MOS IN THE SKIN AND EYES
o Separate from the follicle
THE SKIN AND ITS DEFENSES
• Integument System
o Skin
o Hair
o Nails
o Sweat and oil glands
Layers of the Skin
• Layers of the Skin: Epidermis
o Outermost portion of the skin
o Further subdivided into 4 to 5 distinct layers
– Stratum corneum
Gives the cells ability to withstand damage and
abrasion (keratinized – surface of the skin)
– Stratum basale / basal layer
Attached to the underlying dermis
Source for all of the cells that make up the
epidermis
• Layers of the Skin: Dermis
o Composed of connective tissue
– Rich matrix of fibroblast cells and fibers such as
collagen
– Contains macrophages and mast cells
o Harbors a dense network of nerves, blood vessels, and
lymphatic vessels
o Damage to the dermis results in bleeding
o Blister formation
– Result of friction trauma or burns
– Causes a separation between the dermis and the
epidermis
• Layers of the Skin: Dermis
o Follicles
– Roots of hairs located in the dermis
– Sebaceous (oil) glands and scent glands are
associated with the hair follicle
fcnlxa – St. Luke’s College of Nursing
• Sweat glands
o Located in the dermis
• All glands have openings on the surface of the skin
o Pass through the epidermis
The Skin and Its Defenses
• Antimicrobial Peptides
o Small molecules; antimicrobial substances
o Most effective skin defense against infection
o They are positively charged chemicals that act by
disrupting (negatively charged) membranes of
bacteria
o Many types of these peptides – chiefly responsible for
keeping the microbial count on skin relatively low
• Sebum
o Secreted by sebaceous glands
o Low pH makes skin inhospitable to most
microorganisms
o High concentration of lipids serve as nutrients for
normal microbiota
o Breakdown of fatty acids leads to toxic by-products
that inhibit the growth of other microbes not adapted
to the skin
• Sweat
o Low pH and high salt concentration inhibit microbes
• Lysozyme
o Enzyme found in sweat, tears, and saliva
o Specifically breaks down peptidoglycan
Normal Biota of the Skin
• Human Microbiome Project
o Initiated by US National Institute of Health
o To improve understanding of the microbial flora
involved in human health and disease
o HMP1 (phase 1) focused on identifying and
characterizing human microbial flora
o Hundreds of species of microbes found distributed over
many different areas of the body
o Although five major taxa were represented in the
microbiota, the predominance of these groups varied in
the different regions of the body sampled
o There are large differences among people with respect to
the types of microbes found on various skin sites
o An individual’s own skin microbiota seems to be relatively
stable over time.
• Other observations
o Staphylococcus epidermidis and Propionibacterium
acnes are found in large numbers on skin due to their
tolerance of high salt conditions
o About 4% of the population carry Staphylococcus
aureus – a potential pathogen on the skin
o Establish differences among healthy microbiomes and
those of patients affected by skin disorders
o How a person’s living environment may dictate the
composition and distribution of microbes on the skin
o Many microbes were identified living under the skin –
vast majority of microbes resided within the uppermost
layers of the epidermis
o Nearly 25% of all bacteria were localized to hair
follicles
o Important to determine the role of the microbes in
dermatologic disease
1
 NORMAL BIOTA OF THE SKIN
SKIN DISEASES CAUSED BY MICROORGANISMS
Skin diseases
• MRSA Skin and Soft Tissue
Infections
• Impetigo
• Cellulitis
• Gas Gangrene
• Vesicular or Pustular Rash
Diseases
• Maculopapular Rash
Diseases
• Wart-like Eruptions
• Large Pustular Skin Lesions
• Ringworm (Cutaneous
Mycoses)
• Superficial Mycosis
fcnlxa – St. Luke’s College of Nursing
Focus of discussions
• Name of Infection
• General Idea
• Signs and Symptoms
• Transmissions and
Epidemiology
• Pathogenesis and
Virulence Factors
• Culture and/or Diagnosis
• Prevention and Treatment
Vaccination approach
A) MRSA and Soft Tissue Infections
o Methicillin-resistant
Staphylococcus aureus
o Common cause of skin
lesions in non-
hospitalized people
o Resistant to multiple
antibiotics
o MOS: Staphylococcus aureus
o G+ coccus; grows in clusters
o Non-motile
o Can be highly virulent; but appear as “normal” biota
on the skin of 1/3 of the population
• Signs and symptoms
o Tend to be raised, red, tender, localized lesions
o Often featuring pus and feeling hot to touch
o Occur easily in breaks in the skin caused by injury,
shaving, or even just abrading
o May localize a hair follicle
o Fever – common feature
• Transmission & Epidemiology
o Contaminant of all kinds of surfaces to touch, esp
surfaces not routinely sanitized
o All sources of indirect contact infection
o AVOID: Persons with active MRSA skin infections should
keep them covered
• Pathogenesis & Virulence Factors
o Coagulase – 97% of all humans isolates of S. aureus
produce this enzyme, its presence is considered most
important characteristics for diagnosis
o Hyaluronidase – digests the intercellular “glue”
(hyaluronic acid) that binds connective tissue in host
tissues
o Staphylokinase – digests blood clots; a nuclease that
digest DNA (DNAse), and lipases that help the
bacteria colonized oily skin surfaces
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 • Culture and/or Diagnosis
o PCR – genotyphic based
o Inoculation on blood agar – phenotypic
o Selective media: Mannitol salt agar (MSA)
o Catalase – enzyme that breakdowns hydrogen
peroxidase accumulated during oxidative metabolism
– used to differentiate staphylococci

• Prevention & Treatment

o Good hygiene
o Incision of the lesion and drainage of the pus
o Antimicrobial treatment should include more than one
antibiotic: Vancomycin
o NOTE: Course of recommendation will change based
on antibiotic-resistance patterns.

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B) Impetigo • Prevention & Treatment
o A superficial bacterial o Prevention: Good hygiene
infection that causes the o TX: drug that will target either bacterium; need to
skin to flake or peel off determine exact etiologic agent
o Not a serious disease but o Topical mupirocin – drug of choice, topical; protein
highly contagious; children synthesis inhibitor
are the primary victims o Retapamulin – topical
o Can also occur around o Dicloxacillin or cephalexin – used for sensitive strains
local trauma to the skin o Trimethoprim-sulfamethoxazole (TMP-SMZ) – 1st
o Caused by either S. aureus alternative for MRSA (often resistance to multiple
or S. pyogenes, or a drugs)
mixture of the 2 • Prevention & Treatment
o Symptoms are the same regardless of the organism o Visual inspection
causing the infection o Tx with abx that target both probable causative
• MOS: Streptococcus pyogenes agents
o G+ coccus in Lancefield group A o If 1st tx fails, well-established methods exist to identify
o Β-hemolytic on blood agar microbial infections
o Also causes strep throat, scarlet fever, pneumonia, o Additional biochemical testing is required:
puerperal fever, necrotizing fasciitis, bloodstream – Catalase test use to differentiate the
infections, and rheumatic fever staphylococci from streptococci
o Adhesive elements: LTA, M protein, hyaluronic acid
capsule
• Signs and Symptoms
o Looks like peeling skin, crusty, and flaky scabs or
honey-colored crusts
o Lesions are most often found around the mouth, face,
and extremities, though they can occur anywhere on
the skin
o Superficial and it itches
• Pathogenesis and Virulence Factors
Staphylococcus aureus Streptococcus pyogenes
• Exotoxins called exfoliative toxins A • Symptoms of S. pyogenes impetigo
and B – code for by a phage that are indistinguisble from those
infects some S. aureus strain caused by S. aureus
• Attack a protein that is important • Have arsenal enzymes & toxins
for epithelial cell-to-cell binding; o Streptokinase
breaking this protein leads to the o Plasminogen-binding ability
characteristics blistering o Hyaluronidase
• Produce coagulase o M protein (protect from
o An enzyme that coagulates phagocyctosis)
plasma and blood • Anchors to surfaces (including skin)
o Causes fibrin to be deposited using a variety of adhesive
around the bacteria, elements on its surface (LTA, M
concentrating exotoxin in an protein, and other proteins, and a
area of local damage hyaluronic acid capsule)
• Can be followed by acute
poststreptococcal
glomerulonephritis

C) Cellulitis
o Caused by a fast-
spreading infection
in the dermis and
subcutaneous tissues
• Transmission and Epidemiology o Septicemia can
o Highly contagious and transmitted; direct contact develop – most
o Via fomites and mechanical vectors cases of the disease
o Affects mostly preschool children are uncomplicated
o Individuals of all ages can acquire the disease and px have a good
o Peak of incidence: summer and fall prognosis
o Usually follows the introduction of bacteria or fungi into
the dermis through trauma or no obvious break in skin

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 o Very common in the lower leg • Culture/Dx
o Most common causes: S. aureus and S. pyogenes, o Histological sections
although any bacterium and some fungi can cause o Culture performed but false negatives common
this condition in an immunocompromised px because toxins alone are sufficient for disease
o Infants – group B streptococci B are frequent cause • Prevention
o People with immunocompromise or who have cardiac o Eliminate carriers in contact with neonates
insufficiency are most at risk
• Signs and Symptoms • Treatment
o Pain, tenderness, swelling and warmth o Immediate systemic abx
o Fever and swelling of lymph nodes o Current rec: cloxacillin
o Frequently display red lines leading away from o MRSA is in Serious Threat category in CDC
affected area (lymphangitis – result of MOS and o Antibiotic Resistance Report
inflammatory products being carried by the lymphatic
system)

E) Gas Gangrene
o Also known as clostridial myonecrosis
o Also caused by S. pyogenes and S. aureus, but less
frequently
D) Staphylococcal Scalded Skin Syndrome (SSSS) o Two forms
o Dermolytic condition caused by S. aureus 1. Anaerobic cellulitis - bacteria spread within
o Develops predominantly in damaged necrotic muscle tissue, producing
newborns and babies; children toxins and gas as the infection proceeds
and adults can be affected 2. True myonecrosis - caused by specific exotoxins
o A systemic form of impetigo • MOS: Clostridium perfringens
o An exotoxin-mediated disease o G+
– Phage-encoded exfoliative o Endospore-forming
toxins A and B are o Habitat: soil, human skin, human intestine and vagina
responsible for symptoms o Anaerobic, requires anaerobic conditions to
• Bolus lesions manufacture and release the exotoxins that cause the
o Caused by exfoliative toxins A and B damage
o S/S: • Signs and Symptoms
– Red areas Anaerobic cellulitis True myonecrosis
– Appearance of wrinkled tissue • MOS spread within damaged • More destructive
paper necrotic muscle tissue, • Toxins produced in large
– Then form very large blisters producing toxins and gas as muscles (thigh, shoulder,
– Fever may precede the skin the infection proceeds buttocks)
manifestations • Infections remains localized • Diffuse into nearby health
– Top layers of epidermis peel off completely • Does not spread into healthy tissue
o Lead to widespread desquamation of the skin tissues • Cause local necrosis at sites
o Patients are left vulnerable to secondary bacterial • Damaged tissues then serve
infections as a focus for continued
D) Staphylococcal Scalded Skin Syndrome (SSSS) IN ADULT bacterial growth, toxin
formation and gas
production
• General
o Pain, edema, bloody exudate in the lesion, fever,
tachycardia and blackened necrotic tissue filled with
bubble of gas
o Gangrenous infections of the uterus caused by septic
abortions and clostridial septicemia are particularly
serious complications that can arise

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 • Pathogenesis and Virulence Factors
Several active exotoxins
o Alpha toxin – most potent toxin, causes RBC rupture,
edema and tissue destruction
o Collagenase
o Hyaluronidase
o Dnase
o Gas form in tissues, resulting from fermentation of
muscle carbohydrates, can also destroy muscle
structure
o Histology/MRI can visualize disruptions

• Infections

• Chickenpox
Causative Human herpesvirus
• Transmission & Epidemiology Organism(s) 3 (varicellazoster virus)
Predispose a person to gangrene:
o Surgical incisions Epidemiological Chickenpox: vaccine decreased
o Compound fractures Features hospital visits by 88%, ambulatory visits by
o Diabetic ulcers 59%; shingles: 1 in 3 American adults will
o Septic abortions have it at least once
o Puncture
o Gunshot wounds Common Droplet contact, inhalation of
o Crushing injuries contaminated by endospores from Modes of aerosolized lesion fluid
the environment Transmission
• Prevention & Treatment
Virulence Ability to fuse cells, ability to remain
o Surgical removal
Factors latent in ganglia
o Hyperbaric oxygen therapy
o Clindamycin + penicillin Distinguishing No fever prodrome; lesions are
o Amputation for extensive myonecrosis of a limb Features superficial; in centripetal distribution
(more in center of body)

Culture / Based largely on clinical Appearance;

Diagnosis PCR is available

Prevention Live attenuated vaccine; there is also

vaccine to prevent reactivation of latent
virus (shingles)

Treatment None in uncomplicated cases; acyclovir

for high risk
• Smallpox
Causative Variola virus
Organism(s)

Epidemiological Last natural case worldwide was in 1977

Features Category A Bioterrorism Agent

Common Droplet contact, indirect contact

Modes of
Transmission

Virulence Ability to dampen, avoid immune

Factors response
F) Vesicular or Pustular Rash Disease
Distinguishing Fever precedes rash; lesions are deep
Features and in centrifugal distribution (more on
extremities)

Culture / Based largely on clinical Appearance; if

Diagnosis suspected, refer to CDC

Prevention Live virus vaccine (vaccinia virus)

Treatment Cidofovir; vaccine within 7 days of

exposure

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 • Shingles G) Maculopapular Diseases
• Measles
Causative Herpes zoster; reactivation of the
Organism(s) varicella zoster virus, same virus that Causative Measles virus (Rubeola)
causes chickenpox. Organism(s)

Epidemiological Intestinal infection; contagious Epidemiological Incidence increasing in North America; in

Features Features developing countries incidence is 30
million cases/yr and 1 million deaths
Common Direct contact, swallow small amount of
Modes of bacteria from the stool of the infection Common Droplet contact
Transmission person Modes of
Transmission
Virulence Virus becomes latent within the ganglia
Factors Virulence Syncytium formation, ability to suppress
Factors cell-mediated immunity
Distinguishing Presents with asymmetrical lesions on the
Features trunk or head; diarrhea; stomach Distinguishing Starts on head, spreads to whole body,
pain/cramps; fever, nausea Features lasts over a week

Culture / Culture / Clinical diagnosis; ELISA or PCR

Diagnosis Diagnosis

Prevention Prevention Live attenuated vaccine (MMR or

MMRV)
Treatment Attenuated vaccine recommended for
adults Treatment No antivirals; vitamin A, antibiotics for
secondary bacterial infections
• Hand, Foot, and Mouth Disease (HFMD)
• Signs and Symptoms of measles
Causative Enteroviruses, usually Coxsackie
o Sore throat, dry cough, headache, conjunctivitis,
Organism(s)
lymphadenitis, and fever; Koplik’s spots appear as a
Epidemiological Sporadic in most of world; unusual prelude to the characteristic red, maculopapular
Features outbreaks in East and Southeast Asia exanthem
since 1997 caused by an enterovirus o Small number of cases develop laryngitis,
bronchopneumonia, and bacterial secondary
Common Direct and droplet contact infections
Modes of o In 6% of the cases, the virus can cause pneumonia
Transmission o Most serious complication is subacute sclerosing
panencephalitis: progressive neurological
Virulence N/A degeneration of the cerebral cortex, white matter,
Factors and brain stem

Distinguishing Fever prodrome; lesions in mouth first • Rubella

Features
Causative Rubella virus
Culture / Usually based on clinical presentation Organism(s)
Diagnosis and history
Epidemiological Ten to twelve cases (usually imported);
Prevention Hand hygiene Features worldwide: 100,000 infants/yr born with
congenital rubella syndrome
Treatment None
Common Droplet contact
Modes of
Transmission

Virulence Inhibition of mitosis, induction of

Factors apoptosis, and damage to vascular
endothelium

Distinguishing Milder red rash, lasts approximately 3

Features days

Culture / Acute IgM, acute/convalescent IgG

Diagnosis

Prevention Live attenuated vaccine (MMR or

MMRV)

Treatment N/A

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 • Congenital Rubella
Infection in the first trimester
o Induces miscarriage
o Causes multiple permanent defects in the newborn
Congenital defects caused by rubella
o Deafness
o Cardiac abnormalities
o Ocular lesions
o Rashes
o Mental and physical retardation

• Fifth Disease
Causative Parvovirus B19
Organism(s)

Epidemiological 60% of population seropositive by age 20

Features

Common Droplet contact, direct contact

Modes of
Transmission

Virulence
Factors

Distinguishing “Slapped-face” rash first, spreads to

Features limbs and trunk, tends to be confluent
rather than distinct bumps

Culture / Usually diagnosed clinically

Diagnosis

Prevention

Treatment

• Roseola
Causative Human herpesvirus 6 H) Warts and Wart-like Eruptions
Organism(s) • Warts
o Papillomas
Epidemiological >90% of population seropositive; 90% of – Develop in nearly all
Features disease cases occur before age of 2 individuals, children more
than adults
Common Unknown o Seed warts
Modes of – Painless, elevated rough
Transmission growths on fingers and
other body parts
Virulence Ability to remain latent o Plantar warts
Factors – Deep, painful papillomas
on the soles of the feet
Distinguishing High fever precedes rash stage; rash not
o Flat warts
Features always present
– Smooth, skin-colored lesions that develop on the
Culture / Usually diagnosed clinically face, trunk, elbows, and knees
Diagnosis
• Molluscum Contagiosum
Prevention o Develop in nearly all
individuals, children more
Treatment than
o Smooth, waxy nodules on
the face, trunk, and limbs
o May be indented in the
middle and contain a milky
fluid
o Highest incidence in certain regions of the Pacific Islands
o Children: face, arms, legs, and trunk
o Adults: genital area
o Immunocompromised: can be disfiguring and more
widespread on the body

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 • Signs and Symptoms of Cutaneous Mycoses
o Ringworm of the Scalp (Tinea Capitis) – results from the
fungal invasion of the scalp and the hair of the head,
eyebrows, and eyelashes
o Ringworm of the Beard (Tinea Barbae) – also called
barber’s itch, affects the chin and beard of adult males;
contracted mainly from animals
o Ringworm of the Body (Tinea Corporis) – can appear
nearly anywhere on the body’s glabrous (smooth and
bare) skin
o Ringworm of the Groin (Tinea Cruris) – jock itch; crural
ringworm occurs mainly in males on the groin, perianal
skin, scrotum, and occasionally the penis; fungus thrives
under conditions of moisture and humidity created by
sweating
o Ringworm of the Foot (Tinea Pedis) – athlete’s foot and
jungle rot; blisters between the toes that burst, crust over,
I) Large Pustular Skin Lesions and can spread to the rest of the foot and nails
• Leishmaniasis o Ringworm of the Nail (Tinea Unguium) – common sites are
o Zoonosis transmitted by female sand fingernails and toenails; first symptoms are usually
flies superficial white patches in the nail bed; more invasive
o Cutaneous leishmaniasis: form causes thickening, distortion, and darkening of the
– Localized infection of the nail
capillaries of the skin
– Found in the Mediterranean, African, and Southeast
Asian regions
o Mucocutaneous leishmaniasis:
– Affects both skin and mucous membranes
– Endemic to parts of Central and South America

• Cutaneous Anthrax
o Most common and least dangerous
infection caused by Bacillus anthracis
o Forms a black eschar when endospores
enter the skin and germinate there
o 11 cases occurred following bioterrorist
attacks in the fall of 2001
o 20% mortality rate if untreated
• Superficial Mycoses
o Involve the outer epidermal surface
o Innocuous infections with cosmetic rather than
inflammatory effects
o Tinea versicolor
– Malassezia yeast
– Causes mild, chronic scaling
that interferes with melanocytes
o Other conditions: folliculitis, psoriasis,
and seborrheic dermatitis

J) Cutaneous and Superficial Mycoses

• Ringworm (Cutaneous Mycoses)
o Dermatophytes:
– Mycoses strictly confined to nonliving epidermal
tissues and their derivatives
o Tinea:
– Derives from the erroneous belief that these
infections were caused by worms
o 39 species in the genera Trichophyton, Microsporum, and
Epidermophyton that cause tinea conditions

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 THE SURFACE OF THE EYE AND ITS DEFENSES

• Conjunctiva
o Exposed to the environment
o Thin membrane-like tissue that covers the eye and lines
the eyelids
o Secretes an oil- and mucus-containing fluid that
lubricates and protects the surface of the eye
• Cornea
o Exposed to the environment
o Dome-shaped central portion of eye lying over the iris
o Five to six layers of epithelial cells that can regenerate
quickly if superficially damaged
o “The windshield of the eye”
• Tears
o Best defense of the eye
o Consist of aqueous fluid, oil, and mucus
o Formed in the lacrimal gland at the outer and upper
corner of each eye • Ocular Trachoma
o Drain into the lacrimal duct at the inner corner o Chronic infection of the
• Immune Privilege epithelial cells of the eye
o Reduced innate immunity of the eye to protect vision caused by Chlamydia
o B and T cell response in the eye is reduced trachomatis
o Anterior chamber is largely cut off from blood supply o Major cause of blindness
o Lymphocytes that gain access to the eye are less around the world
active than elsewhere in the body o Endemic in parts of Africa,
Asia, the Middle East, Latin America, and Pacific
Islands
NORMAL BIOTA OF THE EYE o Ongoing or recurrent infections lead to chronic
• Diversity in the bacteria inflammatory damage and scarring
o Corynebacterium is the dominant genus
• Eye microbiome resembles that of the skin:
o Diphtheroids
o Coagulase-negative staphylococci
o Micrococcus
o Nonhemolytic streptococci
o Some yeast
o Neisseria species

DEFENSES AND NORMAL BIOTA OF THE EYE

Defenses Normal Biota

Eyes Mucus in conjunctiva Corynebacterium,
and in tears; lysozyme Staphylococcus
and lactoferrin in tears epidermidis, Micrococcus,
and Streptococcus species • Keratitis
o More serious infection
than conjunctivitis
EYE DISEASES CAUSED BY MICROORGANISM o Can lead to complete
corneal destruction
o Can be caused by any
• Conjunctivitis microorganism after
o A relatively common infection of the conjunctiva trauma to the eye
o Bacterial infections: milky discharge o HSV-1: misdirected
o Viral infections: clear exudate activation of oral herpes
o Allergic response: copious amounts of clear fluid
o Redness and eyelid swelling are common • Acanthamoeba Keratitis
o Photophobia o Amoeba found in tap water
o Informal name for common conjunctivitis is pinkeye and freshwater lakes
o Frequent infection in contact
Neonatal Conjunctivitis lens wearers

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 • River Blindness
o Chronic parasitic infection
o Endemic in Latin America, Africa, Asia, and the Middle
East
o Worm: Onchocerca volvulus transmitted by black flies
– Microfilariae migrate through the bloodstream to
the eyes
– Wolbachia infections inside the worm contribute
to the damage in human tissues

INFECTIOUS DISEASES AFFECTING THE SKIN AND EYES

• Taxonomic Organization: Microorganisms Causing Disease of

the Skin and Eyes

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