Topic 2: Purulent diseases of the skin: Streptostaphylodermia, mixed

pyoderma. Principles of clinical

classification, diagnosis, and treatment. Acne.
Parasitic diseases of the skin.
Furuncles, carbuncles, and abscesses are the more common types of purulent skin
and soft tissue infections (SSTIs).

Furuncles (or “boils”) are infections of the hair follicle that extend into the dermis
and subcutaneous tissue. These usually extend from an area of folliculitis.

Carbuncles form when multiple furuncles coalesce through the subcutaneous tissue
with purulent drainage from follicles. They are often divided by a septum.

Cutaneous abscesses refer to the collection of purulent material that can develop in
the dermis, subcutaneous tissue, or both. They can also develop as a complication
of furuncles and carbuncles.

ETIOLOGY AND PATHOGENESIS

Furuncles and carbuncles are typically caused by Staphylococcus aureus (both

methicillin-susceptible Staphylococcus aureus [MSSA] and methicillin-resistant
Staphylococcus aureus [MRSA]). Infections secondary to a penetrating trauma or
involving the perioral or perineal area increase the likelihood of a polymicrobial
infection, including S aureus, Streptococcus pyogenes, gram-negative bacilli, and
anaerobes. Depending on host factors and exposures, other causes can include
blastomycosis, cryptococcosis, nontuberculous mycobacterial infection, and
nocardiosis.

Purulent SSTIs often affect healthy, immunocompetent adults. Risk factors are
similar to those for nonpurulent SSTIs (see Table 9.19-2). Additional risk factors
include immunocompromised state (particularly neutrophil defects), suboptimal
hygiene (eg, sharing contaminated hygiene items like shaving razors), hot and
humid climates, MRSA carriage, and additional MRSA risk factors (see
Nonpurulent Skin and Soft Tissue Infections: Erysipelas and Cellulitis).

CLINICAL FEATURES

SSTIs should be categorized as mild, moderate, or severe

A furuncle is a well-demarcated, painful nodule involving a hair follicle that

frequently occurs in areas of friction (neck, axillae, thighs, buttocks). Its extension
into dermal and subcutaneous tissue can result in suppurative abscesses and
cellulitis. Carbuncles can occur anywhere but often develop at the back of the
neck. If a carbuncle forms, patients can have associated systemic symptoms (eg,
fevers, chills, rigors). Both furuncles and carbuncles (especially the latter) can be
further complicated by bacteremia, toxic shock syndrome, necrotizing fasciitis, and
sites of metastatic infection (eg, osteomyelitis, endocarditis).

Other considerations include the location of the abscess, whether it is amenable to

drainage, and if there are any predisposing conditions. For example, the presence
of perianal abscesses in a patient with chronic diarrhea should prompt
consideration of Crohn disease, whereas recurrent abscesses since young childhood
should prompt consideration of underlying immunodeficiency, such as chronic
granulomatous disease.

DIAGNOSIS

The diagnosis is generally clinical. Laboratory investigations are not required in a

mild, uncomplicated infection in an immunocompetent host. If there is evidence of
purulent drainage, wound samples can be obtained and sent for Gram staining and
culture. However, this does not preclude the initiation of treatment, if indicated.

Cultures of blood, wounds, and drainage fluid at the time of incision and drainage
(I&D) are indicated prior to initiation of antimicrobial therapy in the following
circumstances:

1) The patient being systemically unwell.

2) Failure of prior antibiotic therapy.

3) History of recurrent or multiple abscesses.

4) Immersion injury or animal bite.

5) Immunocompromise and other comorbidities (eg, malignancy, neutropenia,

splenectomy, immunodeficiency).

Ultrasonography should be performed if there is clinical suspicion of an abscess.

Radiography can be considered to assess for subcutaneous gas but it will not
exclude a deeper SSTI.

Differential Diagnosis

1. Infectious:

1) Nodular lymphangitis (eg, sporotrichosis, nocardiosis, Mycobacterium marinum

infection, cutaneous leishmaniasis, dimorphic fungal infections).

2) Botryomycosis (a chronic granulomatous infection secondary to S aureus

infection, often seen in immunocompromised hosts).
3) Kerion (a form of tinea capitis presenting as a painful, exudative mass on the
scalp).

2. Noninfectious:

1) Erythema nodosum and pyoderma gangrenosum.

2) Epidermoid cyst.

3) Hidradenitis suppurativa.

Many of these noninfectious causes can become secondarily infected.

TREATMENT

All purulent SSTIs should have definitive source control. Furuncles will often
rupture and spontaneously begin draining with application of warm compresses.
Larger furuncles and carbuncles often require I&D, and >80% of furuncles resolve
with I&D. Antibiotics should be used if there is evidence of cellulitis beyond the
furuncle itself (Table 9.19-1). Ultrasound-guided aspiration alone is insufficient
and often results in treatment failure.

Depending on the location of the abscess, the risk of a polymicrobial infection may
be increased (eg, perirectal abscesses) and this will alter antimicrobial therapy
choices.

Recurrent skin abscesses at the same site should prompt evaluation of other local
causes, such as hidradenitis suppurativa, foreign body/material, or pilonidal cysts.
Recurrent abscesses should be drained and samples should be sent for culture.
Underlying immunodeficiencies, such as chronic granulomatous disease, should be
investigated in adults with recurrent abscesses that began in early childhood.

Acne
Acne is a skin condition that occurs when your hair follicles become plugged with
oil and dead skin cells. It causes whiteheads, blackheads or pimples. Acne is most
common among teenagers, though it affects people of all ages.

Effective acne treatments are available, but acne can be persistent. The pimples
and bumps heal slowly, and when one begins to go away, others seem to crop up.

Depending on its severity, acne can cause emotional distress and scar the skin. The
earlier you start treatment, the lower your risk of such problems.Symptoms
Common acne
Common acneOpen pop-up dialog boxCystic acne
Cystic acneOpen pop-up dialog box
Acne signs vary depending on the severity of your condition:

Whiteheads (closed plugged pores)

Blackheads (open plugged pores)
Small red, tender bumps (papules)
Pimples (pustules), which are papules with pus at their tips
Large, solid, painful lumps under the skin (nodules)
Painful, pus-filled lumps under the skin (cystic lesions)
Acne usually appears on the face, forehead, chest, upper back and shoulders.

When to see a doctor

If self-care remedies don't clear your acne, see your primary care doctor. He or she
can prescribe stronger medications. If acne persists or is severe, you may want to
seek medical treatment from a doctor who specializes in the skin (dermatologist or
pediatric dermatologist).

For many women, acne can persist for decades, with flares common a week before
menstruation. This type of acne tends to clear up without treatment in women who
use contraceptives.

In older adults, a sudden onset of severe acne may signal an underlying disease
requiring medical attention.

The Food and Drug Administration (FDA) warns that some popular
nonprescription acne lotions, cleansers and other skin products can cause a serious
reaction. This type of reaction is quite rare, so don't confuse it with any redness,
irritation or itchiness that occurs in areas where you've applied medications or
products.

Seek emergency medical help if after using a skin product you experience:

Faintness
Difficulty breathing
Swelling of the eyes, face, lips or tongue
Tightness of the throat