Impetigo

contagious superficial bacterial infection of the skin

Types : 1) bullous 2) Non-Bullous 3) ecthyma
caused by staphylococcus aureus / Group A streptococcus
transmitted by direct contact
 Clinical Presentation
Nonbullous (IMPETIGO CONTAGIOSA)
- begins as a single lesion typically manifesting as red macule/papule
that quickly becomes vesicle.
-ruptured vesicle will dry to form the characteristic honey-coloured
crust
- face & extremities
-benign, self limiting process , resolves witihin 2 week without scarring
- complication : acute post-steptococcal glomerulonephritis
Bullous
- Bullous impetigo begins as a superficial vesicle (1-2cm) that rapidly
progresses to a flaccid bulla (5cm), with sharp margins and no
surrounding erythema.
- When the bulla ruptures, a moist yellow crust forms.
-usually arises on grossly normal skin and favors moist intertriginous
areas, such as the diaper area, axillae, and neck folds.
-resolves within 3-6 weeks without scarring
-complication : staphylococcal scalded skin syndrome
Ecthyma (ulcerative impetigo)

-usually begins as a vesicle (small blister) or pustule on an inflamed area of skin.

-A hard crust soon covers the blister.
-the crust can be removed to reveal an indurated ulcer that may be red, swollen
and oozing with pus.
-Lesions may stay fixed in size and sometimes resolve spontaneously without
treatment, or they may gradually enlarge to a sore of 0.53 cm in diameter.
-resolve slowly leaving a scar
-affects buttocks, thighs, legs, ankle and feet.
-complications: cellulitis,erysipelas, lymphangitis, gangrene, lymphadenitis, and
bacteraemia,Permanent scarring
Rarely, post-streptococcal glomerulonephritis
 lab diagnosis (history and clinical manifestation)
- bacterial culture and sensitivity - positive S.aureus or steptococci
-APSGN - elavated antideoxyribonuclease B (anti-DNase B) and
antihyaluronidase (AH) titers &antistreptolysin O
-urinalysis - is necessary to evaluate for APSGN if the patient develops
new-onset edema or hypertension. Hematuria, proteinuria, and
cylindruria are indicators of renal involvement.
 Management
The superficial crusts should be removed with gentle cleansing with an antibacterial
soap. Wet dressings could also be applied to remove thicker crusts
Localized impetigo can be treated with topical medications including:
Bacitracin ointment 3 times a day for 3 to 5 days.
Mupirocin (Bactroban) ointment 3 times a day for 3 to 5 days.
Retapamulin (Altabax) ointment twice a day for 5 days.
Severe or more widespread impetigo may require oral antibiotics, such as first-
generation cephalosporins, dicloxacillin, amoxicillin/clavunate, or azithromycin.
Impetigo usually responds well to treatment, but may be recurrent.
Dermatophyte Infection
Introduction :
Dermatophyte infection( ringworm ) caused by
1) Microsporum : canis, audouinii , gypseum
2) Trichophyton : rubrum,verrucosum, schoenlenii ,tonsurans , mentagrophytes
3) Epidermophyton : floccosum

Fungal can originate from soil (geophilic), animal(zoophilic) or human

skin(anthropophilic)

Major clinical subtypes of dermatophyte infections are:

I. Tinea corporis Infection of skin
II. Tinea pedis Infection of the foot
III. Tinea cruris Infection of the groin
IV. Tinea capitis Infection of scalp hair
V. Tinea unguium (onychomycosis) Infection of the nail
Tinea Corporis
Lesion :
i. erythematous
ii. annular
iii. scaly
iv. well-defined edge
v. central clearing
vi. asymmetrical
vii. single or multiple
Organisms : Microsporum
canis, Trichophyton
verrucosum
#If a cutaneous dermatophyte infection is misdiagnosed and treated with topical corticosteroid, the
appearance of the infection may be altered = tinea incognito*
*diminished erythema and scale, loss of a well-defined border, exacerbation of disease, or a deep-seated
folliculitis (Majocchi's granuloma)
 Tinea Cruris
Itchy, erythematous semicircular
plaque with sharply defined
scaly boarder in the medial
aspects of groins
extend to thigh, with a raised
active edge
caused by Trichophyton
rubrum,E. floccosum
Tinea Pedis (Athlete's Foot)
Itchy rash between toes
with peeling, fissuring and maceration
3 pattern : Interdigital , Moccasin, Vesiculobullous
caused by T.rubrum, T.interdigitale, Epidermophyton floccosum
# Involve one sole or palm + fine scaling = characteristic of T.rubrum infection
# Vesiculation or blistering = T.mentagrophytes
 Interdigital pattern with scales, fissures, or maceration or malodor
usually in the fourth and fifth web spaces
Moccasin pattern with diffuse, dry, silvery white scale
Vesiculobullous pattern with vesicles and/or bullae on the plantar
surface, especially instep areas, accompanied by inflammation and
tenderness
Tinea Capitis
Dermatophyte infection of scalp hair shafts
presents as scalp inflammation + scaling + pustules + partial hair loss
1) Infection within shaft (Endothrix)
organism : T.tonsurans
patchy hair loss
broken hairs at surface ('black dot')
little inflammation
No fluorescence with Wood's light
2) Infection outside hair shaft (Ectothrix)
organism : M.canis, M.audouinii
more inflammation
identify by green fluorescence with Wood's light

# Kerion- boggy, pus filled skin lesion on the inflammatory area of tinea capitis
caused by T.verrucosum
There are 6 patterns of tinea capitis:
Dandruff-like adherent scale, with no alopecia
Areas of alopecia dotted with broken hair fibers that appear like black
dots
Circular patches of alopecia with marked gray scales.This is most
commonly seen in Microsporum infections
Moth-eaten patches of alopecia with generalized scale
Alopecia with scattered pustules
Kerion, a boggy, thick, tender plaque with pustules that is caused by a
marked inflammatory response to the fungus. This is often misdiagnosed
as a tumor or bacterial infection
 Tinea unguium (Onychomycosis)
Fungal infection of nail plate 4 major pattern :
Distal subungual
Present with : prximal subungual
white superficial
yellow/brown nail discoloration candida
crumbling
thickening
subungual hyperkeratosis
Diagnosis and Treatment :
Skin scraping, hair plucking, nail clipping
confirm diagnosis by microscopy and culture
Topical antifungals :
a) Terbinafine
once or twice/day for 1-3 weeks
b) Miconazole
Systemic - for extensive disease and scalp or nail involvement
a) Terbinafine - 250 mg/day for 1 week
b) Itraconazole - 200 mg/day for 1 week
c) Griseofulvin - 500 to 1000 mg/day for 2-4 weeks

Short course of systemic corticosteroid required for kerion to limit hair loss