Chapter 4

Bacterial infections of Skin

Learning objectives of bacterial infections of skin 

Define Pyoderma and classify it.

List the normal flora of skin.

Define impetigo.

List the differentiating features of

Bullous and non-bullous impetigo.

Describe the Clinical features, investigations of impetigo.

Outline the management of impetigo.

Define folliculitis, classify it and describe the management of it.

Describe the C/F, investigations and management of ecthyma/ cellulites/

Erysipelas/furuncle/ carbuncle/ SSSS.

List the skin infection produced by B- hemolytic streptococci.

List the skin infection produced by staph

Bacterial infection of the skin (Pyoderma)

Classification of pyodermas

Primary
 Impetigo
 Ecthyma
 Folliculitis
 Superficial
 Deep
 Folliculitis of leg
 Furuncle
 Carbuncle
 Sycosis Barbae
 Cellulitis/ Erysipelas
 Pyonychia
 SSSS
 TSS
 Secondary
 Secondary infection of preexisting dermatoses

 eg. Atopic dermatitis, Scabies

Impetigo (contagious superficial infection)

Non-bullous Bullous

1. Cause
- Streptococcal (Group A) Staph. aureus
- Staph. Aureus (Phage Groups II)
2. Pre-school and young school age All ages
3. Very thin walled vesicle on an erythematus base Bullae of 1-2cm
4. Transient Persist for 2-3 day
5. Yellowish-brain crusts (thick) Thin, flat, brownish crust
6. Irregular peripheral extension without Central healing with
healing peripheral extension
7. Regional adenitis Rare
8. Constitutional symptoms present Absent
9. Face (around the nose, mouth & limbs) occur anywhere
 10. Palms & sole spared May involved
11. MM, very rare May involved

Predisposing factors
 Malnutrition
 Diabetes
 Immuno-compromise status

Complications
 Streptococcal infection
 PSGN (strep M-type 49)
 Scarlet fever
 Urticaria
 Erythema mutiforme

Ecthyma Streptococcal & staph

 Common in children
 Small bullae or pustules on erythematous base
 Formation of adherent dry crusts
 Beneath which ulcer present
 Indurated base
 Heals with scar and pigmentation
 Buttocks, thighs and legs, commonly affected

Folliculitis
 Superficial folliculitis
 Infection of hair follicles
 Commonly caused by staph. aureus
 Children
 Scalp & limb
 Rarely painful
 Heals in a week
 Deep folliculitis of leg
 Chronic
 Staph. aureus
 Hair follicles of leg
 Multiple
 Atrophic scar
Furuncle (Boil)
 Acute
 Staph. aureus
 Small, follicular noduler -- Pustule--necrotic--discharge pus
 Painful
 Constitutional symptoms
 Heals with scar
 Age: Adult
 Site: Neck, Wrist, Waist, Buttocks, Face

Complication
 Cavernous Sinus thrombosis, (upper lip & check)
 Septicemia (malnutrition)
Carbuncle
 Extensive infection of a group of contagious follicles
 Staph. aureus
 Middle or old age
 Predisposing factors
 Diabetes
 Malnutrition
 Severe generalized dermatoses
 During prolonged steroid therapy
 Painful, hard lump
 Suppuration begins after 5-7 days
 Pus discharge from multiple follicular orificies
 Necrosis of intervening skin
 Large deep ulcer
 Constitutional symptoms

Sycosis barbae
a. Beard region
b. Pustules surrounded by erythema
c. Males
d. After puberty
e. After trauma
f. Upper lip and chin
 g. Staph. aureus

Cellulitis
 Acute/sub-acute/chronic
 Inflammation of loose connective tissue
 Streptococcal (Group A)
 Erythematous, edematous, swelling
 Pain/tenderness
 Constitutional upset
 Paronychia
 Acute
 Erythematous swelling of proximal and lateral nail fold
 Painful

Staphylococcal scalded skin syndrome (Ritter’s Disease)

 Exotoxin of staph (Phage Group II)
 Acantholysis
 Occult staph. upper respiratory tract infection or purulent conjunctivitis
 Infants and children
 Tender red skin
 Denuded skin
 Heals 7 - 14 day
 Don’t grow staph. from blister fluid
 Complication 2%
 Cellulitis
 Pneumonia
 Prognosis : Rule

Principles of therapy of pyoderma

 Good personal hygiene
 Management of predisposing factors
 Local
 Attend to traumas, Pressure, Sweating, Bites
 Treat pre-existing dermatosis
 Investigate carrier sites: Nose, Axilla, Perineum
Systemic
 Treatment of disease like DM
 Nutritional deficiency

ImmunodeficiencyLocal therapy

 Cleaning with soap-water and weak KMN04 solution

 Removal of crusts with KMN04 soluation

 Application of antibacterial cream

 Systemic therapy

 Suitable Antibiotic

Recurrent staphylococcal infection

 Persistent nasal carriage
 Abnormal neutrophitic chumotaxis
 Deficient intracellular killing
 Immunodeficient status
 D.M.
 T/t of staph. carriage elimination
 Nasal & perineal care
 Rifampicin 600 mg/d 7-10 days
 Clindamycin 150 mg/d 3 months
 Topical mupirocin
 Replacement of microflora with a less pathogenic stains of S.aurus (strain 502)
 S.aureus produces skin infection

I. Direct infection of skin and adjuscent tissues

a. Impetigo
b. Ecthyma
c. Folliculitis
d. Furunculosis
e. Carbuncle
f. Sycosis
II. Cutaneous disease due to effect of bacterial toxin
a. Staphylococcal scalded skin syndrome
b. Toxic shock syndrome

ß-hemolytic streptococcus produces skin infection

Direct infection of skin or subcutaneous

a. Impetigo (non bullous)
b. Ecthyma
c. Erysipelas
d. Cellulitis
e. Vulvovaginitis
f. Blistering distal dactylitis
g. Necrotizing fascitis

II. Secondary infection

Eczema infection

III. Tissue damage from circulating toxin

Scarlet fever

IV. Skin lesion attributed to allergic hypersensitivity to streptococcal antigens

E.Nodosum
Vasculitis
V. Skin disease provocated or influenced by streptococcal infection (mechanism uncertain)
Guttate psoriasis

Consider the following in relation to bacterial infection of skin

a. Cellulitis is the inflammation of subcutaneous tissue as well as dermis caused by

Streptococcus.
b. Non- Bullous impetigo is caused by streptococci
c. In erysipelas, inflammation is limited to dermis and upper part of subcutaneous
tissue.
d. Furunculosis is caused by Streptococcus

References
1. Trent JT, Federman D , Kirsner RS. Common bacterial skin infections. Ostomy
Wound Manage. 2001, 47: 30-34.
2. Ko WT, Adal KA , Tomecki KJ. Infectious diseases. Med Clin North Am. 1998, 82:
1001-1031.
3. O'Dell ML. Skin and wound infections: An overview. Am Fam Physician. 1998, 57:
2424-2432.
4. Carroll JA. Common bacterial pyodermas. Taking aim against the most likely
pathogens. Postgrad Med. 1996, 100: 311-322.
5. Brook I, Frazier EH. Clinical and microbiological features of necrotizing fasciitis. J
Clin Microbiol. 1995, 33: 2382-2387.
6. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J
Med. 1996, 334: 240-245.
7. Drake LA, Dinehart SM , Farmer ER, et al: Guidelines of care for superficial mycotic
infections of the skin: Onychomycosis. Guidelines/Outcomes Committee.
American Academy of Dermatology. J Am Acad Dermatol. 1996, 34: 116-121.
8. Drake LA, Dinehart SM , Farmer ER, et al: Guidelines of care for superficial mycotic
infections of the skin: Tinea capitis and tinea barbae. Guidelines/Outcomes
Committee. American Academy of Dermatology. J Am Acad Dermatol. 1996, 34:
290-294.
9. Drake LA, Dinehart SM , Farmer ER, et al: Guidelines of care for superficial mycotic
infections of the skin: Tinea corporis, tinea cruris, tinea faciei, tinea manuum, and
tinea pedis. Guidelines/Outcomes Committee. American Academy of
Dermatology. J Am Acad Dermatol. 1996, 34: 282-286.
10. Hay RJ. The management of superficial candidiasis. J Am Acad Dermatol. 1999, 40:
(6 Pt 2): S35-S42.
11. Drake LA, Dinehart SM , Farmer ER, et al: Guidelines of care for superficial mycotic
infections of the skin: Pityriasis (tinea) versicolor. Guidelines/Outcomes
Committee. American Academy of Dermatology. J Am Acad Dermatol. 1996, 34:
287-289.