Clinical methods & Therapeutics

1. Pustular lesion
By
Dr. Laraib Jameel Rph
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2. Carbuncles
• Definition: A carbuncle is a cluster of boils that
have multiple pus “heads.” They’re tender and
painful, and cause a severe infection which could
leave a scar.
• A carbuncle is also called a staph skin infection.
• Boils: A boil, also called a furuncle, begins as a
painful infection of a single hair follicle. Boils can
grow to be larger than a golf ball.
• So carbuncle is multiple fruncle.

3. Carbuncles

4. • A hair follicle is a part of the skin, which grows
a hair by packing old cells together. Attached
inside the top of the follicle are sebaceous
glands, which are tiny sebum-
producing glands in almost all skin except on
the palms, lips and soles of the feet. The
thicker the hair, the more the number of
sebaceous glands there are.

5. • Causes: A carbuncle usually develops when Staphylococcus
aureus bacteria enter your hair follicles. These bacteria are also
referred to as “staph.”
• Entrance/Portal site: Scrapes, an insect bite and other broken skin
make it easy for bacteria to enter your body and cause an infection.
This can result in boils or carbuncles (a cluster of boils) filled with
fluid and pus.
• Location: Carbuncles are usually found on the back of the neck,
shoulders, or thigh. They can also appear on your face, armpits, or
buttocks; or any area you sweat or experience friction.
• Favourite environment of staphs: The moist parts of your body are
particularly susceptible to this infection because bacteria thrive in
these areas where you sweat or experience friction.
• Synonym/ Alternative names: Staph skin infection, Carbunculosis

6. • Risk factors: Being in close contact with someone who has a carbuncle increases
your chances of developing one. (Because the infection can spread when people
share space, materials, or devices, such as clothing and whirlpool footbaths.)
• The following factors also increase the risk of developing a carbuncle:
• poor hygiene
• Diabetes (High levels of blood sugar, or glucose, can reduce the immune system's
ability to respond to infection.)
• a weak immune system
• Skin conditions: Psoriasis, eczema, and acne increase susceptibility.
• kidney disease (renal carbuncle)- metastasis
• Medications: Some medications weaken the immune system. (organ transplant
rejection)
• shaving and other activities that break the skin
• Men get carbuncles more often than women. (Overcrowded ,unhygienic living
conditions, scraps on face during shave)

7. • Symptoms:
• Symptoms of boils: Boils can occur anywhere on your skin,
but hair-bearing areas where you're most likely to sweat or
experience friction. So it appear mainly on the face, back of
the neck, armpits, thighs and buttocks.
• So sign & symptoms of boils include:
• A painful, red bump that starts out small and can enlarge to
more than 2 inches (5 centimeters)
• Red, swollen skin around the bump
• An increase in the size of the bump over a few days as it fills
with pus
• Development of a yellow-white tip that eventually
ruptures and allows the pus to drain out.

8. • Symptoms of carbuncles:
• A carbuncle is a swollen lump or mass under the skin.
• It may be the size of a pea or as large as a golf ball.
• Color: the carbuncle may be red and irritated and might hurt when you touch it.
• A carbuncle usually:
• Develops over several days
• Have a white or yellow center (contains pus)
• Weep, ooze, or crust
• Spread to other skin areas
• Sometimes, other symptoms may occur.
• These may include:
• Fatigue
• Fever
• General discomfort or sick feeling
• Skin itching before the carbuncle develops

9. • Exams and Tests
• The health care provider will look at your skin. The diagnosis is
based on what the skin looks like.
• If u don’t get better from standard treatment, A sample of the pus
may be sent to a lab to determine the bacteria causing the infection
(bacterial culture). The test result helps your provider determine
the appropriate treatment.
• Treatment:
• Antibiotics. Sometimes your doctor may prescribe antibiotics to
help heal severe or recurrent infections.
• For larger boils and carbuncles, treatment may include:
• Incision and drainage. Your doctor may drain a large boil or
carbuncle by making an incision in it. Deep infections that can't be
completely drained may be packed with sterile gauze to help soak
up and remove additional pus.

10. • Lifestyle and home remedies
• For small boils, these measures may help the infection heal
more quickly and prevent it from spreading:
• Warm compresses. Apply a warm washcloth or compress
to the affected area several times a day, for about 10
minutes each time. This helps the boil rupture and drain
more quickly.
• Never squeeze or lance a boil yourself. This can spread the
infection.
• Prevent contamination. Wash your hands thoroughly after
treating a boil. Also, launder clothing, towels or
compresses that have touched the infected area,
especially if you have recurrent infections.

11. • Complications
• Rarely, bacteria from a boil or carbuncle can enter your bloodstream and
travel to other parts of your body. The spreading infection, commonly
known as blood poisoning (sepsis), can lead to infections deep within your
body, such as your heart (endocarditis) and bone (osteomyelitis).
• Preventions:
• Wash your hands regularly with mild soap. Or use an alcohol-based hand
rub often. Careful hand-washing is your best defense against germs.
• Keep wounds covered. Keep cuts and abrasions clean and covered with
sterile, dry bandages until they heal.
• Avoid sharing personal items. Don't share towels, sheets, razors, clothing,
athletic equipment and other personal items because Staph infections can
spread via objects, as well as from person to person. If you have a cut or
sore, wash your towels and linens using detergent and hot water with
added bleach, and dry them in a hot dryer.

12. Furuncle/Boils
• Definition: furuncle, begins as a painful infection
of a single hair follicle.
• Furuncles/Boils
can grow to be
larger than a golf
ball, and they
commonly occur
on the buttocks,
face, neck, armpits and groin.

14. Comparison b/w carbuncle & furuncle.
Furuncle
• begins as a painful infection of a single hair
follicle.
• Also known as boil
• Not as deeper as carbuncles.
• Furuncles, or boils, are skin abscesses that
result from staphylococcal infection. They
affect a hair follicle and surrounding tissue.
• Symptoms: Furuncles develop rapidly as pink
or red bumps. They are often painful. The
surrounding skin is typically red, inflamed
and tender.
• Its infection is not so deeper.
• Not so
• Not so as Furuncles may go away without
any intervention. Sometimes they burst and
heal without a scar within 2 days to 3 weeks.
Carbuncle
• It involves a group of infected hair follicles in one
skin location.
• Also known as cluster of boils.
• is a deeper skin infection because it involves a
group of infected hair follicles in one skin location.
• Carbuncles are groups of furuncles that join
together under the skin. They affect the deeper
layers, and they can lead to scarring.
• Symptoms: A carbuncle is less common than a
furuncle, or boil. It is a collection of boils on one
site. It is larger than a single boil, measuring up to 4
inches across. A carbuncle usually has one or more
openings that drain pus onto the skin.
• Carbuncle infections tend to be deeper and more
severe than those caused by furuncle
• The infection may lead to generalized body
symptoms, including a fever of 100.4 degrees
Fahrenheit or higher, and a general feeling of being
unwell, weak, and exhausted.
• The risk of scarring is higher, and they take longer to
develop and to resolve than furuncles.

16. Similarities between
carbuncles & furuncles
• starts as a red lump.
• The most common cause of a carbuncle &
furuncle is a bacterium known
as Staphylococcus aureus (S. aureus).
• Furuncles and carbuncles typically affect the
thighs, armpits, buttocks, face, and neck.
• risk of developing furuncles and carbuncle
are same (diabetes, poor immune system
etc).
• They affect males more frequently than
females, and especially older men with poor
health or a weakened immune system.
• Both condition shares same treatment,
some times furuncles go away on its own
without any intervention.
Initial appearance
Cause
Location
Risk factors
Susceptibility
Home remedies &
Treatment

17. Cancrum/Phagedena
• Definition: is a rapidly spreading gangrenous stomatitis which
occurs chiefly in debilitated (weakness) or malnourished children,
destroying the soft and hard tissue structures.
• Or it is gangrenous infection of the mouth and face.
• By WHO: it is categorized by the World Health Organization (WHO)
as a necrotizing ulcerative stomatitis.
• Synonyms: Cancrum oris or noma or fusospirochetal gangrene.
• Gangrene is a condition that occurs when body tissue dies. It is
caused by a loss of blood supply due to an underlying illness, injury,
and/or infection.
• Stomatitis is inflammation of the mouth and lips. It refers to any
inflammatory process affecting the mucous membranes of the
mouth and lips, with or without oral ulceration

19. Noma/ cancrum oris

20. • Anatomicaly it is a severe disfiguring gangrene of the
mouth and face that begins as a gingival ulcer and spreads
rapidly through the tissues of the mouth and face. Then
disrupts anatomic barriers and spreads through muscle and
bone.
• The resulting gangrene may involve the maxilla, the
mandible, and extend to the nose and infraorbital margins
• The maxilla is the bone that forms your upper jaw.
• The mandible, lower jaw or jawbone is the largest,
strongest and lowest bone in the human face. It forms the
lower jaw and holds the lower teeth in place.
• The infraorbital margin is the lower margin of the eye
socket

21. • NOMA IS….
• is a severe and aggressive gangrenous process (a
condition wherein body tissues die due to infection or
lack of blood supply) that affects the mouth, nose, and
lips. This fatal disease is particularly prevalent among
children in sub-Saharan Africa, with an estimated
frequency of 1 to 7 cases per 1,000 individuals. Noma
usually begins as an ulcer on the mucus membrane at
the alveolar margin of the mouth and rapidly spreads
into other parts of the mouth, including teeth,
jawbone, cheek, tongue, lips, and nose. This eventually
results in extensive necrosis and destruction of soft
tissues and bones.

22. • Cause:
• a combination of malnutrition, bacterial infection, and compromised
immunity is considered to be the main reason behind the onset and
progression of this devastating disease.
• A type of malnutrition called Kwashiorkor
• Kwashiorkor: a form of malnutrition, found in children, caused by dietry
insufficiency of protein in combination with carbohydrate.
• Pathogenesis:
• The exact pathophysiology of noma is not completely understood. The
disease mostly affects malnourished children living in underdeveloped
tropical countries who have had systemic diseases, such as malaria,
measles, primary herpes simplex, scarlet fever, tuberculosis, cancer, or
enteritis.

23. • Bacterial species that are frequently associated with noma include
• Fusobacterium necrophorum and Prevotella intermedia.
• In neonates, the disease is mainly caused by Pseudomonas aeruginosa.
• It is known from scientific findings that acute necrotizing gingivitis and oral
herpetic ulcers are the most vital precursor lesions that gradually develop into
noma due to infection caused by Fusobacterium necrophorum and Prevotella
intermedia.
• MECHANISM: Precisely, Fusobacterium necrophorum facilitates the gangrenous
process by producing endotoxins, dermonecrotic toxins, and cytoplasmic toxins.
• In addition, this Gram-negative anaerobic bacillus also triggers the growth
of Prevotella intermedia by producing necessary growth-stimulating factors.
• Endotoxin is one of the most important bacterial components of gram (-) outer cell
wall & it contributes to the inflammatory process.
• cytoplasmic toxin is more sensitive to degradation than is the toxin in the complex
cell wall

24. • Risk factors:
• Several risk factors are associated with the pathogenesis of noma. The
most vital factor is severe malnutrition, especially protein-calorie
malnutrition.
• Other factors that significantly contribute to the pathogenesis of noma
include:
• Living in underdeveloped countries
• Poor environmental sanitation
• Poor oral hygiene
• Frequent exposure to human/animal feces
• Prior history of viral or bacterial infection
• The risk of developing noma is also increased by diseases that cause
immunodeficiency, such as HIV infection. An impaired or compromised
immune system (due to infection or other factors) is considered as the
hallmark for developing noma.

25. • Signs and Symptoms
• The typical signs and symptoms of noma include
• swollen gums, swollen cheek lining, and ulcer formation.
• These ulcers spread rapidly and destroy oral and para-oral
soft tissues and bones, causing deformity of the face and
loss of teeth.
• The color of the oral cavity may also change into a greyish
color.
• In addition, the ulcer rapidly turns into edema with foul-
smelling drainage, causing bad breath and skin odor. This
also causes excessive saliva secretion from the mouth.

26. • Diagnosis
• A physical examination is done initially to check for inflamed mucus
membranes, oral cavity ulcers, and skin ulcers. This is followed by
taking a detailed medical history of the patient.
• X-ray, MRI, or CT scans of the jaw, head, and neck can also be
done to check the extent and severity of the damage.
• Bacterial culture analysis using oral
swabs can be done to detect the
causative species. In some special
cases, biopsy of the oral tissue is
also performed.
• Blood tests are recommended to determine the immune system
functioning.

27. • Treatment
• The conditions associated with noma are often life-threatening, if
not treated appropriately on time. Administration of systemic
antibiotics along with proper nutrition is considered to be the
golden standard for managing noma. Supplementation with folic
acid, iron, vitamin B complex, and ascorbic acid is also
recommended in some cases. In addition, measures should be
taken to avoid dehydration and maintain proper electrolyte
balance.
• Plastic surgery is necessary to reform facial bones and regain the
function of mouth and jaw, in addition to removing damaged
tissues.
• Complications mainly include face deformity, discomfort, difficulty
eating, drinking, and even speaking, and social isolation.

28. Guinea Worm Disease
• Guinea worm disease (GWD), is an infection caused by the parasite Dracunculus
medinensis.
• Synonym: (Dracunculiasis)
• A parasite is an organism that feeds off another organism to survive. GWD is
spread by drinking water containing Guinea worm larvae
• Larvae are immature forms of the worm. GWD affects poor communities in remote
parts of Africa that do not have safe water to drink.
• GWD can occur at any time of the year but occurs most commonly during peak
transmission season, which varies from country to country. In dry regions, people
generally get infected during the rainy season, when stagnant surface water is
available. In wet regions, people generally get infected during the dry season,
when surface water is drying up and becoming stagnant.
• GWD is primarily a human disease. However, in recent years infections in
animals, particularly in dogs, have been reported. As a result of research into the
cause of Guinea worm infections in animals, it is now believed that GWD might
also be spread to both animals and humans by eating certain aquatic animals
that might carry Guinea worm larvae, like fish or frogs, but do not themselves
suffer the effects of transmission

29. Dracunculus medinensis.

30. • Spread of disease:
• People become infected with Guinea worm by drinking water from ponds and
other stagnant water containing tiny “water fleas” that carry the Guinea worm
larvae. The larvae are eaten by the water fleas that live in these water sources.
• Once drunk, the larvae are released & in the stomach and penetrate the digestive
track, passing into the body cavity. During the next 10–14 months, the female
larvae grow into full-size adults. These adults are 60–100 centimeters (2–3 feet)
long and as wide as a cooked spaghetti noodle.
• When the adult female worm is ready to come out, it creates a blister on the skin
anywhere on the body, but usually on the legs and feet. This blister causes a very
painful burning feeling and it bursts within 24–72 hours. Immersing the affected
body part into water helps relieve the pain. It also causes the Guinea worm to
come out of the wound and release a milky white liquid into the water that
contains millions of immature larvae. This contaminates the water supply and
starts the cycle over again. For several days, the female worm can release more
larvae whenever it comes in contact with water.

31. • Sign & Symptoms:
• People do not usually have symptoms until about one year after
they become infected.
• A few days to hours before the worm comes out of the skin, the
person may develop a fever, swelling, and pain in the area.
• Way to come out: More than 90% of the worms come out of the
legs and feet, but worms can appear on other body parts too.
• Symptoms can include:
• Slight fever
• Itchy rash
• Nausea
• Vomiting
• Diarrhea
• Dizziness

32. • People in remote rural communities who have Guinea
worm disease often do not have access to health care.
• When the adult female worm comes out of the skin, it
can be very painful, slow, and disabling.
• Often, the wound caused by the worm develops a
secondary bacterial infection. This makes the pain
worse and can increase the time an infected person is
unable to function to weeks or even months.
• Sometimes, permanent damage occurs if a person’s
joints are infected and become locked.

33. • Diagnosis:
• Diagnosis of GWD is by clinical history and
observation of lesions
• or the presence of an emerging female worm.

34. • Treatment:
• There is no drug to treat Guinea worm disease and no vaccine to prevent
infection.
• Once part of the worm begins to come out of the wound, the rest of the worm
can only be pulled out a few centimeters each day by winding it around a piece of
gauze or a small stick.
• Sometimes the whole
worm can be pulled out
within a few days, but
this process usually takes weeks.
• As the worm is slowly and
carefully removed, the lesion
in the skin should be kept
cleaned and treated with
topical antibiotics if it becomes
infected.

35. • Medicine,
• such as aspirin or ibuprofen, can help reduce pain and
swelling.
• Antibiotic ointment can help prevent secondary
bacterial infections.
• The worm can also be surgically removed by a trained
doctor in a medical facility before a blister forms.
• Complications:
• Complications of Guinea worm disease include
secondary bacterial infections and/or systemic
problems like sepsis, joint destruction, and cellulitis.

36. • Who is at risk of infection:
• Anyone who drinks from a pond or other stagnant
water source contaminated with Guinea worm larvae is
at risk for infection. Larvae are immature forms of the
Guinea worm. People who live in countries where
GWD is occurring (such as Chad, Ethiopia, Mali, and
South Sudan) and consume raw or undercooked
aquatic animals (such as small whole fish that have not
been gutted, other fish, and frogs) may also be at risk
for GWD. People who live in villages where there has
been a case of GWD in a human or animal in the recent
past are at greatest risk.

37. Blister/Bullae
• Definition: Blisters are small pockets of fluid that usually form in the upper
layers of skin or between epidermis & dermis, after it's been damaged.
Blisters can develop anywhere on the body but are most common on the
hands and feet.
• Why blisters are filled with fluid?
• Fluid collects under the damaged skin, cushioning (support) the tissue
underneath. This protects the tissue from further damage and allows it to
heal.
• Fluid: Most blisters are filled with a clear fluid (serum), but may be filled
with blood (blood blisters) or pus if they become inflamed or infected.
• The clear, watery liquid inside a blister is called serum. It leaks in from
neighboring tissues as a reaction to injured skin. If the blister remains
unopened, serum can provide natural protection for the skin beneath it.
• Small blisters are called vesicles.
• Bullae: Those larger than half an inch are called bullae.

39. Lets ask interesting questions

40. Questions
• QNo1- Should you pop or break a blister?
• QNo2- in which cases Doctor drain the fluid
from blister?
• QNo3- Are you prone to getting blisters?
• QNo4- Can blisters scar?

41. • Ans1- Blisters should never be unroofed as this is your
body’s way of forming a bandage,
• Ans2- But for certain people at risk for infection, a doctor
may choose to use a sterile needle to allow fluid to drain.
This is especially the case for people with compromised
immune systems (people with HIV, diabetes, or those who
take medications that suppress the immune system).
• Ans3- Some preexisting skin disease can put you at risk
for blisters. (eczema, psoriasis) secondly Or the cause could
be as simple as walking around with wet or damp feet
(whether from sweat or from being in water). In either
case, you’re more prone to blisters because the skin barrier
is compromised

42. • Ans4- The depth of the blister determines
whether or not it will scar. “The deeper the
injury (particularly when it comes to a
chemical or heat burn), the more likely it is for
a scar to form. Typically, friction blisters do not
scar as they tend to be more superficial.

43. • Causes:
• Blisters can be caused by:
• friction to the skin
• heat for example, from sunburn or a scald
• contact with chemicals, such as detergent
• medical conditions, such as chickenpox,
herpes, Pemphigus, Epidermolysis bullosa,
eczema, psoriasis and impetigo

44. Types of blisters
• The main types of blisters are:
• friction blisters
• blood blisters
• heat blisters
• Other types of blister are named after the
medical condition they are linked to, such
as chickenpox and atopic eczema blisters.

45. Types of Blisters
Friction blister
• Any repetitive friction or rubbing can cause blisters.
• These blisters will usually appear on the hands or feet, as these are the
areas that most often encounter repetitive abrasion, whether walking,
running or playing the drums.
• Areas of skin with a thick
horny layer, attached tightly
to underlying structures
(such as palms of hands
and soles of feet) are more
likely to generate blisters.
• Blisters occur more readily if the conditions are warm, for example,
inside a shoe. (in damp areas, skin is compromised) They also form more
easily in damp conditions, compared with wet or dry environments.

46. Heat/Temperature blisters
• The timing of burn helps categorize the formation of blister. Second-degree burns will blister
immediately, but first-degree burns blister a couple of days after the incident.
• Burn: A burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals
or radiation.
• Scald: Burn due to hot liquid
• Second degree burn: This type of burn
affects both the epidermis and the second layer of skin (dermis).
So second-degree burns are more serious because the damage
extends beyond the top layer of skin.
• Sign: This type burn causes the skin to blister and become
• extremely red and sore(pain).
• Some blisters pop open, giving the burn a wet
or weeping appearance. Over time, thick, soft, scab-like tissue
called fibrinous exudate may develop over the wound.
• At the opposite end of the spectrum, frostbite also produces blisters.
• In both cases, the blister is a defense mechanism deployed to protect lower levels of skin from
temperature-related damage.

47. • Frostbite: Frostbite is an injury caused by freezing of the skin and
underlying tissues. Frostbite is most common on the fingers, toes, nose,
ears, cheeks and chin.
• Exposed skin in cold, windy weather is most vulnerable to frostbite.
• Signs and symptoms of frostbite
include:
• At first, a prickling feeling
• Numbness
• Red, white, bluish-white skin
• Hard or waxy-looking skin
• Clumsiness due to joint &
muscle stiffness
• Blistering after rewarming,
in severe cases

48. Blood blisters
• Crushing and pinching
• If a small blood vessel near the surface of the
skin is ruptured, blood can leak into the gap
between the
layers of skin causing
a blood blister to form.
This is a blister filled
with blood.

49. Blister due to Chemical exposure
• Chemical exposure
• Skin can occasionally blister because of certain chemicals. This is known as contact dermatitis.
• It can affect some individuals on contact with the following:
• cosmetics
• detergents
• solvents
• nickel sulfate, used in electroplating
• balsam of Peru, a flavoring
• insect bites and stings
• chemical warfare agents, including mustard gas
• Eczema: Eczema is the name for a group of conditions that cause the skin to become red, itchy and
inflamed. Blisters may sometimes occur.
• There are two types of contact dermatitis:
A. Irritant contact dermatitis can result from repeated exposure to a substance that irritates the
skin, such as:
• acids and alkalis
B. Allergic contact dermatitis
• Allergic contact dermatitis occurs when a person's immune system reacts to a particular substance,
known as an allergen.

50. Blisters due to Medical conditions
• A number of medical conditions can cause blisters.
• These include:
• Chickenpox:
• Chickenpox is a very
contagious infection
caused by the
varicella-zoster virus.
It mainly affects kids,
but adults can get it, too.
The telltale sign of chickenpox is a super-itchy skin rash with red
blisters. Over the course of several days, the blisters pop and start to
leak. Then they crust and scab over before finally healing.

51. • Herpes: The cold sores produced by the herpes simplex virus are
clusters of blisters.
• Cold sore: an inflamed blister in or near the mouth, caused by
infection with the herpes simplex virus.
• Synonym: fever blisters — are a common viral infection. They are
tiny, fluid-filled blisters on and around your lips.
• These blisters are often
grouped together in patches.
After the blisters break, a
crust forms over the resulting
sore. Cold sores usually heal
in two to four weeks without
leaving a scar.

52. • Bullous impetigo: (bullous+ impetigo) Mostly seen in children under 2
years, blisters can form on the arms, legs, or trunk.
• Impetigo is a common and contagious skin infection. Bacteria
like Staphylococcus aureus or Streptococcus pyogenes infect the outer
layers of skin, called the epidermis. The face, arms, and legs are most
often affected.
• The infection often begins in
minor cuts, insect bites, or a
rash such as eczema, any place
where the skin is broken. But it can
also occur on healthy skin.
• It’s called primary impetigo
• when it infects healthy skin and
• secondary impetigo when it occurs in broken skin. It isn’t always easy or
necessary to make this distinction.

53. • Dyshidrosis: (Dys-bad hidrosis-sweat) is a skin condition that causes
small, fluid-filled blisters to form on the palms of the hands and sides of
the fingers. Sometimes the bottoms of the feet are affected too.
• The blisters that occur in dyshidrosis generally last around three weeks
and cause intense itching.
• Symptoms
• The blisters
are usually small about the width of a
standard pencil lead and grouped in
clusters
• Causes
The exact cause of dishidrosis isn't known.
It can be associated with a similar skin
disorder called atopic dermatitis (eczema),
as well as with allergic conditions, such as hay fever.

54. • Bullous pemphigoid: An autoimmune disease that affects the skin and
causes blisters, this is most common in older patients.
• Bullous pemphigoid is a rare skin condition that causes large,
fluid-filled blisters. They develop
on areas of skin that often flex
such as the lower abdomen, upper
thighs or armpits.
Bullous pemphigoid occurs when
your immune system attacks a thin
layer of tissue below your outer layer
of skin. The reason for this abnormal
immune response is unknown, although
it sometimes can be triggered by taking
certain medications.

55. • Pemphigus: A rare group of autoimmune diseases, this affects the skin and
mucous membranes. The immune system attacks an important adhesive molecule
in the skin, detaching the epidermis from the rest of the layers of skin.
• The signs and symptoms of two common types of pemphigus are as follows:
• Pemphigus causes blisters on your skin and mucous membranes. The blisters
rupture easily, leaving open sores, which may ooze and become infected.
• Pemphigus vulgaris. This type usually
begins with blisters in your mouth and then
on your skin or genital mucous membranes.
The blisters typically are painful but don't itch.
Blisters in your mouth or throat may make it
hard to swallow and eat.
• Pemphigus foliaceus. This type causes
• blisters on the chest, back and shoulders.
• The blisters tend to be more itchy than
• painful. Pemphigus foliaceus doesn't cause mouth blisters.

56. • Epidermolysis bullosa: This is a genetic disease of the connective
tissue that causes blistering of the skin and mucous membranes.
• The blisters may appear in response to minor injury, even from
heat, rubbing, scratching or adhesive tape. In severe cases, the
blisters may occur inside the body, such as the lining of the mouth
or the stomach.
• Causes
• Epidermolysis bullosa is usually inherited. The disease gene may be
passed on from one parent who has the disease (autosomal
dominant inheritance). Or it may be passed on from both parents
(autosomal recessive inheritance) or arise as a new mutation in the
affected person that can be passed on

57. Epidermolysis bullosa

58. Mechanism of blister formation
• The most common type of blister for most individuals is the friction
blister. In their most basic form, they occur due to increased
shear stress between the surface of the skin and the rest of the body.
• The layer of the skin most susceptible to shear forces is the stratum
spinosum. As this layer tears away from the tissues below, a plasma-like
fluid leaks from the cells and begins to fill the gap that is created. This
fluid encourages new growth and regeneration.
• Roughly 6 hours after the blister appears, cells at the base of the blister
start to take up amino acids and nucleosides. These are the building
blocks of protein and DNA.
• At 24 hours, cell division is markedly increased. New skin layers above the
stratum spinosum are steadily formed.
• At 48 hours, a new layer of skin can be seen
• As these new cells develop, the fluid is reabsorbed and the swelling
subsides.

59. • Why blisters on feet/ palm causes more
pain??
• Painful blisters on the palm of the hands or
soles of the feet are often caused by tissue
shearing in deeper layers of the skin. These
layers lie next to nerve endings, thereby
producing more pain.

60. • Treatment
• Most blisters will heal without medical intervention. As the new skin grows beneath the blister, the
fluid will slowly disappear and the skin will naturally dry and peel off.
• Blisters are best left intact to prevent infection of the affected area.
• Popping blisters is not recommended, because the bubble is a protective layer that fends off
infection.
• Once the barrier is removed, the wound is open to potential invasion by bacteria and can become
infected.
• Covering the blister with a band-aid or gauze can help protect it from additional trauma while it
heals.
• Allow the fluid to drain away naturally and carefully wash it with mild soapy water.
• Cover the blister and the surrounding area with a sterile, dry dressing.
• Some medications, such as hydrocolloid dressings, can help prevent further discomfort and
encourage the healing process.
• Similarly, with blood blisters, allow them to heal under in their own time. They can be more
painful than standard blisters and an ice pack can offer some relief. Place a towel over the affected
area, ensuring that the ice pack does not come into contact with the skin directly.

61. Hydro-colloid dressing

62. • Prevention
• Friction blisters are best prevented by removing the cause of the friction. This can
be achieved in a number of ways.
• Avoiding blisters on the feet
• Wear well-fitted, comfortable footwear and clean socks. Badly fitted or stiff shoes,
such as high heels, carry a higher risk of blistering. Moist skin blisters more easily,
so socks that manage moisture or frequent sock changes can be helpful.
• During exercise and sports, specially designed sports socks can reduce the amount
of available foot sweat.
• Avoiding blisters on the hands
• When using tools, carrying out manual work or playing a sport where holding a bat
is necessary, wearing gloves will prevent the majority of blisters.
• In some sports, such as gymnastics, weightlifting or rowing, taping up the hands is
good practice. Additionally, talcum powder acts to reduce friction and can be
used in combination with gloves and tape, or as a stand-alone option. But,
because talcum powder absorbs moisture, it will not work well for long durations
of activity.

63. • First aid for blister:
• If a blister isn't too painful, try to keep it intact.
• Don’t break skin over a blister may provide a
natural barrier to bacteria and decreases the risk
of infection.
• Cover it with an adhesive bandage or moleskin.
Cut a piece of moleskin into a doughnut shape
and place the pad so that it encircles and
protects the blister.

64. • How to drain a blister
• To relieve blister-related pain, drain the fluid while leaving the
overlying skin intact. Here's how:
• Wash your hands and the blister with soap and warm water.
• Swab the blister with iodine.
• Sterilize a clean, sharp needle by wiping it with rubbing alcohol.
• Use the needle to puncture the blister. Aim for several spots near
the blister's edge. Let the fluid drain, but leave the overlying skin in
place.
• Apply an ointment such as petroleum jelly to the blister and cover
it with a nonstick gauze bandage. If a rash appears, stop using the
ointment.
• Follow-up care.

65. Abscess
• Definition: An abscess is a cavity filled with pus
(pyoderma or sepsis). It contains white blood
cells, dead tissue and bacteria.
• Pyoderma: Infection of skin by pyogenic bacteria

66. • Abscesses can develop anywhere in the body.
• skin abscesses – which develop under the skin
• internal abscesses – which develop inside the body, in an
organ or in the spaces between organs
• Incisional abscess
• An incisional abscess is one that develops as a complication
secondary to a surgical incision.
• It presents as redness and warmth at the margins of the
incision with purulent drainage from it.
• If the diagnosis is uncertain, the wound should be
aspirated with a needle, with aspiration of pus confirming
the diagnosis and availing for Gram stain and bacterial

67. Types of abscess
Other types of abscess
• There are many other types of abscess, including:
• Anorectal abscess – a build-up of pus in the rectum and anus
• Bartholin's abscess – a build-up of pus inside one of the Bartholin's
glands, which are found on each side of the opening of the vagina( vaginal
orifice)
• brain abscess – a rare but potentially life-threatening build-up of pus
inside the skull
• Dental abscess – a build-up of pus under a tooth or in the supporting
gum and bone
• quinsy (peritonsillar abscess) – a build-up of pus between one of your
tonsils and the wall of your throat (as complication of tonsilitis+ bacterial
infection)
• pilonidal abscess – a build-up of pus in the skin of the cleft of the
buttocks (where the buttocks separate)
• spinal cord abscess – a build-up of pus around the spinal cord

68. • Causes of abscesses
• Most abscesses are caused by a bacterial infection, parasites, or foreign
substances, but bacteria is most common cause.
• When bacteria enter your body, your immune system sends infection-fighting
white blood cells to the affected area.
• As the white blood cells attack the bacteria, some nearby tissue dies, creating a
hole which then fills with pus to form an abscess. The pus contains a mixture of
dead tissue, white blood cells and bacteria.
• Internal abscesses often develop as a complication of an existing condition, such
as an infection elsewhere in your body. For example, if your appendix bursts as a
result of appendicitis, bacteria can spread inside your tummy (abdomen)
and cause an abscess to form.
• The most common bacterial organism responsible for the development of skin
abscesses is Staphylococcus aureus, although various other organisms can also
lead to abscess formation. With the emergence of methicillin-
resistant Staphylococcus aureus (MRSA), health care providers must now consider
this organism as the possible cause when a skin abscess is encountered.

69. • Pathophysiology:
• An abscess is a defensive reaction of the tissue to prevent the
spread of infectious materials to other parts of the body.
• The organisms or foreign materials kill the local cells, resulting in
the release of cytokines. The cytokines trigger an inflammatory
response, which draws large numbers of white blood cells to the
area and increases the regional blood flow.
• 2- The final structure of the abscess is an abscess wall, or capsule,
that is formed by the adjacent healthy cells in an attempt to keep
the pus from infecting neighboring structures. However, such
encapsulation tends to prevent immune cells from attacking
bacteria in the pus, or from reaching the causative organism or
foreign object.

70. • Symptoms of an abscess
• A skin abscess often appears as a swollen,
pus-filled lump under the surface of the skin.
• You may also have other symptoms of an
infection, such as a high temperature (fever)
and chills.
• warmth and redness in the affected area
• A boil is a common example of a skin abscess.

71. • Some common Symptoms of internal abscesses
• The symptoms of an internal abscess can also vary depending on exactly where in
the body the abscess develops. For example, a liver abscess may cause jaundice,
whereas an abscess in or near the lungs may cause a cough or shortness of breath.
• General symptoms of an internal abscess can include:
• discomfort in the area of the abscess
• fever
• increased sweating
• feeling sick
• vomiting
• chills
• pain or swelling in your tummy (abdomen)
• loss of appetite and weight loss
• extreme tiredness (fatigue)
• diarrhoea or constipation

72. • Risk factors:
• You’re at increased risk for this bacterial infection if you have:
• close contact with an individual who has a staph infection, which is why these
infections are more common in hospitals
• a chronic skin disease, like acne or eczema
• diabetes
• a weakened immune system, which can be caused by infections such as HIV
• poor hygiene habits
• Infected hair follicles
• Infected hair follicles, or folliculitis, may cause abscesses to form in the follicle.
Follicles can become infected if the hair within the follicle is trapped and unable to
break through the skin, as can happen after shaving.
• Trapped hair follicles are commonly known as ingrown hairs. Ingrown hairs can set
the stage for an infection. Abscesses that are on or in a hair follicle will often
contain this ingrown hair.
• Folliculitis may also occur after spending time in an inadequately chlorinated pool
or hot tub.

73. • Exams and Tests
• The doctor will take a medical history and may ask you:
• How long the abscess has been present
• If you recall any injury to that area
• What medicines you may be taking
• If you have any allergies
• If you have had a fever at home
• The doctor will examine the abscess and surrounding areas. If it is near your anus,
the doctor will perform a rectal exam. If an arm or leg is involved, the doctor will
feel for a lymph gland either in your groin or under your arm.
• Your doctor may also take a culture or a small amount of fluid from the abscess to
test for the presence of bacteria. No other testing methods are necessary to
diagnose an abscess.
• However, if you’ve had reoccurring skin abscesses and your doctor feels that an
underlying medical condition may be the cause, they may take a blood or urine
sample.

74. Difference between cyst and abscess
CYST
• cyst is a sac enclosed by
distinct abnormal cells
• Symptoms: a cyst grows slowly
and isn’t usually painful,
unless it becomes enlarged.
• When an already-formed cyst
becomes infected, it becomes
an abscess.
• Not infected.
ABSCESS
• an abscess is a pus-filled
infection in your body caused
by, for example, bacteria or
fungi.
• Symptoms: an abscess is
painful, irritated, often red,
and swollen, and the infection
can cause symptoms
elsewhere in the body.
• But an abscess doesn’t have to
begin as a cyst. It can form on
its own.
• an abscess is infected

75. • Treatment: A small skin abscess may drain naturally, or simply shrink, dry
up and disappear without any treatment.
• Abscesses can be treated in a number of different ways, depending on the type
of abscess and how large it is.
• The main treatment options include:
• antibiotics
• a drainage procedure
• surgery
• Skin abscesses
• Some small skin abscesses may drain naturally and get better without the need for
treatment. Applying heat in the form of a warm compress, such as a warm flannel,
may help reduce any swelling and speed up healing.
• However, the flannel should be thoroughly washed afterwards and not used by
other people, to avoid spreading the infection.
• For larger or persistent skin abscesses, your GP may prescribe a course of
antibiotics to help clear the infection and prevent it from spreading.

76. • Skin abscesses
• Some small skin abscesses may drain naturally and get better without the
need for treatment. Applying heat in the form of a warm compress, such
as a warm flannel, may help reduce any swelling and speed up healing.
• However, the flannel should be
thoroughly washed afterwards and
not used by other people, to avoid
spreading the infection.
• For larger or persistent skin abscesses, your GP may prescribe a course of
antibiotics to help clear the infection and prevent it from spreading.
• Sometimes, especially with recurrent infections, you may need to wash
off all the bacteria from your body to prevent re-infection
(decolonisation). This can be done using antiseptic soap for most of your
body and an antibiotic cream for the inside of your nose.

77. • Surgery (Incision and drainage)
• If your skin abscess needs draining, you'll probably have a small
operation carried out under anesthetic– usually a local anesthetic
where you remain awake and the area around the abscess is
numbed.
• During the procedure, the surgeon makes a cut (incision) in the
abscess, to allow the pus to drain out. They may also take a sample
of pus for testing.
• Once all of the pus has been removed, the surgeon will clean the
hole that is left by the abscess using sterile saline (a salt solution).
• The abscess will be left open but covered with a wound dressing,
so if any more pus is produced it can drain away easily. If the
abscess is deep, an antiseptic dressing (gauze wick) may be placed
inside the wound to keep it open.
• The procedure may leave a small scar.

78. • Internal abscesses
• The pus usually needs to be drained from an
internal abscess, either by using a needle inserted
through the skin (percutaneous abscess
drainage) or with surgery.
• The method used will depend on the size of your
abscess and where it is in your body.
• Antibiotics will usually be given at the same time,
to help kill the infection and prevent it spreading.
These may be given as tablets or directly into a
vein (intravenously).

79. • Percutaneous drainage
• If the internal abscess is small, your surgeon may be able to drain it
using a fine needle. Depending on the location of the abscess, this
may be carried out using either a local or general anaesthetic.
• The surgeon may use ultrasound scans or computerised
tomography (CT) scans to help guide the needle into the right place.
• Once the abscess has been located, the surgeon drains the pus
using the needle. They may make a small incision in your skin over
the abscess, then insert a thin plastic tube called a drainage
catheter into it.
• The catheter allows the pus to drain out into a bag and may have to
be left in place for up to a week.
• This procedure may be carried out as a day case procedure, which
means you'll be able to go home the same day, although some
people will need to stay in hospital for a few days.

80. • Surgery
• You may need to undergo surgery if:
• your internal abscess is too large to be drained with a
needle
• a needle can't get to the abscess safely
• needle drainage hasn't been effective in removing all of
the pus
• The type of surgery you have will depend on the type
of internal abscess you have and where it is in your
body. Generally, it involves making a larger incision in
your skin to allow the pus to be washed out.

81. • Can Abscesses Be Prevented?
• Good hygiene is the best way to avoid infection.
Keep cuts and wounds clean, dry, and covered to
protect them from germs.
• Also, don't share clothing, towels, razors, or bed
linens with anyone else. When these items get dirty,
wash them separately in very hot water.
• Wash your hands well and often using plain soap and
water for at least 20 seconds each time. It's OK to use
alcohol-based instant hand sanitizers or wipes (the kind
that you can pick up at a drugstore) if you're not near
any soap and water.

82. Endemic ulcer
BURULI ULCER
• Definition: is a chronic, debilitating, necrotizing disease of the skin,
soft tissue and sometime bone caused by Mycobacterium ulcerans.
• Mycobacterium ulcerans: The organism belongs to the family of
bacteria that causes tuberculosis and leprosy.
• HOSTORY: Buruli ulcer was first described by Sir Albert Cook in
patients from Buruli County in Uganda,
• Synonym: Bairnsdale ulcer
• Buruli ulcer was first diagnosed in the Bairnsdale area in the 1930s.
• Endemic: a disease regularly found among particular people or in a
certain area.
• Although it has been reported in over 33 countries around the
world, the greatest burden of disease is in the tropical regions of
West and Central Africa, Australia, and Japan

83. Buruli ulcer

84. • Causative organism
• Mycobacterium ulcerans is a slow-growing mycobacterium that
classically infects the skin and subcutaneous tissues, giving rise to
(nodules, plaques) and ulcerated lesions.
• After tuberculosis and leprosy, Buruli ulcer is the third most
common mycobacteriosis of humans. M. ulcerans grows optimally
on routine mycobacteriologic media at 33 °C .
• Buruli ulcers generally begin as a painless dermal papule or
subcutaneous edematous nodule, which, over a period of weeks to
months, breaks down to form an extensive necrotic ulcer with
undermined edges.
• PAPULE- PIMPLE LIKE
• NODULE- SMALL COLLECTION OF TISSUES THAT CAN PALPABLE
• EDEMATOUS- SWELLING WITH EXCESSIVE ACCUMULATION OF
FLUID

85. • Pathogenesis: M ulcerans are slow-growing mycobacteria that produce a soluble polyketide
exotoxin called mycolactone, which can diffuse extensively in the subcutaneous tissue.
• properties mycolactone has both immunosuppressive properties + cytotoxic properties, dramatic
tissue destruction occurs without inducing inflammation or systemic symptoms, such as fever,
malaise, or adenopathy.
• Progression: The toxins made by the bacteria destroy skin cells, small blood vessels and the fat
under the skin, which leads to ulceration and skin loss.
• Molecular targets
• Mycolactone targets proteins, which controls actin dynamics and leads to a loss of cellular
detachments and cell death.
• (actin protein- present in all eukaryotes & functions as muscle contraction, cell motility, cell
division, cytokines)
• Mycolactone also inhibits the function of the Sec61 translocation, which is responsible for protein
translocation into the endoplasmic reticulum. This affects 30-50% of mammalian proteins, including
circulating inflammatory mediators and proteins involved in lipid metabolism, coagulation, and
tissue remodeling. Therefore, patients with M ulcerans infections have global and chronic defects
in protein metabolism.

86. • Molecular targets
• 1- Mycolactone targets proteins, which controls actin dynamics
and leads to a loss of cellular detachments and cell death.
• (actin protein- present in all eukaryotes & functions as muscle
contraction, cell motility, cell division, cytokines)
• 2- Mycolactone also inhibits the function of the Sec61
translocation, which is responsible for protein translocation into
the endoplasmic reticulum. This affects 30-50% of mammalian
proteins, including circulating inflammatory mediators and proteins
involved in lipid metabolism, coagulation, and tissue remodeling.
• Therefore, patients with M ulcerans infections have global and
chronic defects in protein metabolism.

87. • Signs and symptoms
• Buruli ulcer often starts as a painless swelling (nodule). It can also initially present
as a large painless area of induration (plaque) or a diffuse painless swelling of the
legs, arms or face (oedema). Local immunosuppressive properties of the
mycolactone toxin enable the disease to progress with no pain and fever. Without
treatment or sometimes during antibiotics treatment, the nodule, plaque or
oedema will ulcerate within 4 weeks with the classical, undermined borders.
Occasionally, bone is affected causing gross deformities.
• The progression of symptoms can include:
• A spot that looks like a mosquito or spider bite forms on the skin (most commonly
on the limbs).
• The spot grows bigger over days or weeks.
• The spot may form a crusty, non-healing scab.
• The scab then disintegrates into an ulcer.
• The ulcer continues to enlarge.
• Unlike other ulcers, this ulcer is usually painless and there is generally no fever or
other signs of infection.

88. • Transmission:
• It is not known how humans become infected,
although it is thought that mosquitoes may
have a role in transmitting the infection. Buruli
ulcer is not thought to be transmitted person-
to-person.
• Recent evidence suggests insects may be
involved in the transmission of the
infection. These insects are aquatic bugs

89. • Diagnosis of Buruli ulcer
• Buruli ulcer is usually diagnosed by a doctor, based on:
• medical history
• travel history – if you have travelled to an area associated with
Buruli ulcer
• physical examination – to identify a slowly enlarging, painless ulcer
• swabs or biopsy taken from the ulcer, which are tested in a
laboratory.
• Laboratory test:
• Four standard laboratory methods can be used to confirm Buruli
ulcer;
• polymerase chain reaction (PCR), direct microscopy, histopathology
and culture.

90. • Treatment:
• If treated early, antibiotics for eight weeks are effective
in 80% of people. This often includes the
medications rifampicin and streptomycin.
Clarithromycin or moxifloxacin are sometimes used
instead of streptomycin.
• Surgery: Treatment may also include cutting out the
ulcer. This may be a minor operation and very
successful if undertaken early. Advanced disease may
require prolonged treatment with extensive skin
grafting. Surgical practice can be dangerous in the
developing countries where the disease is common.

91. • Prevention of Buruli ulcer
• Although the exact cause of infection in humans is not
known, it makes sense to protect yourself from potential
sources of infection such as soil and insect bites.
Suggestions to reduce the risk of infection include:
• Wear gardening gloves, long-sleeved shirts and trousers
when working outdoors.
• Avoid insect bites by using suitable insect repellents.
• Protect cuts or abrasions with sticking plasters.
• Promptly wash and cover any scratches or cuts you receive
while working outdoors.
• visit your doctor if you have a slow-healing skin lesion.