilitytodistinguishbetweenHSV1,HSV2,andvaricellainfectionshaveledtotheuseof
otherdiagnosticmethods.Rapidtestsarewidelyavailablesuchasdirectfluorescentantibody(DFA)andpolymerasechainreaction(PCR)studiesthat
canprovideresultsinlessthan24hoursandcandifferentiatebetweentheviruses.Toadequatelyperformthesetests,avesicleneedstobeunroofed,and
materialfromtheblisterbase(wherethevirusispresent)issentforexamination.Viralculturehastraditionallybeenthegoldstandardfordiagnosis,but
theculturecantake48hoursorlongertobeinterpreted.Cultureisstillvaluableifresistancetestingisnecessaryinpatientswithrecalcitrantorchronic
infections(typicallyimmunocompromisedpatients).Serologictestingisnotrecommendedfordiagnosisbecauseseroprevalenceratesarehighanddo
notcorrespondwithactiveinfection.
Oralantiviralagentsareconsideredfirstlinetherapiesforherpessimplexvirusinfectionandaremosteffectiveifinstitutedatpresentationofthe
prodromeofanoutbreak.Oralantiviralagentsincludingacyclovir,valacyclovir,andfamciclovirareconsideredfirstlinetherapies,anddoseand
durationoftreatmentaredependentonthetypeandextentofinfection(primaryversusrecurrent).Topicaltherapiesarelesseffectiveinimproving
symptomsandreducingdiseaseduration.Withfrequentoutbreaks,dailysuppressivetherapyalsocanbeinstituted.

KeyPoints
Theclassicpresentationofherpessimplexviralinfectionsisagroupofpainful,smallvesiclesonanerythematousbase,transitioningtopustules
andsubsequentcrustingofthelesionsovertime.
Oralantiviralagentsareconsideredfirstlinetherapiesforherpessimplexvirusinfectionandaremosteffectiveifinstitutedatpresentationofthe
prodromeofanoutbreak.

Varicella/HerpesZoster
RelatedQuestion
Question37
Varicellazosterviralinfections(VZV)caneitherbeprimary(chickenpox)orreactivation(herpeszoster).Primaryvaricellaoftenisseeninchildrenor
youngadults,butisnowseenlessfrequentlybecauseofvaccinationofyoungchildren.
Herpeszoster(shingles)iscausedbythereactivationoflatentVZV.Shinglestypicallypresentswithgroupedvesiclesonanerythematousbaseina
singledermatome(Figure40andFigure41).Elderlypersonsandimmunocompromisedpatientsareatincreasedrisk,andrecurrentoutbreaksofherpes
zostershouldpromptanevaluationforpossiblemalignancyorimmunodeficiency.Lesionsareinfectiousuntiltheybecomecrustedover,andpersons
withherpeszostershouldavoidcontactwithotherswhomaybesusceptibleincludingpregnantwomenorimmunocompromisedpersons.
Figure40.OpeninNewWindow

Herpeszosterinfectioncharacterizedbyvesicopustulesonanerythematousbaseinadermatomaldistribution.

Figure41.OpeninNewWindow

Herpeszosterinfectionontheflankwithgroupedvesiclesandpunchedouterosionsonanerythematousbase.

Theclinicalpresentationofherpeszosterischaracteristic.Prodromalsymptoms,suchasburning,stinging,ortingling,oftenoccurinalocalizedregion,
followedbyaneruptionofgroupedvesiclesorpustulesonanerythematousbase.Theoutbreakisunilateralanddoesnotcrossthebody'smidline.The
mostcommondermatomesaffectedareinthethoracicregion.Facialinvolvementmayrequirefurtherevaluation.Withinvolvementofthefirstdivision
ofthetrigeminalnerve(foreheadextendingoveruppereyelid,ornasaltipinvolvement),ophthalmologicevaluationismandatoryasherpeszoster
ophthalmicusandpossibleblindnesscanresult.Evaluationbyanotolaryngologistmayberequiredifvesiclesarenotedintheexternalearcanal,as
peripheralfacialparalysisandauditory/vestibularsymptomscanoccur(RamsayHuntsyndrome).Differentiationbetweengenitalherpesandherpes
zosterinthesacraldermatomesalsomaybedifficult.Diagnosiscanbemadeclinically,orthetestspreviouslyoutlinedcanbeused.
DisseminatedVZVmustbeconsideredwhenmorethanthreedermatomesareaffectedormorethan20lesionsoutsideofadjacentdermatomesare
present.Thisismorecommoninimmunocompromisedpersonswhoareatriskforassociatedhepatitisorpneumonia.
Oralacyclovir,valacyclovir,orfamcicloviriseffectivefortreatingherpeszosterifinitiatedwithin24to48hoursofpresentationandcanshortenthe
diseasecourseaswellashelppreventpostherpeticneuralgia.Ifpostherpeticneuralgiadevelops,gabapentin,pregabalin,tricyclicantidepressants,or
topicalanestheticssuchastopicallidocaineandcapsaicincanbehelpful.Treatmentwithgabapentinatpresentationofherpeszosteralsomayreduce
theriskofpostherpeticneuralgia.Ashinglesvaccineisavailabletodecreasetheincidenceofherpeszosterreactivationanddecreasetheseverityand
durationofpostherpeticneuralgia.Thevaccineisindicatedforpersons60yearsofageandolder.However,itisaliveattenuatedvaccineandisnot
recommendedinimmunosuppressedorpregnantpersons(seeMKSAP17GeneralInternalMedicine).

KeyPoints
Herpeszoster(shingles)iscausedbythereactivationoflatentvaricellazostervirusandoftenpresentswithgroupedvesiclesonanerythematous
baseinasingledermatome.
Whenherpeszosterinvolvesfirstdivisionofthetrigeminalnerve(foreheadextendingoveruppereyelid,ornasaltipinvolvement),
ophthalmologicevaluationforeyeinvolvementismandatoryasblindnesscanresultwhenmorethanthreedermatomesareinvolvedconsider
treatmentfordisseminatedvaricellazosterviralinfections.
Oralacyclovir,valacyclovir,orfamciclovir,ifinitiatedwithin24to48hoursofpresentation,canshortenthecourseofherpeszosterandhelp
preventpostherpeticneuralgia.

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Warts
RelatedQuestion
Question11
Wartsareaninfectionofskinandmucosacausedbyhumanpapillomavirus(HPV).TherearenumerousdifferentHPVsubtypes,whichmayhavea
predilectionfordifferentanatomicsites.HPViscontagiousandspreadbydirectskincontactorcontactwithinfectedsurfaces,andselfinoculation
withinanindividualcanoccur.Therearemanypresentationsofwartsdependingonthesiteandclinicalappearance.Verrucavulgarisisanexophytic,
hyperkeratoticpapulethatoftendevelopsonthehandsbutmaybefoundanywhere(Figure42).Verrucaplantarisischaracterizedbylarger,
hyperkeratoticlesionsontheplantarsurfaceofthefeetthatcanbedifficulttotreat.Differentiationfromcallusesispossiblebecausewartscausedilated
capillaries,whichclinicallypresentasblackdotsandobliterationofnormaldermatoglyphics(ridgesandfurrowsontheskinsurfaceformingloops,
whorls,andarches).Flatwarts(verrucaplana)areflattoppedpapulesthatoftenarespreadeasily,especiallyfromshaving.
Figure42.OpeninNewWindow

Verrucavulgarislesionsaresmall,skincoloredgrowths,oftenoccurringinclusters,andarecausedbythehumanpapillomavirus.

Anogenitalwarts(condylomataacuminata)arethemostcommonsexuallytransmittedinfectionandaremostoftencausedbyHPVtypes6and11.They
presentassingleormultiplepapulesonthepenis,vulva,orperianalareaandmaybevariablysizedflattoppedorcauliflowerlikepapules(Figure43).
Lesionsarediagnosedbasedonclinicalappearance,butlarge,atypicallesionsorthoserecalcitranttotherapyshouldbebiopsiedtoruleout
premalignantormalignanttransformation.
Figure43.OpeninNewWindow

Typicalanogenitalwarts(condylomaacuminata)overthepenileshaftandforeskinwithadjacenterosionsafterimiquimodtherapy.

Althoughwartsmayresolvespontaneously,treatmentoftenisrequired.Overthecounterpreparationsofsalicylicacidorwartremovercanbeeffective.
Ifresolutiondoesnotoccur,additionaldestructivetechniquescanincludecryotherapy,topicalapplicationofprescriptionstrengthsalicylicacid,
cantharidin,podophyllin,orlasertherapy.Paringofthehyperkeratosesassociatedwithawartmaybenecessarytoincreasethetherapeuticeffect.
Immunetherapies,includinginjectionofCandidaantigenandtopicalimiquimod,alsocanbeeffective.Surgicalremovaloflarge,bulkylesionsalso
canbeused.Numeroustherapieshavebeenreportedtobeeffective,butcontrolledtrialsarelackingtocomparemodalities.
HPVvaccinationisrecommendedforyoungpersons(bothfemaleandmale)ages9to26yearstopreventcervicalandanalcarcinoma.Anogenital
wartsalsocanbepreventedifthevaccineiseffectiveagainstHPV6and11(seeMKSAP17GeneralInternalMedicine).Itisunclearwhetherthe
vaccineconfersprotectionagainstotherstrainsofHPV.

MolluscumContagiosum
Molluscumcontagiosumisacommonpoxvirusinfectionamongchildren,youngadults,andimmunosuppressedpersons.Inchildren,itpresentsas
multiplesmall,fleshcoloredumbilicatedpapules(Figure44).Inflamedorlargelesionsandasurroundingeczematousdermatitiscanbeobserved.In
youngadults,molluscumcontagiosumisconsideredasexuallytransmittedinfectionthatalsocausessimilarumbilicatedpapulesinthegenitalarea.
Diagnosiscanbemadebytheclinicalappearance.Althoughlesionscanselfresolve,thismaytakemonthstoyears.Becauselesionsareextremely
contagious,treatmentisrecommended.Therapyincludesdestructivetechniquesincludingcryotherapy,salicylicacid,cantharidin,orphysicalremoval
withcurettage.
Figure44.OpeninNewWindow

Molluscumcontagiosum,withpinkpapulesthathaveacentralumbilication.

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Bibliography
AvciO,TanyildiziT,KuskuE.Acomparisonbetweentheeffectivenessoferythromycin,singledoseclarithromycinandtopicalfusidicacidin
thetreatmentoferythrasma.JDermatolTreat.2013Feb24(1):704.PMID:21923567
CohenJI.Clinicalpractice:herpeszoster.NEnglJMed.2013Jul18369(3):25563.PMID:23863052
DaumRS.Clinicalpractice:skinandsofttissueinfectionscausedbymethicillinresistantStaphylococcusaureus.NEnglJMed.2007Jul
26357(4):38090.PMID:17652653
GormleyRH,KovarikCL.Humanpapillomavirusrelatedgenitaldiseaseintheimmunocompromisedhost:partI,II.JAmAcadDermatol.2007
Jul26357(4):38090.PMID:22583721
GuptaAK,BatraR,BluhmR,BoekhoutT,DawsonTLJr.SkindiseasesassociatedwithMalasseziaspecies.JAmAcadDermatol.2004
Nov51(5):78598.PMID:15523360
HuangSS,SeptimusE,KleinmanK,etal.TargetedversusuniversaldecolonizationtopreventICUinfection.NEnglJMed.2013Jun
13368(24):225565.PMID:23718152
LiuC,BayerA,CosgroveSE,etal.ClinicalpracticeguidelinesbytheInfectiousDiseasesSocietyofAmericaforthetreatmentofmethicillin
resistantStaphylococcusaureusinfectionsinadultsandchildren.ClinInfectDis.2011Feb152(3):28592.PMID:21217178
MoriartyB,HayR,MorrisJonesR.Thediagnosisandmanagementoftinea.BMJ.2012Jul10345:e4380.PMID:22782730
OonSF,WinterDC.Perianalcondylomas,analsquamousintraepithelialneoplasmsandscreening:areviewoftheliterature.JMedScreen.
201017(1):449.PMID:20356945
RigopoulosD,LariosG,GregoriouS,AlevizosA.Acuteandchronicparonychia.AmFamPhysician.2008Feb177(3):33946.PMID:
18297959
ThomasKS,CrookAM,NunnAJ,etal.Penicillintopreventrecurrentlegcellulitis.NEnglJMed.2013May2368(18):1695703.PMID:
23635049
ThiscontentwaslastupdatedinMarch2016.Moredetails

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