• Impetigo 
• Folliculitis 
• Cellulitis 
• Erysipelas
• Paronchyia

Impetigo 

• General Considerations: contagious, autoinoculable
• Staph or group A strep
• 1 degree infections in minor superficial breaks  OR  2o infections of preexisting dermatoses
• m/c children and infants, hx of eczema

• Honey colored gummy crust with underlying erythema
• Can be very itchy
• May consist of macules, vesicles, pustules,bullae
• Primarily seen on face, thumb( macterated) and other exposed areas
• Ecthyma- deeper form; ulceration, scarring; extremities

• Good physical examination
• Bacterial culture that reveals staph or strep
• Lab: gm stain and culture (S. aureus in temperate climates, Strep in tropical)

• Topical Treatment
• Mupirocin ointment  – antibacterial ointment
• 5 days is enough to clear up
• Warm compresses
• Gently wash crust with wash cloth
• Intranasal Mupirocin
• Systemic Treatment
• Antibiotics
• Penicillin
• Cephalexin
• Erythromycin
• Doxycycline
• Very unusual; some pt. who have worsening/recurrent impetigo use this
• For recurrences ; figure out why they keep getting it

• Infection of the upper portion of the hair follicle, characterized by follicular papules or pustule
• Involvement can extend deeper to the entire length of the follicle
• Most commonly caused by bacteria
• Can be caused by virus, and steroid induced

• May be tender
• May be pruritic
• Red Papule or pustule confined to the hair follicle.  May find erythema around hair follicle

• Good physical exam
• • location & lesion
• Bacterial culture reveals S. Aureus
• KOH to rule out fungus (if necessary)

• Topical treatment
• • Mupirocin ointment
  • Aluminum Chloride (for buttocks)
  • helps it dry it up ; can be used as a wash for the backside as well
  • Topical clindamycin
  • Wash with antibacterial soap
  • Don’t use LOOFA/wash cloth - harbors a lot of bacteria
  • Avoidance of heat, friction and occlusion
• Systemic treatment
• • Oral anti-staph antibiotics
  • penicillin, doxy

• Can progress to  deeper follicular and perifollicular infection with abscess formation (furuncle)
• • one pustule
• Carbuncle – deeper infection comprised of interconnecting abscesses/contiguous hair follicles  
• • Multiple hair follicles inflamed and deep
• Many types of folliculitis will recur unless predisposing conditions are corrected.
• • Usually assumed its MRSA
• Treatment
• • I & D
  • Warm soaks - allows abx move to area quicker
  • Antibiotic (Doxycycline, Bactrim, Clindamycin)

• Gm - folliculitis: develops during Abx tx of acne 
• Hot tub folliculitis: Pseudomonas
• Pruitic or tender follicular pustular lesions w/i 1-4 d
• May be more dense under swimsuit areas
• esp. wooden hot tubs ( unless strict control of pH and Cl) 
• Nonbacterial folliculitis: friction and oils 
• Steroid acne: topical or systemic CS
• Eosinophilic Folliculitis:urticarial papules w/ eosinophilic infiltration; AIDS pts.
• Pseudofolliculitis: ingrowing hairs in beard area; papules and pustules at side of follicles (cf. in)...grow a beard or laser hair removal

• Cellulitis is an acute, spreading infection of dermal and subcutaneous tissues.
• Characterized by a red, hot, edematous, tender area of the skin, often at the site of bacterial entry
• Often seen on lower legs
• Etiology and Epidemiology of Cellulitis
• • Caused most frequently by  S. Aureus or Group A strep.

     

• Can occur at any age
• Caused by:
• Underlying dermatoses
• Trauma
• Surgical wound
• Number one cause - athletes foot

• Warm , Red, Painful , can be shiny and edematous
• Borders usually sharply defined, irregular
• Begins as a small tender patch that expands over hours w/ worsening illness (fever, chills, malaise); UL

• Physical Exam
• DVT
• Necrotizing faciitis ( very toxic appearance, bullae, overlying skin necrosis, rhabdo ; increased CK or DIC)
• Lymph Nodes
• WBC may be elevated; neutrophilia ( left shift)
• Bacterial cultures - culture if central ulceration, pustule, abscress

• Supportive
• • Rest ,Elevation ,Moist Heat ,Analgesia
• Antimicrobial Therapy
• • Empiric tx to cover both Staph and strep (top choices are usually Dicloxacillin, Cephalexin, Clindamycin, Vancomycin
  • IV or parenteral ABX x2-5 days
  • Hospitlization based on severity
  • CA MRSA : vanco/clindamycin/ sulfa + b-lactam
  • per amanda: difloxacillin,cephalexin, clindamycin,vanco
  • if PO abx, consider doubling first dose
• Supportive Therapy
• • Support stockings - help facilitate blood flow
  • Antiseptics to skin - antibacterial wash
  • Antibiotic prophylaxis - might be necessary if it is recurrent ; often times not needed

• Superficial ( dermis and upper SQ tissue) form a cellulitis; lymphatic involvement ( streaking) ; more clearly defined margins 
• m/c cause of virulent soft tissue infection in a healthy host without evident portal of entry 
• occurs on the cheek or lower legs
• due to b-hemolytic streptococci ( GABHS) 
• Caused by Group A strep 

• Most commonly seen on lower legs, face
• Itching, burning, tenderness and pain may be moderate to severe.  
• Possible malaise, chills
• Bright red spot near angle of nose -> glistening hot
• Heals without scar
• Red, sometimes painful, streaks of lymphangitis may extend toward regional lymph nodes.

• Physical Exam 
• Lymph Nodes 
• WBC may be elevated 
• Leukocytosis ( neutrophilia in cellulitis) 
• Bacterial cultures 

• Elevate Head 
• IV or OP oral Abx 
• PCN VK 250 mg PO qid x 7d
• Clindamycin 250 mg PO bid x 7-14d
• Same as Cellulitis as well 
• Supportive
• • Rest,Elevation ,Moist Heat ,Analgesia
• Antimicrobial Therapy
• • Empiric tx to cover both Staph and strep (top choices are usually Dicloxacillin, Cephalexin, Clindamycin, Vancomycin
• Supportive Therapy
• • Support stockings - help facilitate blood flow
  • Antiseptics to skin - antibacterial wash
  • Antibiotic prophylaxis - might be necessary if it is recurrent ; often times not needed

• Infection of the soft tissue around the nails
• Acute
• • One nail that is involved, pus pocket
  • people who bite their nails or skin area near the nails
  • Usually from Staph
  • Treat – Drainage, possible abx
• Chronic
• • > 1 nail
  • Often from candida
  • Treat – antifungals topical or oral

• Tinea Capitis 
• Tinea Corporis 
• Tinea Versicolor
• Tinea Cruris 
• Tinea Pedis 
• Candidiasis
• Onychomycosis 

• Dermatophytic trichomycosis of the scalp
• “Ring worm” of the scalp
• Fungus causing tinea capitis invades hair follicle and hair shaft. The affected hairs can harbor the fungus for a year or more.
• Etiology and Epidemiology
• • 90 % of tinea capitis is caused by T. Tonsurans.
  • Most common in toddlers and school-aged children
  • More common in black children

• Pruritus

• Scaling and flaking of scalp

• Hair loss

• Tenderness (in later stages)

• Gray patch

• Kerion 
• Inflammatory Tinea Captitis
• Secondary bacterial infection
• Characterized by one or more large, tender boggy masses with erythema, pustules, crusting, and alopecia
• Lymphadenopathy is frequent.
• Such infections may result in scarring and permanent alopecia

• Physical Exam
• KOH Prep  (Spores and Hyphae)
• Fungal culture - pluck hair
• Bacterial Culture (rule out for kerions)

• Physical Exam
• KOH Prep  (Spores and Hyphae)
• Fungal culture - pluck hair
• Bacterial Culture (rule out for kerions)

• Prevention
• • Ketoconazole or selenium sulfide shampoo
• Topical agents
• • Ineffective by itself in management of tinea capitis
• Oral Antifungal agents
• • Griseofulvin ** Better absorbed with fatty meal**
  • Most Common Used
  • Itraconazole
  • Terbinafine
  • ***Everyone in family should be treated***

• Chronic asymptomatic dermatosis associated with overgrowth of Pityrosporum orbiculare/Malassezia Furfur
• Is well demarcated
• Hypopigmentation  on trunk (usually noted in summer when spots won’t tan), pink colored on untanned skin

• Most frequently found in young adults (during years of higher sebaceous activity)
• Excess heat and humidity predispose to this condition

• Selenium sulfide lotion or Ketoconazole shampoo.   Apply daily to affected areas for 10 minutes, then rinse.
• Azole cream (apply BID x 2 weeks for localized areas
• If severe, oral Ketoconazole or Fluconazole
• Tends to recur 80% of time
• Dyspigmentation can persists for several weeks

• Must differentiate from vitiligo
• In vitiligo lost complete pigment 
• location is usually in hands, underarms
• KOH Prep

• Dermatophyte infections of the trunk, legs, and arms, excluding the feet, hands, and groin
• AKA; Ringworm

• often asymptomatic ; all ages 
• Small to large scaling, sharply marginated plaques

• Peripheral scaliness with central clearing
• Can be single or with multiple lesions
• If single is left untreated will have more 
• Pitya Rosacea can mimic this

• Will respond to most all topical antifungals (azoles, Naftifene, Butenafine, Clotrimazole, Terbinafine, Ciclopirox)
• Treatment should be for 2 weeks – continue treatment for at least 1 week after resolution of rash
• Do not use Lotrisone!
• • Combo of  topical anti fungal and strong topical steroid
  • Steroids make fungus worse

• Dermatophytosis of the groin, pubic region and thighs.
• AKA jock itch
• Etiology and Epidemiology

• Seen primarily in adults
• Male> female (mostly postpubertal)
• Seen in warm, humid environment, tight clothing, obesity

• Pruritis, burning sensation after sweating or hot water, although may be asymptomatic
• Large scaling well demarcated plaques, central clearing
• Often occurs bilateral – begins in the crural folds
• Usually dull red

• Fungal Infection of the feet 
• AKA athletes foot 
• Most common area infected by dermatophytes 
• Most often in teen years and young adults 
• Men> women
• Moisture, sweating, occlusive footwhere are the perfect setting for foot fungus to grow 

• Pruritus (most intense when socks and shoes are removed)
• Can have pain with secondary bacterial infection
• May see maceration, peeling, fissuring of toe webs or soles of feet with underlying erythema
• Look for fungal infection of toenails

• Good physical exam
• Positive KOH prep (spores and hyphae)
• Fungal culture
• Pathology (biopsy)

• Antifungal powder
• • Keeps area dry
• Topical Antifungal creams (BID x 4 weeks)
• • Imidazoles/Azoles
  • Others- Allylamines, Naphthiomates, Ciclopirox
• Oral antifungal medication
• • Griseofulvin
  • Itraconazole
  • Terbinafine

• Superficial infection occurring on moist cutaneous sites
• AKA Yeast
• Locations
• Intertrigo (body folds)
• Genital (balanitis, vulvitis)
• Occluded skin
• Diaper dermatitis
• Mouth (thrush)

• Candida Albicans
• Any age
• Men=women
• Diabetes, antibiotics, immunocompromised, obesity, chronic debilitation, steroids, are all predisposing factors

• Soreness, burning, itching, worse after heat or moisture exposure
• Erythematous plaques with satellite red papules
• Intense itching, burning about vulva/anus
• Superficially denunded, beefy red areas in depths of body folds w/ satellite red papules
• Whitish curd-like concretions on mucosal lesion
• Locations: body folds, genital, occluded skin, diaper dermatitis (↑ pH), mouth (thrush)

• Keep area as dry as possible.
• Powder with miconazole
• Nystatin or Azole creams BID
• Nystatin also comes in suspension
• LOW strength topical steroid for symptoms!  NOT HIGH strength.  Will make this worse!!
• Oral Fluconazole, Itraconazole if severe

• Aka Tinea Ungumium
• Fungal infection of one or more fingernails or toenails

• Nails are lusterless, brittle, hypertrophic, friable , often discolored

• KOH prep 
• Fungal culture - clip the nails 

• Systemic therapy
• • Terbinafine - toenails 
  • LFTs and CBC w/ platelets q mo of tx
  • grow out in 12-18 mons
    
  • Itraconazole
  • More common ; take 3 months time for toe nails and 6 weeks to tails
  • Fluconazole
  • Griseofulvin – for fingernails only ; always cured
• Fingernails higher success rate than toenails
• Side effects and monitoring
• Efficacy of topical treatment
• • Two new topical treatment - 20% efficacy
  • Before use to be 5%
  
  

• Herpes Simplex 
• Herpes Zoster
• Molluscum Contagiosum 
• Verruca (warts)

• Herpes simplex virus is characterized clinically by grouped vesicles arising on an erythematous base on keratinized skin or mucous membrane.
• Asymptomatically developed
• Transmitted skin-skin, skin-mucosa, mucosa-skin
• HSVI versus HSVII

• Men=women
• Most commonly in young adults
• Type I – oral infections
• Type II – genital infections

Herpes Simplex - Signs and symptoms

Primary 

• Is where virus becomes established in a nerve ganglion
• Is worse than recurrences
• Last the longest and is the biggest the first time
• Erythema base with multiple vesicles.  Can erode & ulcerate
• Keratanized skin and mucous membrane
• Crust and Heals in 2-4 weeks or 1 wk?
• Lymphadenopathy

Herpes Simplex: Signs and Symptoms 

Recurrences 

• Lesions similar to primary but on reduced scale
• Heals in 1-2 weeks
• 1/3 will have recurrence
• Reasons for recurrence
• Sun exposure
• Stress
• Hormonal change
• Fever, common cold
• Site of infection/trauma
• Immunocompromise

• Good Physcial Exam 
• Patients c/o burning and stinging of areas
• Lab : Direct fluorescent antibody slide test 
• Tzanck smear : unroof a blister and look for certain cells under microscope
• Viral Culture 

• Avoid skin to skin contact 
• Patients need to start antiviral therapy at first sign of recurrence 
• Topical Abreva txt  - local 
• Antiviral Therapy  - systemic all 7-10 d initially ; doesnt require when recurrent?
• Acyclovir PO
• Valacyclovir PO
• Famcloclovir PO
• chronic supressive txt if >4/yr 

• Acute  dermatomal infection associated with reactivation of varicella-zoster virus
• It is limited to a dermatome innervated by a corresponding sensory ganglion
• AKA shingles

• Usually over ago 50, incidence increases with age
• Men=women
• Seen commonly in those with HIV, fatigue, stress, cancer, and others immunocompromised
• Reactivation of latent VZV

• Prodromal Stage
• • Pain or tingling 48 + hours  prior to eruption
  • Pain is very significant
• Active vesiculation
• • Red papules, pustules, vesicles.  Pt will have pain in involved skin.
• Crust formation
• • Will last for 3-5 weeks
• May be associated with constitutional symptoms
• Sites often affected
• • Most commonly thoracic then face
  • Follows dermatome
  • Does NOT cross midline
  • If eyes involved ALWAYS get opth consult
• Post-herpetic neuralgia
• • Lasts months to years
  • Burning, shooting pain.

Same as Herpes simplex

• Good physical exam
• Patients c/o burning and stinging of area
• Tzanck smear
• Viral culture

• immunocomponent host: antiviral tx w/i 72 hrs of rash ( perf. in prodromal stage); x 7 d
• Acyclovir 800 mg 5/d
• Famciclovir 500 mg tid 
• Valacyclovir 1 g TID 
• systemic corticosteroids for sx (prednisone 60 mg/d to start, x 3 wks)
• Immunocompromised host
• Tx as above; continue until lesions have completely crusted and healed ( up to 2 wks)
• Avoid corticosteroids
• May need IV acyclovir
• Local measures: lotions
• Postherpetic: Neuralgia Therapy
• Capsaicin Ointment 0.025 -0.075% OR lidocaine topical patches 

• Due to poxvirus, shingles or multiple dome-shaped waxy papules ( 2-5 mm....1-2 mmper amanda) that is umbilicated 
• children, boys 
• Kids - trunk and extremities 
• Adults - groin and lower abd 
• Spread by wet skin to skin contact , can be an STI 
• a/w atopic dermatitis 
• Common with AIDS ( T cell <100) 
• Usually asx, no surrounding inflammation ( until healing) ( cf. folliculitis) 

• Usually asymptomatic
• Skin colored or pink dome shaped lesions with depression in center
• Usually 1-2 mm - small
• Discrete papules or in groups
• • not inflamed
  • as they go away, will get more inflamed
• Common to see in those that have atopic dermatitis
• • Kids scratch eczema, so virus just gets inside

• Regresses spontaneously but contagious 
• Can be removed with small curette
• • uncomfortable esp for kids
• Liquid nitrogen (cryotherapy)
• • - 350 F ; gives it a frostbite so it is painful
• Keratolytic creams
• • Exfoliate the top layer of the virus - can cause further irritation
• Imiquimod (topical immune response modifier)
• • Use  also on superficial skin cancer, genital warts

Verruca 

• Skin growths caused by HPV 
• Only imp. with genital dysplasia
• Benign epidermal proliferations 
• Types of warts 
• Common Warts 
• Foot ( Plantar Warts) 
• Flat Warts
• Genital Warts 

• Verruca Vulgaris aka seed warts 
• Fingers and back of hands, broken skin ( cuticles)

• Verruca Plantaris 
• Soles of feet ( points of maximal pressure) , sometimes cluster 
• Usualy do not stick above surface
• Can be painful 

• Aka Verruca Plana 
• Dorsal Hand, face
• Smaller and smoother 
• Large # ( 20-100) 

• Condyloma Acuminata 
• Adult pt 
• Sexual transmission 
• Oncogenic potential ( subtypes 16, 18,31) 

• No symptoms
• Tenderness with plantar otching with anogenital 
• Prevention : vaccine for teenagers and young adults