1. Morning Report Derm Day

2. Ecthyma gangrenosum
• Cutaneous infection most commonly associated with
Pseudomonas bacteremia
• Pts who are critically ill and immunocompromised
• Characteristic lesions of ecthyma gangrenosum are
hemorrhagic pustules that evolve into necrotic ulcers
• Painless, round, red patches in the skin which rapidly become
pustular with surrounding redness
• Gangrenous ulcer with a black/gray scab surrounded by a red
halo
• Mainly affects the anogenital area and armpits

3. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Pseudomonas aeruginosa infection. Ecthyma gangrenosum. This 32-year-old man with human immunodeficiency virus infection
noted the onset of a very tender plaque on the right buttock associated with fever and malaise. A. Five-day-old lesion with a central
infarcted, necrotic area surrounded by erythema. B. At 5 weeks, the lesions had improved after ciprofloxacin treatment, which was
discontinued because of an adverse drug reaction. Without antibiotic treatment, the necrotic area enlarged and was associated
with bacteremia. Eventually, the lesion reepithelialized, but the patient died of pseudomonal pneumonia.
Legend:
From: Part 9. Disease Due to Microbial Agents, Infestations, Bites, and Stings
Fitzpatrick's Dermatology in General Medicine, 8e, 2012
From: Part 9. Disease Due to Microbial Agents, Infestations, Bites, and Stings
Fitzpatrick's Dermatology in General Medicine, 8e, 2012

5. Workup
• Gram stain of fluid from the central
haemorrhagic pustule or blister can rapidly
indicate the diagnosis
• Blood cultures prior to antibiotics
• Skin biopsy:
– Histopathology shows vascular necrosis with few
inflammatory cells but many surrounding bacteria
– Gram negative rods seen surrounding necrotic
vessels

6. Treatment
• Treat underlying bacteremia

7. Pyoderma gangrenosum
• Rare, inflammatory disease of unknown
etiology
• Sterile neutrophilic infiltration of the skin
• Female predominance
• Typically associated with other systemic
diseases
– IBD, arthritis, malignancy
• Multiple subtypes
– Ulcerative, bullous, pustular, vegetative

8. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Established lesion of ulcerative pyoderma gangrenosum showing well-defined ulceration with surrounding zone of erythema.
Legend:
From: Chapter 33. Pyoderma Gangrenosum
Fitzpatrick's Dermatology in General Medicine, 8e, 2012
From: Chapter 33. Pyoderma Gangrenosum
Fitzpatrick's Dermatology in General Medicine, 8e, 2012

9. Workup
• No specific serologic testing available
• Histopathologic findings not specific, but may
be suggestive of the diagnosis in right clinical
context
– Tissue neutrophilia without significant
leukocytoclastic vasculitis
• Must exclude other mimicking conditions
– Infection, vascular insult, malignancy

10. Treatment
• Systemic immunosuppressive medication is
mainstay
• Topical and local therapy as indicated
• Treatment of causative systemic illness as
indicated
– IBD, arthritis, malignancy

11. Acute Febrile Neutrophilic
Dermatosis
• Commonly known as Sweet Syndrome
• Characterized by acute onset of fever, neutrophilia,
with erythematous, tender skin lesions
• All manifestations resolve rapidly with initiation of
systemic corticosteroids
• Multiple types
– Classical: associated with upper
respiratory/gastrointestinal infections, IBD, pregnancy
– Malignancy-associated: undiagnosed hematologic
malignancy or suggestive of recurrence of known
hematologic malignancy
– Drug-induced: typically due to G-CSF

12. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Multiple confluent papules and plaques of Sweet syndrome that at first sight give the illusion of vesiculation but are solid on
palpation. (From Honigsmann et al: Akute febrile neutrophile Dermatose. Wien Klin Wochenschr 91:842, 1979, with permission.)
Legend:
From: Part 2. Disorders Presenting in Skin and Mucous Membranes
Fitzpatrick's Dermatology in General Medicine, 8e, 2012
From: Part 2. Disorders Presenting in Skin and Mucous Membranes
Fitzpatrick's Dermatology in General Medicine, 8e, 2012

13. Workup
• Skin biopsy
– Mature neutrophilic infiltration of dermis
– Lesion should also be sent for infectious cultures

14. Treatment
• Systemic corticosteroids, potassium iodide
and colchicine are all first line therapies

15. Erysipelas
• Superficial cutaneous cellulitis with marked dermal
lymphatic vessel involvement
• Classically caused by Group A streptococci
– Can be caused by Staphylococci, Group C/G strep
• Differences between erysipelas and classic cellulitis
– Sharply defined borders
– Erythema classically bright red
– Skin can be described as peau d’orange
• Distribution
– 70-80% of cases involve lower extremities
– Up to 10% involve face
• Classically start unilaterally but tend to cross nasal bridge and involve
face symmetrically

16. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Erysipelas is a group A streptococcal infection of the superficial dermis and consists of well-demarcated, erythematous,
edematous, warm plaques.
Legend:
From: Chapter e7. Atlas of Rashes Associated With Fever
Harrison's Principles of Internal Medicine, 18e, 2012
From: Chapter e7. Atlas of Rashes Associated With Fever
Harrison's Principles of Internal Medicine, 18e, 2012

17. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Erysipelas. Painful, edematous erythema with sharp margination on both cheeks and the nose. There is tenderness, and the
patient has fever and chills.
Legend:
From: Chapter 178. Non-Necrotizing Infections of the Dermis and Subcutaneous Fat: Cellulitis and Erysipelas
Fitzpatrick's Dermatology in General Medicine, 8e, 2012
From: Chapter 178. Non-Necrotizing Infections of the Dermis and Subcutaneous Fat: Cellulitis and Erysipelas
Fitzpatrick's Dermatology in General Medicine, 8e, 2012

18. Treatment
• Depends on severity and presumed causative organism
• Choice of antibiotic should reflect local resistance
patterns
• Outpatient
– Penicillinase-resistant PCN/oral cephalosporin for
suspected non-MRSA
– TMP/SMX, clindamycin, doxycycline, fluoroquinolone for
suspected MRSA
• Inpatient
– IV forms of outpatient abx for suspected non-MRSA
– IV vancomycin for suspected MRSA