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.
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
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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
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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
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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
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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.”
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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.
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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.
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.
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
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.
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.
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
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
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.
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.
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
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.
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.
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