Cutaneous Infections

Dr .S. Ahamed Uwyse

Consultant Dermatologist
North Colombo Teaching Hospital
Ragama
 Microbiomes of the skin

• Resident flora (commensal micro organisms) is mixture

of harmless micro organisms
staph epdermidis , diphtheroids ,propionibacterium,
species of yeasts
• Skin flora varies person to person
• Defend the skin from the out side pathogen
• Over growth of commensals may become pathogenic
sometimes
 Bacterial infection
Impetigo contagiosa

• It is a pyoderma – purulent bacterial infection

• Caused by [Link] mainly and streptococci as well or both

• Commonly affect children (< 6yrs) , but my affect any age group

• Staph. Aures produce exfoliative toxin producing the lesions

• Any part of the body may be involved , but facial lesions are
common.

• Stah. Aures are colonized mainly in the [Link](30%population)

and also perineal region , axilla, hand.
• Pts with atopic eczema (60 %-90%) are colonized with stah. Aur in
the skin

• Starting as erythematous macule , papule or pustules ,then form the

crusted lesions which gives yellowish or golden colour

• bullous lesions may also appear([Link]) called bullous impetigo

which are common in infants and neonates

• Complication – PSGN (type 3 HS reaction ) , SSSS. by [Link]

infection (exfoliative toxin)
Management
• Topical treatment
mupirocin oint drug of choice for affected areas
for recurrent cases , decolonization of the bacteria is important
for nasal decolonization , apply mupirocin oint 2 times daily for 1
week. For body, use povidone iodine or chlorhexidine .

• Systemic therapy
cephalosporin ,Co amoxy clav , clindamycin , flucloxacillin could be
used orally or IV
 Staphylococcal scalded skin syndrome
(Ritter’s disease)
• Common in neonates , infants and children
• Caused by exfoliative toxin A and B produced by staph aures
• Foci of local infection such as nasopharengeal , skin infection
release the toxin to the system.
• Toxin split skin at granular cell layer, targeting desmosome
(desmoglen 1)
• Lesions start initially periorificially and skin folds, then spread to the
other areas of the body.
• Lesions starting as tender erythematous patches with or without
blisters, then the skin peels off with systemic symptoms
• Treat with IV antibiotics , local skin care and fluid management
 Ecthyma

• caused by [Link] and [Link]

• deep punched out ulcers (full thickness ulcer).
• commonly occurs in the legs – shin , dorsum of the feet.
• common in children, may occur in adult.
• treatment as same as impetigo
 Erysipelas

• Mainly streptococcal (beta haemolytic gr A,B,G)

• Infection involves the skin, up to the superficial part of the dermis
• Palpable erythematous lesion with well demarcated edge.
• Blisters may appear on the lesion
• Associated with constitutional symptoms(fever, chills and rigors)
• Commonly affecting the face and legs.
• Cellulitis, necrotizing fasciitis occurs as complication
• Treatment
[Link] ,cephalosporin , clindamycin ,erythromycin
local wound management, if ulcerated
 Cellulitis

• Suppurative inflammation involving the sub cutaneous tissue.

• Frequently caused by [Link] , [Link].
• Infection occurs through the wound on the skin (intertrigo, [Link])
• Start as erythematous patchy lesion with tenderness , then spread
locally. Vesicles may occur on the lesions
• Lymphangitis may occur
• Constitutional symptoms may accompany
• May complicate as localized abscess, necrosis , necrotizing fasciitis
 Scarlet fever

• Caused by [Link], usually follows pharyngitis and tonsillitis,

but may rarely follows surgical wound or burn injuries.
• toxin mediated - erytherogenic exotoxin
• Common in children.
• Diffuse erythematous exanthem, usually starting from the neck,
then spreading to the chest ,axilla, groin , then to the extremities.
• Small papules may arise over the erythematous lesions ,giving the
goose skin appearance or sand paper appearance.
• Pastia lines – accentuation of the skin fold (axilla, anti cubital fossa)
and linear petechial eruption
• Facial flushing with circumoral pallor
• Branny desquamation with peeling of palm and sole during the
healing phase ( 2 weeks)
• Treatment – penicillin, erythromycin , cephalosporins
 folliculitis
• Staphylococcal folliculitis
• Gram negative folliculitis caused by [Link] ,klebsiella, enterobacter
following prolonged antibiotic therapy
• Sycosis barbae
chronic staph folliculitis of the bearded area with multiple pustules
and papules.
burning or itching may be present
• Superficial pustular folliculitis (impetigo of Bockhart )
thin walled pustules at the follicular orifices
occurs in the scalp, face ,extremities
caused by staph
• Treatment
systemic therapy -- flucloxacillin ,co amoxy clav ,cephalosporin ,
vancomycin
topical therapy – topical antibacterial creams
 Fruncle and Carbuncle
• Staph infection involving the deep part of the hair follicles and
perifollicular areas.

• Fruncle -- painful erythematous nodule, later become fluctuant and

forming abscess.

• Carbuncle – confluence of fruncles (2 - 3 or many ) with separate

heads.

• Immunocompromised state predispose the infection

• Involving face ,neck, axillae, groin , buttock

• Treatment according to pus cultre and ABST

empirically flucloxacillin, erythromycin ,cephalosporin,
co amoxy clav
fruncle
carbuncle
 Intertrigo

• Inflammatory dermatitis occurring in a place where two skin surfaces

are in apposition .
• Primarily a non infective condition.
• Due to moisture and friction, becoming macerated and secondarily
infected with fungi or bacteria
• Finger webs, toe webs, axilla, groin, infra mammary areas .
• Treatment
mosturisers ,antifungal or antibacterial creams
in severe cases , systemic therapy be needed
 Erytherasma

• Caused by corynebacterum.
• Erythematous or browny scaly lesion with well defined edge.
• Non itchy
• Axilla ,groin , inframammary areas
• Wood’s light examination – coral red fluorescence due to presence
of porphyrin
• Teratment
oral erytheromycin
topical erythromycin or clindamycin
topical antifungal also effective
 Pitted keratolysis

• Usually affect the planter surface

• Excessive sweating predisposes the infection
• Caused by corynebacterium , kytococcus sedanterius
• Shallow asymptomatic pits , may become confluent forming furrows
• Treatment
erythromycin or clindamycin solution topically
miconazole or clotrimasole cream
oral erythromycin also efective
 Trichomycosis axilaris

• Caused by corynebacterium ([Link],[Link]) and serrtia

marsecens.
• Axillary hair becomes beaded with concretions with yellowish
disclouration
• Treatment
Shaving ,frequent washing and topical antibiotic cream application
 Cutaneous anthrax

• Caused by bacillus anthracis

• Zoonosis , by direct contact of the animal or animal product
• Occurs in exposed areas
• Start as painless pruritic papules vesicle ulcerate with
central blackish eschar , later may be surrounded by a rim of
vesicles
• Regional lymph adenitis occurs
• Toxic features occurs in 50% cases
• Septicaemia may occur in untreated cases
• Smear demonstrate the organism
• Treatment – penicillin , ciprofloxacin, clindamycin, macrolides
• Spontaneous healing may occur within 1-3 weeks with scarring
 Cutaneous Tuberculosis

• Primary cut. TB

• Secondary cut. TB
lupus vulgaris
warty tuberculosis
scrofuloderma
tuberculosis cutis orificialis
military tuberculosis

• Tuberculids
 Primary TB
• Commonly occurs in children , previously not exposed
• Direct inoculation of the bacilli into the skin , forming a ulcer within
2-4 weeks of inoculation.
• Asymptomatic ulcer with undermined and ragged edge , covered
with crust - tuberculosis chancre
• Regional lymphadenitis with abscess formation , resulting in a
discharging sinus
• Usually heals spontaneously
 Lupus vulgaris
• Commonest form of cutaneous tuberculosis in adults.
• Occurs in previously sensitized (exposed) pts
• May occur at the site of inoculation or in the scrofuloderma scar or
at site of BCG vaccination
most commonly occurs in a distance site from the primary focus by
haematogenous spread
• Lesions usually occurs on the face , trunk , extremities
• Usually a single Plaque, occasionally multiple
• plaque lesion may be juicy, composed of reddish brown papules ,
showing apple jelly appearance on diascopy, may ulcerate and
become destructive, heals with deforming scar
• Scaly plaque lesion , crusted plaque lesion may occur
• Annular lesion may occur in the trunk
• rarely it may become malignant , as it run a long course
 Warty TB
• It is also occurs in a sensitized pt
• Commonly occurs in adult who handle TB pts or tissue or animal
product infected with TB
• Direct inoculation occurs at the site of trauma or abrasion
• Develop a plaque lesion with verrucous surface , fissuring may
occur
 Scrofuloderma

• common in children
• Involvement of the skin from the underlying lymph nodes (axillary,
cervical) ,bone, joints – direct spread
• Painless swelling with discharging sinuses
• Heal with scarring
 Orificial TB

• Occurring in the mucosa or skin adjoining the orifices

• Usually in immunocompromised or debilitated pts with intestinal,
respiratory , genitourinary TB
• Present like chronic ulcer in mucous membrane or skin (mouth,
anus)
 Miliary TB of the skin

• rare condition
• May occur in immunocompromised pts
• Multiple , wide spread , erythematous or reddish brown macules
papules or vesiculopustular may occur by haematogenous spread
from the primary focus
• Mortality rate is high
 Tuberculids

• tuberculid lesions occurs because of hypersensitivity reaction

(type 3) due to release of antigens from the active or silent focus
of TB else where in body.
these pts show high level immunity
• Tuberculids don’t show any bacilli by staining or culture , PCR may
show presence of TB antigens.
• Other school of thought says, Tuberculids lesion are due to
haematogenous spread to the skin from internal focus of TB
• Types of tuberculids
papulonecrotic
lichen scrofulosorum
erythema induratum (Bazin disease)
 Papular necrotic tuberculids

Lichen scrofulosorum
Erythema induratum

Also called nodular vasculitis

Immunological reaction (type 3) affect the blood vessels (vasculitis )in
the subcutaneous tissue , resulting in lobular panniculitis.
Tender erythematous or violaceous nodular or plaque lesions occurs in
the leg (calf) , may ulcerate
Single or multiple lesions may occur
 Fish tank (aquarium) granuloma

• Caused by [Link] – atypical mycobacterium

• It infect aquarium fish , human get infected by handling the fish tank
• It develop as papule or nodule after 3 weeks of contact , then
gradually enlarges.
surface looks warty
less commonly , it may ulcerate or form abscess
• Treatment
cryotherapy
doxycycline, minocycline, clarithromycin, co-trimoxasole
 Bruli ulcer
• Caused by mycobacterium ulcerans which lives on vegetation.
• Necrotic ulcer with undermined edges
• Ulcers usually found on the legs
• Treatment – surgical exicision
streptomycin and rifampicin
 Viral infection

• Human papilloma virus infection

• Molluscum contagiosum
• HSV infection
• Varicella infection
• Measles
• Rubella
• Hand foot mouth disease
• Erythema infectiosum
 HPV infection
Common warts (verruca vulgaris)
• caused by HPV type 1, 2,4,7
• Skin coloured verrucous papules or nodules , sessile lesion or horn
like lesions
• Koebner’s phenomena present
• Can resolve spontaneously without scarring
• Treatment
application of salicylic acid and lactic acid(17%) comb
cryotherapy
EC
MMR vaccine
Anogenital warts (condyloma acuminata)
• Caused by HPV types 6,11,16,18
• Type 16 and 18 ma be carcinogenic – cervical cancer
• Sexually transmited
• In infants and younger children , direct transmission during birth or after
from the mother (vertical transmission)
• DD -- skin tags , condylomata lata (secondary syphilis) – moist warty large
lesion with broad base
• Treatment
ablative therapy – cryotherapy, EC, CO2 laser
podophilin topical application – wash after 3-4 hrs, weekly
imiquimod application – immunomodulater
cidofovir topical application (anti viral agent)
 Molluscum contagiosum

• Caused by MCV (type 1-3)

• IP > 2- 8 weeks
• Common in children
• May occur in adults (sexually active)
• Spreaded by skin to skin contact
• Severe infection in immunocompromised children
• Spontaneously clears in 2- 4 yrs time
• Small (1- 2 mm) pearly white , dome shaped papules with central
umbilication
• Sometimes giant Molluscum can occur
• eczematous reaction may occur around the lesions in 10% cases
• Treatment
10% KOH application
curettage
imiquimod application
Tretinoin cream
 HSV infection
• Caused by HSV type 1 and 2
• HSV 1 > lips , oral ,perioral
• HSV 2 > genital herpes
Herpes labialis - grouped (herpetic) vesicular lesions or erosion on the lips or
periorally
Herpetic gingival stomatitis
common in infants and young children
ulcers on the buccal mucosa and gingiva
cervical lymphadenopathy may be associated
Neonatal herpes
occurs within first 4weeks
getting infected during delivery
affect skin, mouth, eye
CNS involvement can occur
highly contagious
Genital herpes
• mainly caused by HSV type 2
• vulvovaginitis , urethritis, cervicitis, cystitis can occur
• Very painful condition
• grouped vesicles or erosions occurring at the genital areas
• perianal areas may also be involved
Eczema herpeticum
• Kaposi's varicelliform eruption
• wide spread skin lesions occurs
• common in infants and younger children ,but may occur in adults
• associated with atopic eczema or other preexisting skin diseases
Recurrent herpes infection
• Reactivation of the lesions occurs at the previous site
• Severity of the disease is milder
Investigation
• Isolation of HSV in viral culture is gold standard
• Tzanck smear – multinucleated giant cells identified
• PCR
Treatment
• Supportive management
• Can heal spontaneously
• Acyclovir 15 mg / kg 5 times a day for 7 -10 days orally , in severe cases IV
acyclovir needed
Complication
Encephalitis with seizure or disseminated infection may occur in infants and
children
 Varicella infection
• Caused by varicella zoster virus
• IP roughly 2 weeks
• 90% of the cases in children , but occurs in adults as well
• Start as papules then become vesicles with erythematous base
( dew drop of a rose petal ).
vesicles getting eroded forming crusted lesions
• polymorphic in nature
• atypical forms ma be present (only papular eruption )
• Pruritus present
• Mucous membrane involvement ( palate , uvula, tonsil )
• Recurrent infection in immunosuppressed pts
• Complication is usually in adults – pneumonia , encephalitis
Diagnosis
• Usually clinical diagnois
• Tzanck smear - giant cells , balloon clls
Treatment
• Supportive therapy
• Acyclovir 800 mg 5 times /day orally for adults , complicated cases IV
Passive immunization
VZ immunoglobulins given to prevent the spread to the contacts within
72 hrs of diagnosing the index case
can be given to pregnant mothers ( before 20 weeks of pregnancy) to
prevent congenital varicella syndrome in the neonate
Vaccination
live attenuated vaccine
Can be given above 1 year
2 doses given 4-8 weeks apart
contraindicated in pregnancy
after vaccination , better to avoid pregnancy for 3 months
 Herpes zoster
• Due to activation of latent virus in the sensory root ganglia
• Common in adults , may occur in children
• Dermatomal distribution , usually unilateral
multi dermatomes involved in immunocompromised pts
• Preceded by radicular pain , then vesicular eruption follows
• Thoracic involvement is common , ophthalmic branch of the
trigeminal nerve may be involved causing blindness
Hutchinson's sign – lesion seen on the tip of the nose
• Spontaneously heal in 1-3 weeks time, with scarring
• Acyclovir – 800 mg 5 times /day orally
• Post herpetic neuralgia
 Mucocutaneous manifestation of HIV infection

• Candidiasis – oral, pharyngeal, oesophageal , vaginal , intertrigo

• Severe form of atopic dermatitis , [Link] , extensive
dermatophyte infection
• Herpetic gingivostomatitis ,extensive Molluscum contagiosum,
severe form of varicella, HPV infection
• Crusted scabies
• Increased drug reaction
• Kaposis sarcoma on the skin (HHV 8 ) – bluish patchy lesion or
pyogenic granuloma like lesion
• Hairy leukoplakia (EB virus)
• Bacillary angiomatosis due to the bacillus causing cat scratch fever
• Severe form of psoriasis
 HFM disease
• Caused by coxsackie virus A16 , entero virus 71
• Vesicular eruption occurs in the hand ,foot ,mouth, buttock
• Associated with mild fever
• Atypical forms also occurs (necrotic lesions)
• Heals spontaneously
Herpangina
• Caused by coxsackie virus gr A (gr B also)
• Severe sore throat with vesicles in pharynx , tonsil , palate
• Ulcerate later
• Fever may occur
• Symptomatic treatment
• Spontaneous cure
herpangina
 measels
• Caused by measles virus
• IP - 10 days
• Net like rash starting from the face , then spread to trunk
• Fever , conjunctival suffusion, photophobia , URT infection
• Koplik’s spot in the buccal mucosa (whitish spots )
• Heals with desquamation
• MMR vaccination for prevention
 Rubella
• Caused by rubella virus
• IP – 2 to 3 weeks
• Spreaded by direct contact with nasal or throat secretion
• Fever , sore throat , running nose before the rash
• Lymphadenopathy commonly occurs (retro auricular , [Link],
occipital )
• Pinkish macular rash (2-3 mm ) start on the face , then spread to the
trunk
• Petechiae noted on the soft palate (Forchheimer sign)
• Heals spontaneously with desquamation
• Rubella syndrome develop, if a pregnant mother get infected during
1st trimester
 Erythema infectiosum

• Caused by parvo virus B19

• Occurs as out break
• Reticulate erythema of cheeks (slapped cheek ), lasting for 3-4 days
• Pinkish lace like rash occurs in the limbs and the trunk
• Transient anaemia , arthralgia may occur
• Spontaneous recovery
 Superficial fungal infection

• 20 – 25 % 0f the population are affected by some form of

fungal infection.
• Classification of superficial fungal infection
Dermatophytosis
Pityriasis versicolor
Candidiasis
 Dermatophytosis
• It affects the skin , nail and hair
• Branched filamentous fungi
• Classification of dermatophytes
trichophyton – [Link] , [Link],[Link]
epidermophyton – [Link]
microsporum -- [Link] , [Link]
• In the skin , it mainly affect the epidermis
• Clinical lesions in the skin described as tinea or ring worm
• It affects various part of the skin
Tinea capitis - scalp
T. facie - face
T. corporis - body
T. Cruris - groin
T. pedis - foot
T. unguim - nail
 Tinea capitis
• Commonly affect children
• Caused by [Link], T. tonsuran , [Link] , microsporum
species like [Link] ( zoophilic fungi) , [Link]
• Tinea capitis involve the scalp and the hair.
• Clinical presentation
Patchy scaly lesions with loss of hair or
diffuse scaly lesion with or without loss of hair like seborrheic
dermatitis ( caused by [Link] )
black dot like appearance on the scalp due to breakage of the hair
Kerion
favus
• hair involvement
endothrix – fungi growing within the hair shaft (trichophyton spe)
ectothrix -- fungi growing outside the hair follicle (microsporum spe)
Kerion
• Caused mainly by Microsporum species ([Link])
• Patchy highly inflammatory lesion with boggy swelling , exuding pus
• Heals with scarring and scarring alopecia
Favus
• Mainly caused by [Link]
• Yellowish crusts forms on the scalp with loose hairs , resulting in
atrophic scar.
• It affects skin as well
Investigations
• Microscopic examination of hair and scraping from the scalp
• Fungal culture
• Wood’s light examination (microsporum spe – bright green
fluorescence ,T. schoenleinii)
Tinea . capitis
kerion

favus
Treatment
• Griseofulvin is the drug of choice for [Link]
10-20 mg / kg for 6-12 weeks
• Terbinafine is useful in [Link] caused by trichophyton species
250 mg daily for adults for 2- 4 weeks
• Itraconazole , 5 mg /kg /day for 2-10 weeks
• Topical treatment
antifungal shampoos and cream or lotion applied
• for kerion
Griseofulvin 20 mg /kg /day
antibiotics if secondary bacterial infection
Short course of oral steroid may helpful to reduce the inflammation
wash with antifungal shampoo
Tinea corporis
• Involving the trunk and extremities
• Any species of dermatophytes can cause
• Start as reddish, itchy , scaly papular lesions , then it enlarges as
plaques with active margin and central clearance
• It may appear as annular or polycyclic lesions
Tinea cruris
• Very common condition
• erythematous plaque lesion with active edge
• Affects groin and upper thigh
• Usually bilateral
• Scrotum and labia are spared
• D/D - [Link] , psoriasis , erytherasma
Tinea pedis
• Also called athlete’s foot
• Common in adults and adolescents
• Mainly caused by [Link] and [Link]
• It may affect the dorsum of the feet and toe webs
erythematous scaly lesion with papules, pustules and vesicles
maceration may be seen in webs
• Moccasin type involving the planter surface with scaling and
fissuring
Management
• Direct microscopic examination of the scrapings or culture useful in
diagnosis
• Topical treatment is sufficient for mild and localized conditions
miconazole, clotrimazole , ketoconazole , iconasole ,terbinafine
creams for 4 – 6 weeks
• extensive infection need systemic antifungals
griseofulvin , itraconazole , terbinafine for 2- 4 weeks
Periodic acid – Schiff’s stain
Tinea imbricata caused by
[Link]
Tinea corporis
Tinea corpois
 onycomycosis
• It affect the nail plate, nail bed, matrix
• Toe nails are affected more than the finger nails
• Caused by candida, dermatophytes , non dermatophyte molds
Types of onycomycosis
• Distal and lateral subungual onycomycosis –
common type ,caused by [Link]
Subungual hyperkeratosis, thickening of nail plate with discolouration
and onycolysi
• Superficial (white) --
white patches on the nail, nail surfaces looks crumbled and soft
Caused by [Link]
• Proxymal subungual --
Common in HIV pts , white and yellow patches seen on the proximal nail
• Distal onycomycosis --
Commonly caused by candidiasis , affecting distal part of the nail
• Dystrophic onycomycosis --
Occurs in the totally dystrophic nail , commonly caused by cadidiasis
Diagnosis
• Nail scrapings – direct microscopy , culture
Treatment
• Topical treatment useful in [Link] onycomycosis and early distal
and lateral subungual type
In children, topical treatment is effective as penetration is good
• Systemic therapy is most effective in onycomycosis in adults
Terbinafine , itraconazole , fluconazole
 Pityriasis versicolor
• Caused by dimorphic type of fungus , malassezia (pityrosporum)
dimorphic – yeast form and hyphal form which is pathogenic
malassezia species – [Link], [Link] ,[Link],[Link]

• It is a commensal , colonises the skin very early in life

• Warm and moist, pregnancy, immunodefficency and genetic factors

may predispose to develop clinical conditions

• May be contagious

• Hypo or hyper pigmented lesions occurring as discrete or coalescent

ovoid macules with fine scales,

• perifollicular leisons may also occur

Diagnosis
Clinically or by scrapings of the lesions and direct microscopy
spaghetti and meat ball appearance

Treatment
anti fungal creams or shampoos for extensive lesions
Systemic therapy – itraconazole , ketoconazole, fluconazole
griseofulvin not effective
 Candidiasis
• Caused by candida which is a yeast type of fungi

• Its commensal , colonized on the skin and mucous membrane,

becoming pathogenic when grows in large number

• Species of candida -- [Link] , [Link] and [Link].

• Candidiasis may be precipitated by immunocompromised state or by

prolonged use of antibiotics

• Intertriginous areas are commonly affected.

skin lesions are erythematous rash with pustules and crust or scales
with satellite lesions at the periphery
may become macerated , mainly intertriginous lesions
• Oral thrash
whitish plaque lesions on the buccal mucosa and the tonque
If the plaque is removed , reddish base is exposed
• Genital candidiasis
balanitis or balanoposthitis occurs in males , itchy and painful
condition
vaginal thrash in female
vulva become inflamed and oedematous
• Chronic paronychia
common in washer woman
• Chronic Mucocutaneous candidiasis
due to impaired CMI due to auto immune process
associated with poly glandular autoimmune syndrome type1
(hypoparathyroidism , adrenal insufficiency, CM candidiasis)
autosomal recessive condition
 Diagnosis
• Scraping of the lesions and direct microscopy
• KOH preparation shows ovoid bodies and pseudohyphae due to
budding yeast
• Gram stain shows gram positive ovoid bodies (yeast form)
• Fungal culture
Treatment
• remove the predisposing factors
• Topical antifungal cream or lotion
Nystatin suspension for oral thrash
• Oral antifungals
Used in severe cases
Fluconazole --150 mg single dose is enough in mild cases, in severe
cases 100-200 mg daily for 5-10 days or more
CMC candidiasis need long term treatment
itraconazole – 200 mg/day for 5-10 days enough in many cases
Gram stain preparation

KOH preparation
Parasitic infestation
 Scabies
• Caused by a mite – sarcoptes scabiei.
• Spreaded by direct contact
• Female mite burrow in the str. corneum of the skin, it’s a diagnostic
feature
• Presented with severe nocturnal itching
• Pruritic papules ,pustules, ulcers, nodules may occur.
• Affecting finger webs, palm , wrist, axilla, breast ,genital areas,
buttock
• In children , it may affect whole body.
• Crusted scabies (Norwegian scabies), severe form of scabies
occurring in immunocompromised , elderly , psychiatric pts
Diagnosis
• Mainly clinical diagnosis
• Scrapings and direct microscopy

Treatment
Sulphar ointment ,applied for 3-5 days
Crotamiton cream
5% permethrin lotion, single application and repeat aftr 1-2 weeks
In crusted scabies, continuous treatment till the lesions disappear
Ivermectin orally , single dose sufficient
Treat secondary bacterial infection , if present
Control itching with antihistamine
Topical steroid therapy for short course to reduce itching and inflamation
Norwegian scabies
Pediculosis
Head lice
 Body lice
• Transmission via infested bedding or clothing
• Severe and widespread itching especially on the
trunk
• Treatment –
treat the infested clothing and bedding, higtemperature
laundering , dry cleaning
5% permethrin cream on patient's skin
 Pubic lice
• Usually spread by sexual contact
• Commonly infest young adults
• Severe itching in pubic aerea eczematization
secondary infection
• Also found in axillae, on the body hair and in the eyelashes

• Treatment – Carbaryl
- Malathion
- Permethrin
- applied for 12 hours or over night
- repeat after 1 week
 CUTANEOUS LARVA MIGRANS

• Creeping eruption / Sand-worm eruption / Plumber’s itch /

Duckhunter’s itch

• Due to animal hook worms

Ancylostoma brasiliense / A. Caninum/ A. Ceylonicum/
Uncinaria stenocephala /
Bunostomum phlebotomum(hook worm of cattle and sheeps)
CLINICAL FEATURES

• Non-specific dermatitis at the site of penetration

• Itchy, slightly raised, flesh-coloured / pink, bizarre/serpentine linear

creeping eruptions

• Large numbers of larvae may be active at the same time

• Advance at a rate of a few millimetres to a few centimetres daily

• Advancing end is active and marked by inflammatory papule or

pustule
Treatment
• Albendasole 400 mg / day for 3 days or more or oral thiabendasole
• Thiabendasole topically , useful in children
• cryotherapy
 LEISHMANIASIS

• In Sri Lanka – caused by Leishmania donovani

MON 37

• Reservoirs – Canine and rodents

• Human – Accidental host

Human to human transmission can occur

• Transmitted by an infected female sandfly

 EPIDEMIOLOGY

OLD WORLD CUTANEOUS NEW WORLD CUTANEOUS

LEISHMANIAIS LEISHMANIAIS
( Africa – north and east , southern (America,Brazil,Mexico,Colombia )
europe, middle east ,India , china ,
former USSR )
• Cutaneous Leishmaniasis • Cutaneous Leishmaniasis
L. major / L. tropica / [Link]. L. mexicana ,L. braziliensis,
[Link]
• Diffuse cutaneous leishmaniasis • Diffuse cutaneous Leishmaniasis
L. aethiopica L. amazonensis

• Sandfly – Phlebotomus • Sandfly - Lutzomyia

Mucocutaneous leishmaniasis caused by American species

L. braziliensis
 Parasite exists in two morphological forms
• Promastigote in sandfly
elongated, rod shaped
&10-20 µm in length
external flagellum

• Amastigote in vertebrate host

small oval & 1-4 µm in
diameter
no flagellum
vector
Life cycle of leishmaniasis
CLINICAL CLASSSIFICATION
 CUTANEOUS LEISHMANIASIS
Clinical features
•

Sites of the lesions

• Commonly on exposed areas face ,ear, extremities, scalp

• Lip , glans penis – chancre like lesions

• Paronychial

• Pulp of the finger

Satellite lesions
Chronic localized skin lesion
BCC like Papular urticaria like
Healing may occur spontaneously after several months and is followed by
scarring and changes in pigmentation
 MUCO-CUTANEOUS LEISHMANIASIS

• Similar to cutaneous leishmaniasis

• Extends to the adjacent mucosa and cartilage
• Marked disfigurement
• Never heal spontaneously
 DIFFUSE CUTANEOUS LEISHMANIASIS
• Initial primary lesion disseminates to involve other areas of skin
• Multiple disseminated nodules or plaques may occur over the limbs,
buttocks, face and trunk , sparing palms and soles, axilla and groin
• Due to impairment of CMI
• No systemic involvement

VISCERAL LEISHMANIASIS
• When parasite spread to the bone marrow, spleen, liver
 INVESTIGATIONS

1. Smear ( Tissue impression or Slit skin smear or needle aspirate)

Stained with Giemsa to look for amastigotes

2. Histopathology (biopsy from active border)

intra or extra cellular amastigote (dot and dash) in H&E or Giemsa stain

3. PCR (biopsy or needle aspirate)

4. Culture (needle aspirate or biopsy)

NNN – (Novy-MacNeal-Nicolle) medium

5. Serology (Rapid detection of rK 39 Ag)

 TREATMENT

Sodium stibogluconate
Intralesional or Intramuscular or Intravenous
Cryotherapy , ablative laser

Alternative therapies

Hypertonic Sodium Chloride Solution (7% -10%)

Azoles – Fluconazole 200mg daily for 6 weeks
Itraconazole 100mg twice daily for 6-8 wks
Miltefosine – 2.5 mg/kg/day for 28 days orally
Ivermection
Paromomycin ointment
Rifampicin
 Leishmania Recidivans
• Complicating chronic destructive form of disease

• Usually L. tropica

• Rare 3-10%

• Resembles lupus Vulgaris (lupus Leishmaniasis)

apple jelly nodules on diascopy

• Recurrence of lesions at previously healed

original ulcer

• Generally within 2 years

• Impaired cellular immunity

Leprosy
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