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DE-SP/0411/02
BACTERIAL SKIN INFECTIONS
DE-SP/0411/02
DE-SP/0411/02
■ Bacterial skin infections (Pyodermas)
Classification
Non – follicular pyodermas: Impetigo, ecthyma, erysipelas, cellulitis
Follicular pyodermas: Folliculitis, furunculosis, carbuncle
Treatment
■ Superficial Fungal skin infections
Predisposing factors
Dermatophytosis
Anti-fungal drugs
Pityriasis versicolor
Cutaneous candidiasis
2 Overview
DE-SP/0411/02
BACTERIAL SKIN INFECTIONS
OR PYODERMAS
DE-SP/0411/02
PYODERMA: Types
PYODERMAPYODERMA
SECONDARY
(to underlying
disease)
PRIMARY
ScabiesScabies
Miliaria/Prickly heatMiliaria/Prickly heat
Eczema/DermatitisEczema/Dermatitis
Fungal infectionFungal infection
PediculosisPediculosis
4
Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
DE-SP/0411/02
PYODERMA:
Classification
5
DiffuseDiffuse
LocalisedLocalised
SuperficialSuperficial
PerifolliculitisPerifolliculitis
SuperficialSuperficial
DeepDeep
PYODERMAPYODERMA
Non-
FOLLICULAR
FOLLICULAR
Impetigo contagiosa
Bullous Impetigo
Ecthyma
Erysipelas
DeepDeep Cellulitis
SuperficialSuperficial
DeepDeep
FolliculitisFolliculitis
FuruncleFuruncle
CarbuncleCarbuncle
Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
DE-SP/0411/02
PYODERMAS:
NON FOLLICULAR
DE-SP/0411/02
Impetigo
Risk factors3
■ Gram-positive bacterial infection of superficial epidermal layers1
■ Highly contagious - Organisms often pass from one individual to another by
direct hand contact 2
■ Accounts for 10% of skin diseases treated in pediatric clinics in US2
Classification
■ Nonbullous impetigo
(Impetigo contagiosa)
■ Bullous impetigo
7
hot, humid weather
crowded living conditions
poor hygiene
immunosuppression
 Nasal carriage of S. aureus:
important factor in recurrent
infections
1. Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd
ed. India:Bhalani Publishing House;1994.p.223-251.
2. Available at http://emedicine.medscape.com/article/1052709-overview#a0199. Accessed on 21/04/11
3. Popovich D. Accurately Diagnosing Commonly Misdiagnosed Circular Rashes. Pediatr Nurs. 2007;33(4):315-320.
DE-SP/0411/02
Non Bullous or
Impetigo contagiosa
Accounts for 70% cases of impetigo
Caused by S.aureus & S.pyogenes
Clinical presentation
■ Commonly seen in children aged 2 to 5
years
■ Appearance: Multiple honey colored
crusted lesions with a ring of
erythema.
■ Site: Predominantly face (especially
around mouth & nose)
■ Constitutional symptoms: fever,
regional lymphadenopathy.
Complications
■ Post streptococcal glomerulonephritis
in patients infected with nephritogenic
strains
8
Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
DE-SP/0411/02
Bullous Impetigo
Caused by S.aureus
Clinical presentation
■ Commonly seen in infants
■ Appearance: Bullae with turbid
collection of fluid without a
erythematous ring rupture to form
thin crusts. Heal in centre to form
annular lesions.
■ Predominant site - face but any part of
body including mucous membranes
may be involved.
■ Constitutional symptoms &
lymphadenopathy : Rare
Complications
■ Rare
9
Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
DE-SP/0411/02
Ecthyma
Deeper variant of impetigo
Caused by S.aureus & S.pyogenes or
both
Diagnosis:
■ Predominant site: lower limb,
buttocks, legs, thighs
■ Appearance:
small bulla or pustule on
erythematous base  a crusted
(often heaped up), indurated,
tender plaque with erythematous
ring, removal of adherent crust 
irregular ulcer
Heals with scarring
10
Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
DE-SP/0411/02
Erysipelas
 Superficial streptococcal infection extending into cutaneous
lymphatics
CLINICAL PRESENTATION:
■ Predisposing factors: Recent streptococcal infection, HIV infection,
diabetes, alcohol abuse, nephrotic syndrome, or preexisting
lymphedema
■ Appearance: small erythematous, warm patch  indurated
tense,shiny plaque with sharply demarcated margins, superficial
vesiculation may occur. Rapidly spreads through lymphatics  skin
"streaking," regional lymph node swelling, tenderness
COMPLICATIONS
■ Recurrent infections may cause disfiguring & disabling healing
reactions
11
Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
DE-SP/0411/02
Erysipelas12
Image courtesy: CDC/Dr. Thomas F. Sellers/Emory
University. Accessed from:
http://www.wrongdiagnosis.com/phil/html/erysipela
s/2874.html
DE-SP/0411/02
Cellulitis
■ Deeper variant of erysipelas
involving the deeper
subcutaneous tissue.1
■ Predisposing factor: occult
diabetes2
■ Lesions: are ill-defined with
indistinct borders
13
1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
DE-SP/0411/02
PYODERMAS - FOLLICULAR
DE-SP/0411/02
Superficial Folliculitis
■ Superficial bacterial infection
involving terminal part of hair follicle
■ Causes:
Infectious - S. aureus;
Chemical - mineral, vegetable oils
petrolatum (cosmetic or occupational
exposure);
Mechanical - post waxing, pseudo
folliculitis in beard region.
■ Predominant sites: lower limb, post
waxing on thighs or deltoid region,
pseudofolliculitis -in beard area
■ Appearance: Dome shaped follicular
pustules
15
Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications,
Delhi;2006.p.188-229.
DE-SP/0411/02
Deep Folliculitis1,2
■ Deeper variant of folliculitis involving whole depth of hair follicle
■ Causative organism: S.aureus
Clinical presentation
■ Occurs commonly in males 20-40 years of age
■ Predominant sites: beard area (sycosis barbae) especially on upper lip &
below angles of mouth, scalp & nape of neck (sycosis nuchae)
■ Appearance: Deep seated erythematous perifollicular papules & pustules.
Lesion heals with scarring
16
1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications, Delhi;2006.p.188-229.
2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
DE-SP/0411/02
Furunculosis1,2
■ Deep seated follicular & perifollicular
infection culminating into necrosis
■ Causative organism: S.aureus.
Clinical presentation:
■ Occurs in healthy adolescents or adults
■ Predisposing factors: diabetes, steroids
■ Predominant sites: face, axillae, buttocks,
perineal region
■ Appearance : 1-2 tender, firm painful red
follicular nodules  become necrotic
discharge central core. Heal with
barely perceptible scarring.
■ Constitutional symptoms: fever,
lymphadenopathy
17
1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications, Delhi;2006.p.188-229.
2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
DE-SP/0411/02
Carbuncle1,2
■ Deep infection of contiguous hair
follicles
■ Causative organism: S.aureus.
Clinical presentation:
■ Occurs mostly in adults with
diabetes or on steroid therapy
■ Predominant site: back
■ Appearance : Tender, indurated,
lobulated, intensely erythematous
plaque discharging pus from many
openings.
■ Constitutional symptoms: fever,
invariable.
■ Diagnosis: pus culture sensitivity
18
1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st
edition. Peepee publications, Delhi;2006.p.188-229.
2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
DE-SP/0411/02
TREATMENT OF BACTERIAL
SKIN INFECTIONS
DE-SP/0411/02
Bacterial skin
infections: Treatment1
■ Identification & elimination of predisposing factors like
immunosuppresion, malnutrition, diabetes
■ Local hygiene is important & should be maintained
Encourage hand washing2
■ Supportive measures
Removal of crusts
Hot fomentation
Incision & drainage
Rest & limb elevation
Concomitant use of oral or topical anti inflammatory
creams to relieve pain & inflammation
20
1. Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
2. . Popovich D. Accurately Diagnosing Commonly Misdiagnosed Circular Rashes. Pediatr Nurs. 2007;33(4):315-320.
DE-SP/0411/02
Bacterial skin
infections: Treatment
■ Topical or oral antibiotic therapy is the treatment of choice
■ Localized areas are treated with antibacterial applications having a gram
positive spectrum such as:
2% Mupirocin cream or ointment, applied 2-3 times a day
2% Sodium fusidate or fusidic acid cream /ointment, 3-4 times a day
1% Nadifloxacin cream
■ Role of oral antibiotics
When widespread or deep infection is present or
If localized lesions do not improve with topical medication
Penicillinase-stable penicillins like cloxacillin, dicloxacillin are effective
including erythromycin, azithromycin, cephalosporins
21
Popovich D. Accurately Diagnosing Commonly Misdiagnosed Circular Rashes. Pediatr Nurs. 2007;33(4):315-320.
DE-SP/0411/02
Drug MOA Dose 1
Mupirocin Inhibits bacterial protein & RNA
synthesis, by inhibition of isoleucyl-
transfer RNA synthetase2
Primary: apply 2%
ointment topically 3 times
a day for 3-5 days
Secondary: 3 times for
10days
Fusidic acid Interferes with amino acid transfer
(translocase enzyme) inhibiting
bacterial protein synthesis3
Apply 3-4 times daily to
the affected part of the
skin for a period of 7 days
4
Nadifloxacin
(fluroquinolo
ne)
Inhibits DNA gyrase (required for DNA
synthesis & replication), thus inhibits
bacterial multiplication5
Apply 1% cream twice
daily for one to two weeks
Topical Antibacterial
Antibiotics
22
1. Micromedex, Drugdex Evaluations, {Mupirocin (November 12, 2010), Nadifloxacin (February 09, 2007), Accessed on April 15, 2011.
2. Ward, Alan et al.Mupirocin: A Review of Its Antibacterial Activity, Pharmacokinetic Properties & Therapeutic Use. Drugs. 1986;32(5):425-444
3. Verbist L. The antimicrobial activity of fusidic acid. J Antimicrob Chemother. 1990 Feb;25 Suppl B:1-5.
4. Fusidin cream Prescribing information. Available at http://www.mims.com. Accessed on April 15,2011.
5. David CH. Mechanisms of Action & Resistance of Older & Newer Fluoroquinolones. Clinical Infectious Diseases 2000;31(Suppl 2):S24–8.
DE-SP/0411/02
Summary
■ Bacterial infections of the skin could occur de novo or may
secondarily infect pre-existing dermatoses
■ Commonly seen in pediatric population and adolescents
but can affect all age groups
■ Common pathogens implicated are gram positive cocci
(staphylococcus aureus & streptococci)
■ Clinical presentation varies with the site & depth of
involvement
■ Treatment is with topical antibacterial agents; systemic
antibiotics added for extensive infections, deep seated
infections & for infections not improving with topical
antibacterial agents
23
DE-SP/0411/02
“Disclaimer
This educational initiative supported by GlaxoSmithKline Pharmaceuticals
Limited & prepared by Rayz Healthcare Consultancy (lead consultant - Dr. Gulrez
Tyebkhan) is meant strictly & solely for presentations amongst Registered
Medical Practitioners in India.
Although great care has been taken in compiling & checking the information, the
sponsor GlaxoSmithKline Pharmaceuticals Limited shall not be held responsible
or liable for errors, omissions or inaccuracies in this Slide Deck, whether arising
from negligence or otherwise, nor for consequences arising therefrom.”
24
DE-SP/0411/02
Abbreviated prescribing
information – T Bact ointment
■ T-bact Ointment (Mupirocin)
Composition: Mupirocin 2% w/w in a white, translucent water soluble polyethylene glycol base.
Indications: For the topical treatment of primary skin infections such as impetigo, folliculitis,
furunculosis and ecthyma and secondary bacterial skin infections such as infected dermatosis
(e.g., infected eczema), infected traumatic lesions (e.g., abrasions, insect bites, minor wounds
and minor burns). For prophylaxis: May be used to avoid bacterial contamination of small
wounds, incisions and other clean lesions, and to prevent infection of abrasions and small cuts
and wounds. Dosage and administration: Adults, children, elderly and hepatic impairment: 2-3
times a day for up to 10 days, depending on the response. Contraindications: Known
hypersensitivity to any of its constituents. Warnings and precautions: Avoid contact with eyes, or
use in conjunction with cannulae. If contaminated, the eyes should be thoroughly irrigated with
water until the ointment residues have been removed. Do not use intranasally. Do not use in
conditions where absorption of large quantities of polyethylene glycol is possible, especially if
there is evidence of moderate or severe renal impairment. Interactions: No drug interactions
have been reported. Pregnancy and lactation: Adequate human data on use during pregnancy
and lactation are not available. However, animal studies have not identified any risk to
pregnancy or embryo-foetal development. If a cracked nipple is to be treated, it should be
thoroughly washed prior to breast feeding. Use in pregnancy or nursing mothers only when
potential benefits outweigh potential risks. Undesirable effects: Burning, itching, erythema,
stinging and dryness localised to the area of application, cutaneous sensitisation reactions and
very rarely systemic allergic reactions. Version: TBTO/API/IN/2004/006AOC v01 dated 26-Nov-
08. Adapted from Indian Prescribing Information Version 006 / IND 04.
25
DE-SP/0411/02
GlaxoSmithKline Pharmaceuticals Ltd Dr Annie Besant Road, Worli, Mumbai-30
For the use only of a Registered Medical Practitioner
DE-SP/0411/02

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Superficial bacterial infection

  • 2. DE-SP/0411/02 ■ Bacterial skin infections (Pyodermas) Classification Non – follicular pyodermas: Impetigo, ecthyma, erysipelas, cellulitis Follicular pyodermas: Folliculitis, furunculosis, carbuncle Treatment ■ Superficial Fungal skin infections Predisposing factors Dermatophytosis Anti-fungal drugs Pityriasis versicolor Cutaneous candidiasis 2 Overview
  • 4. DE-SP/0411/02 PYODERMA: Types PYODERMAPYODERMA SECONDARY (to underlying disease) PRIMARY ScabiesScabies Miliaria/Prickly heatMiliaria/Prickly heat Eczema/DermatitisEczema/Dermatitis Fungal infectionFungal infection PediculosisPediculosis 4 Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229.
  • 5. DE-SP/0411/02 PYODERMA: Classification 5 DiffuseDiffuse LocalisedLocalised SuperficialSuperficial PerifolliculitisPerifolliculitis SuperficialSuperficial DeepDeep PYODERMAPYODERMA Non- FOLLICULAR FOLLICULAR Impetigo contagiosa Bullous Impetigo Ecthyma Erysipelas DeepDeep Cellulitis SuperficialSuperficial DeepDeep FolliculitisFolliculitis FuruncleFuruncle CarbuncleCarbuncle Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229.
  • 7. DE-SP/0411/02 Impetigo Risk factors3 ■ Gram-positive bacterial infection of superficial epidermal layers1 ■ Highly contagious - Organisms often pass from one individual to another by direct hand contact 2 ■ Accounts for 10% of skin diseases treated in pediatric clinics in US2 Classification ■ Nonbullous impetigo (Impetigo contagiosa) ■ Bullous impetigo 7 hot, humid weather crowded living conditions poor hygiene immunosuppression  Nasal carriage of S. aureus: important factor in recurrent infections 1. Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251. 2. Available at http://emedicine.medscape.com/article/1052709-overview#a0199. Accessed on 21/04/11 3. Popovich D. Accurately Diagnosing Commonly Misdiagnosed Circular Rashes. Pediatr Nurs. 2007;33(4):315-320.
  • 8. DE-SP/0411/02 Non Bullous or Impetigo contagiosa Accounts for 70% cases of impetigo Caused by S.aureus & S.pyogenes Clinical presentation ■ Commonly seen in children aged 2 to 5 years ■ Appearance: Multiple honey colored crusted lesions with a ring of erythema. ■ Site: Predominantly face (especially around mouth & nose) ■ Constitutional symptoms: fever, regional lymphadenopathy. Complications ■ Post streptococcal glomerulonephritis in patients infected with nephritogenic strains 8 Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229.
  • 9. DE-SP/0411/02 Bullous Impetigo Caused by S.aureus Clinical presentation ■ Commonly seen in infants ■ Appearance: Bullae with turbid collection of fluid without a erythematous ring rupture to form thin crusts. Heal in centre to form annular lesions. ■ Predominant site - face but any part of body including mucous membranes may be involved. ■ Constitutional symptoms & lymphadenopathy : Rare Complications ■ Rare 9 Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229.
  • 10. DE-SP/0411/02 Ecthyma Deeper variant of impetigo Caused by S.aureus & S.pyogenes or both Diagnosis: ■ Predominant site: lower limb, buttocks, legs, thighs ■ Appearance: small bulla or pustule on erythematous base  a crusted (often heaped up), indurated, tender plaque with erythematous ring, removal of adherent crust  irregular ulcer Heals with scarring 10 Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229.
  • 11. DE-SP/0411/02 Erysipelas  Superficial streptococcal infection extending into cutaneous lymphatics CLINICAL PRESENTATION: ■ Predisposing factors: Recent streptococcal infection, HIV infection, diabetes, alcohol abuse, nephrotic syndrome, or preexisting lymphedema ■ Appearance: small erythematous, warm patch  indurated tense,shiny plaque with sharply demarcated margins, superficial vesiculation may occur. Rapidly spreads through lymphatics  skin "streaking," regional lymph node swelling, tenderness COMPLICATIONS ■ Recurrent infections may cause disfiguring & disabling healing reactions 11 Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229.
  • 12. DE-SP/0411/02 Erysipelas12 Image courtesy: CDC/Dr. Thomas F. Sellers/Emory University. Accessed from: http://www.wrongdiagnosis.com/phil/html/erysipela s/2874.html
  • 13. DE-SP/0411/02 Cellulitis ■ Deeper variant of erysipelas involving the deeper subcutaneous tissue.1 ■ Predisposing factor: occult diabetes2 ■ Lesions: are ill-defined with indistinct borders 13 1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229. 2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
  • 15. DE-SP/0411/02 Superficial Folliculitis ■ Superficial bacterial infection involving terminal part of hair follicle ■ Causes: Infectious - S. aureus; Chemical - mineral, vegetable oils petrolatum (cosmetic or occupational exposure); Mechanical - post waxing, pseudo folliculitis in beard region. ■ Predominant sites: lower limb, post waxing on thighs or deltoid region, pseudofolliculitis -in beard area ■ Appearance: Dome shaped follicular pustules 15 Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229.
  • 16. DE-SP/0411/02 Deep Folliculitis1,2 ■ Deeper variant of folliculitis involving whole depth of hair follicle ■ Causative organism: S.aureus Clinical presentation ■ Occurs commonly in males 20-40 years of age ■ Predominant sites: beard area (sycosis barbae) especially on upper lip & below angles of mouth, scalp & nape of neck (sycosis nuchae) ■ Appearance: Deep seated erythematous perifollicular papules & pustules. Lesion heals with scarring 16 1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229. 2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
  • 17. DE-SP/0411/02 Furunculosis1,2 ■ Deep seated follicular & perifollicular infection culminating into necrosis ■ Causative organism: S.aureus. Clinical presentation: ■ Occurs in healthy adolescents or adults ■ Predisposing factors: diabetes, steroids ■ Predominant sites: face, axillae, buttocks, perineal region ■ Appearance : 1-2 tender, firm painful red follicular nodules  become necrotic discharge central core. Heal with barely perceptible scarring. ■ Constitutional symptoms: fever, lymphadenopathy 17 1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229. 2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
  • 18. DE-SP/0411/02 Carbuncle1,2 ■ Deep infection of contiguous hair follicles ■ Causative organism: S.aureus. Clinical presentation: ■ Occurs mostly in adults with diabetes or on steroid therapy ■ Predominant site: back ■ Appearance : Tender, indurated, lobulated, intensely erythematous plaque discharging pus from many openings. ■ Constitutional symptoms: fever, invariable. ■ Diagnosis: pus culture sensitivity 18 1. Khanna N. Infections. In: Khanna N editor. Illustrated synopsis of dermatology & sexually transmitted diseases. 1st edition. Peepee publications, Delhi;2006.p.188-229. 2.Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251.
  • 20. DE-SP/0411/02 Bacterial skin infections: Treatment1 ■ Identification & elimination of predisposing factors like immunosuppresion, malnutrition, diabetes ■ Local hygiene is important & should be maintained Encourage hand washing2 ■ Supportive measures Removal of crusts Hot fomentation Incision & drainage Rest & limb elevation Concomitant use of oral or topical anti inflammatory creams to relieve pain & inflammation 20 1. Singh G.Bacterial Infections. In: Valia RG editor. IADVL Textbook and Atlas of Dermatology.3rd ed. India:Bhalani Publishing House;1994.p.223-251. 2. . Popovich D. Accurately Diagnosing Commonly Misdiagnosed Circular Rashes. Pediatr Nurs. 2007;33(4):315-320.
  • 21. DE-SP/0411/02 Bacterial skin infections: Treatment ■ Topical or oral antibiotic therapy is the treatment of choice ■ Localized areas are treated with antibacterial applications having a gram positive spectrum such as: 2% Mupirocin cream or ointment, applied 2-3 times a day 2% Sodium fusidate or fusidic acid cream /ointment, 3-4 times a day 1% Nadifloxacin cream ■ Role of oral antibiotics When widespread or deep infection is present or If localized lesions do not improve with topical medication Penicillinase-stable penicillins like cloxacillin, dicloxacillin are effective including erythromycin, azithromycin, cephalosporins 21 Popovich D. Accurately Diagnosing Commonly Misdiagnosed Circular Rashes. Pediatr Nurs. 2007;33(4):315-320.
  • 22. DE-SP/0411/02 Drug MOA Dose 1 Mupirocin Inhibits bacterial protein & RNA synthesis, by inhibition of isoleucyl- transfer RNA synthetase2 Primary: apply 2% ointment topically 3 times a day for 3-5 days Secondary: 3 times for 10days Fusidic acid Interferes with amino acid transfer (translocase enzyme) inhibiting bacterial protein synthesis3 Apply 3-4 times daily to the affected part of the skin for a period of 7 days 4 Nadifloxacin (fluroquinolo ne) Inhibits DNA gyrase (required for DNA synthesis & replication), thus inhibits bacterial multiplication5 Apply 1% cream twice daily for one to two weeks Topical Antibacterial Antibiotics 22 1. Micromedex, Drugdex Evaluations, {Mupirocin (November 12, 2010), Nadifloxacin (February 09, 2007), Accessed on April 15, 2011. 2. Ward, Alan et al.Mupirocin: A Review of Its Antibacterial Activity, Pharmacokinetic Properties & Therapeutic Use. Drugs. 1986;32(5):425-444 3. Verbist L. The antimicrobial activity of fusidic acid. J Antimicrob Chemother. 1990 Feb;25 Suppl B:1-5. 4. Fusidin cream Prescribing information. Available at http://www.mims.com. Accessed on April 15,2011. 5. David CH. Mechanisms of Action & Resistance of Older & Newer Fluoroquinolones. Clinical Infectious Diseases 2000;31(Suppl 2):S24–8.
  • 23. DE-SP/0411/02 Summary ■ Bacterial infections of the skin could occur de novo or may secondarily infect pre-existing dermatoses ■ Commonly seen in pediatric population and adolescents but can affect all age groups ■ Common pathogens implicated are gram positive cocci (staphylococcus aureus & streptococci) ■ Clinical presentation varies with the site & depth of involvement ■ Treatment is with topical antibacterial agents; systemic antibiotics added for extensive infections, deep seated infections & for infections not improving with topical antibacterial agents 23
  • 24. DE-SP/0411/02 “Disclaimer This educational initiative supported by GlaxoSmithKline Pharmaceuticals Limited & prepared by Rayz Healthcare Consultancy (lead consultant - Dr. Gulrez Tyebkhan) is meant strictly & solely for presentations amongst Registered Medical Practitioners in India. Although great care has been taken in compiling & checking the information, the sponsor GlaxoSmithKline Pharmaceuticals Limited shall not be held responsible or liable for errors, omissions or inaccuracies in this Slide Deck, whether arising from negligence or otherwise, nor for consequences arising therefrom.” 24
  • 25. DE-SP/0411/02 Abbreviated prescribing information – T Bact ointment ■ T-bact Ointment (Mupirocin) Composition: Mupirocin 2% w/w in a white, translucent water soluble polyethylene glycol base. Indications: For the topical treatment of primary skin infections such as impetigo, folliculitis, furunculosis and ecthyma and secondary bacterial skin infections such as infected dermatosis (e.g., infected eczema), infected traumatic lesions (e.g., abrasions, insect bites, minor wounds and minor burns). For prophylaxis: May be used to avoid bacterial contamination of small wounds, incisions and other clean lesions, and to prevent infection of abrasions and small cuts and wounds. Dosage and administration: Adults, children, elderly and hepatic impairment: 2-3 times a day for up to 10 days, depending on the response. Contraindications: Known hypersensitivity to any of its constituents. Warnings and precautions: Avoid contact with eyes, or use in conjunction with cannulae. If contaminated, the eyes should be thoroughly irrigated with water until the ointment residues have been removed. Do not use intranasally. Do not use in conditions where absorption of large quantities of polyethylene glycol is possible, especially if there is evidence of moderate or severe renal impairment. Interactions: No drug interactions have been reported. Pregnancy and lactation: Adequate human data on use during pregnancy and lactation are not available. However, animal studies have not identified any risk to pregnancy or embryo-foetal development. If a cracked nipple is to be treated, it should be thoroughly washed prior to breast feeding. Use in pregnancy or nursing mothers only when potential benefits outweigh potential risks. Undesirable effects: Burning, itching, erythema, stinging and dryness localised to the area of application, cutaneous sensitisation reactions and very rarely systemic allergic reactions. Version: TBTO/API/IN/2004/006AOC v01 dated 26-Nov- 08. Adapted from Indian Prescribing Information Version 006 / IND 04. 25
  • 26. DE-SP/0411/02 GlaxoSmithKline Pharmaceuticals Ltd Dr Annie Besant Road, Worli, Mumbai-30 For the use only of a Registered Medical Practitioner DE-SP/0411/02

Notas del editor

  1. Bacterial skin infection may manifest as primary pyoderma of intact skin or secondary infection of preexisting skin disease or traumatized skin, & it rarely progresses to a systemic infection. Infection occurs by entrance through broken skin, usually from scratching. Commonly associated conditions include atopic dermatitis, dermatophytosis, varicella, herpes simplex, scabies, pediculosis, thermal burns, surgery, trauma, radiation therapy, or insect bites.
  2. Impetigo is a highly contagious gram-positive bacterial infection of the superficial layers of epidermis. It may be caused by Staphylococcus aureus, most commonly in the United States, & by group A beta-hemolytic streptococci (GABHS) most often in developing countries. May be classified as bullous & nonbullous. Nonbullous impetigo occurs in 70% of casesMany patients are colonized in the nares or less commonly in the perineum, axillae, pharynx, & h&s. Organisms pass from one individual to another by direct h& contact. Immunosuppression from medications, systemic diseases, intravenous drug abuse, or dialysis encourages bacterial growth. Impetigo accounts for 10% of skin diseases treated in pediatric clinics, with a peak incidence in summer & fall. Risk factors include hot, humid weather, participation in contact sports, crowded living conditions, & poor hygiene. Diagnosis is usually clinical.
  3. Impetigo contagiosa is a common & highly contagious pediatric skin infection. This infection is most commonly seen in children aged 2 to 5 years but can occur at any age. Impetigo contagiosa: Diagnosis Patient is a child: Most commonly seen in children aged 2 to 5 years but can occur at any age. Appearance: Multiple honey colored crusted lesions surrounded by a ring of erythema. Predominant site affected: Face (especially around the mouth & nose. Gram stain & pus culture may be done to aid the diagnosis & identify the organisms & determine sensitivity. Associated symptoms: fever & regional lymphadenopathy frequent Complications Post streptococcal glomerulonephritis in some patients infected with nephritogenic strains. Eczematization Patients with any type of streptococcal infection should be monitored for decreased urine output, tea-colored or dark urine, headache, nausea, vomiting, & evidence of edema. Physical examination may reveal hypervolemia, edema, or hypertension. Although rare, parents should be alerted to this possible complication & the accompanying symptoms. Nasal carriage of Staph may be an important factor Impetigo occurs in hot & humid climates
  4. Diagnosis Although it was once thought that the organism causing impetigo could be predicted based on its bullous or nonbullous honey-colored crusted appearance, there is some evidence indicating that lesions may be affected by (or associated with) both S. aureus & GABHS (Stulberg, Penrod, & Blatny, 2002). The bullous form of impetigo presents as a large, thin-walled bulla (2 to 5 cm) containing serous yellow fluid. It often ruptures, leaving a complete or partially denuded area with a ring or arc of remaining bulla. Site: Predominant site may be the face but any part of the body including mucous membranes may be involved. Gram stain & Pus culture may show Staph Associated constitutional symptoms & lymphadenopathy are rare Complications are rare.
  5. Deeper variant of impetigo Causative organism: Streptococcus pyogenes or Staph aureus or both Diagnosis: Predominant site is the lower limb, buttocks, legs, thighs Appearance: small bulla or pustule appears on erythematous base & soon forms a crusted (often heaped up), indurated, tender plaque with an erythematous surrounding area. Removal of the adherent crust reveals an irregular ulcer. The lesion heals with scarring.
  6. Superficial bacterial skin infection that characteristically extends into the cutaneous lymphatics Causative organism: Infections on the face are usually caused by Streptococcus pyogenes; those of the legs are caused by non-group A streptococci. Diagnosis: Predisposing factors include recent streptococcal infection, diabetes, alcohol abuse, HIV infection, nephrotic syndrome, or preexisting lymphedema. Appearance : a small erythematous, warm patch that progresses to an indurated tense & shiny plaque. Classically, these lesions have sharply demarcated margins, superficial vesiculation may occur on the plaque. Infection rapidly spreads through the lymphatic vessels, which can produce skin "streaking," regional lymph node swelling, & tenderness. Associated constitutional symptoms: invariable. Diagnosis is typically clinical. Complications Recurrent infections may cause disfiguring & disabling healing reactions
  7. Cellulitis is a deeper varaint of erysipelas involving the deeper subcutaneous tissue The lesions are ill-defined & occult diabetes may be an important factor in the development of cellulitis
  8. Superficial bacterial skin infection that characteristically involves the terminal part of hair follicle Cause: Infectious- Staph aureus; Chemical-due to mineral, vegetable oils petrolatum (cosmetic or occupational exposure); Mechanical-post waxing, pseudo folliculitis in the beard region. Diagnosis: Predominant site is the lower limb, post waxing occurs on the thighs or deltoid region, pseudofolliculitis is seen in the beard area. Appearance: Dome shaped follicular pustules are seen.
  9. Deeper variant of folliculitis that characteristically involves the whole depth of hair follicle Causative organism: Staph aureus Diagnosis: Patient is a male 20-40 years of age Predominant sites are the beard area (sycosis barbae) especially on the upper lip & below the angles of the mouth, scalp & nape of the neck (sycosis nuchae) Appearance: Deep seated erythematous perifollicular papules & pustules are seen. The lesion heals with scarring.
  10. Deep seated follicular & perifollicular infection involving the subcute culminating into necrosis Causative organism: Staph aureus. Diagnosis: Patient is an healthy adolescent or adult Predisposing factors include diabetes, intake of steroids . Predominant sites are face, axillae, buttocks & perineal region Appearance :usually 1-2 tender, firm painful tender red follicular nodules which become necrotic & discharge their central core. Lesions heal with barely perceptible scarring. Associated constitutional symptoms: fever & lymphadenopathy Diagnosis in recurrent lesions: pus culture from lesions or sites such as perineal region, nares; immunological workup only if frequent
  11. Deep infection of contiguous hair follicles Causative organism: Staph aureus. Diagnosis: Patient is mostly an adult diabetic or on steroid therapy. Predominant site is the back Appearance : Tender, indurated, lobulated, intensely erythematous plaque discharging pus from many openings. Associated constitutional symptoms viz. fever, invariable. Diagnosis: pus culture sensitivity, rule out diabetes.
  12. Identification & elimination of immunocompromising factors like malnutrition, diabetes Local hygiene is important & should be maintained. Where ever necessary, Hot fomentation Incision & drainage Rest & limb elevation Concomitant use of oral or topical anti inflammatory creams to relieve pain & inflammation For chronic recurrent infections, the carrier state can be treated with topical mupirocin Parental education is paramount in the prevention & successful treatment of impetigo. Children's fingernails should be kept clean & short, & antibacterial soap used at the first sign of altered skin integrity. Nasal S. aureus has been implicated in recurrent impetigo (Raz et al., 1996), so parents should consistently encourage the use of tissues & h&washing. Children infected with impetigo should not bathe together, share towels, or have skin-to-skin contact.
  13. Topical or oral antibiotic therapy is the treatment of choice. Localized areas are most commonly treated with antibacterial applications such as: 2% Mupirocin cream or ointment, Sodium fusidate or fusidic acid cream or ointment Nadifloxacin Retapamulin