INFECTIONS OF THE SKIN

BACTERIAL SKIN INFECTIONS

1. Staphylococcus aureus
• S. aureus is a Gram-positive coccus usually arranged in grapelike clusters.
• Found in the skin and nasopharynx
• Produce enzymes and toxins responsible for its pathogenicity and also through direct
invasion and destruction of tissues

MODE OF TRANSMISSION
Skin infections are transmitted through direct contact with a person having purulent lesions,
from hands of healthcare or hospital workers, and through fomites like bed linens and contaminated
clothing.

CLINICAL FINDINGS
1. Folliculitis

• Pyogenic (pus-producing) infection involving the hair follicle

2. Furuncle

• Also known as boil, it’s an extension of folliculitis

• Characterized by larger and painful nodules, with underlying collection of dead and
necrotic tissue

3. Carbuncle

• Represents a coalescence of furuncles that extends into the subcutaneous tissue with
multiple sinus tracts

4. Sty or Hordeolum

• Folliculitis occurring at the base of the eyelids

5. Impetigo

• Infection is common in young children and primarily involves the face and limbs
• Initially, it starts as flattened red spot (macule) which later on becomes a pus-filled
vesicle that ruptures and forms crust (honey-colored crust).
• May be caused by both S. aureus and S. pyogenes

6. Staphylococcal scalded skin syndrome (Ritter’s disease)

• Primarily a disease of newborns and young children.

• Manifested as an abrupt onset of a perioral erythema (redness) that covers the whole
body within two days
 • Later, the lesions develop into bullae and cutaneous blisters which undergo
desquamation.
• Within 7 to 10 days, the skin become intact again.
• The toxin responsible for these manifestation is the exfoliative toxin

LABORATORY DIAGNOSIS
Microscopic examination of Gram-stained specimen and culture.
TREATMENT AND PREVENTION
• Beta-lactam antibiotics like penicillin – treatment of choice
• S. aureus, readily develops resistance to penicillin and other penicillin derivatives like
methicillin and nafcillin.
• Oxacillin- only penicillin-derived antibiotic that has remained active against S. aureus.

2. Staphylococcus epidermidis

• Part of normal flora of the skin and is commonly associated with “stitch abscess, UTI and
endocarditis.
• It also causes infections in individuals with prosthetic devices

3. Streptococcus pyogenes

• are Gram-positive cocci, group A beta-hemolytic (cause complete hemolysis of blood)

• M protein--- major virulence factor (anti-phagocytic)
• Produces enzymes and toxins responsible for the pathogenesis of infections caused by
the organism

MODE OF TRANSMISSION
• Soft tissue infections are acquired through direct contact with an infected person or
fomite.
CLINICAL FINDINGS

a. Pyoderma (impetigo)

• Is a purulent skin infection that is localized, commonly involving the face and the upper
and lower extremities.
• The vesicles rupture and form a honey-colored crust.

b. Erysipelas (St. Anthony’s fire)

• It usually follows a respiratory tract or skin infection caused by S. pyogenes.

• Patients manifest with localized raised areas associated with pain, erythema and warmth
• It is grossly distinct from normal skin

c. Cellulitis
 • Infection involves the skin and subcutaneous tissue, and, unlike erysipelas, the infected
and the normal skin are not clearly differentiated
• It is also manifested as local inflammation with systemic signs

d. Necrotizing fasciitis

• Also known as “flesh-eating”

• Involves the deep subcutaneous tissue, then spreads to the fascia, then the muscle and
fat
• May become systemic and cause multi-organ failure, leading to death

COMPLICATIONS
• Acute glomerulonephritis- non-supporative, immune-mediated complications and skin infections
• Rheumatic fever- usually associated with S. pyogenes throat infection

LABORATORY DIAGNOSIS

1. Microscopy- Gram stain of samples of infected tissues

2. Culture
3. Bacitracin test (antibiotic susceptibility test) – (+) zone of inhibitions of growth around the
bacitracin disc
TREATMENT AND PREVENTION
• Penicillin- drug of choice
• Erythromycin or cephalosporin are alternative drugs in case of penicillin allergy.

OTHER BACTERIAL SPECIES

1. Pseudomonas aeruginosa

• is a gram-negative bacillus that is encapsulated

• capable of producting water-soluble pigments (e.g pyocyanin-blue)
• opportunistic pathogen
• common cause of nosocomial infections (hospital-acquired)
• resistant to antibiotics

MODE OF TRANSMISSION
• Colonization of previously injured skin

CLINICAL FINDINGS
• is commonly associated with colonization of burn wounds
• characterized by a blue-green pus that exudes a sweet grape-like odor
• Other skin infections: FOLLICULITIS
• Secondary infections: ACNE, NAIL INFECTIONS

LABORATORY DIAGNOSIS
• Culture shows flat colonies with green pigmentation and a characterized sweet, grape-like odor.
TREATMENT AND PREVENTION
 • resistant to most antibiotics hence culture and sensitivity must be done
• Preventive measures for control of P. aeruginosa should be focused on preventing contamination
of sterile hospital equipment and instruments, and cross-contamination of patients by hospital
personnel

2. Clostridium perfringens

• gram-postive bacillus
• anerobic
• capable of producing endospores
• produces four lethal toxins: alpha, beta, iota, and epsilon toxins
• Alpha- most lethal because it causes massive hemolysis, bleeding and tissue destruction

MODE OF TRANSMISSION
• Colonization of the skin following trauma or surgery
CLINICAL FINDINGS
• causes soft tissue infections like cellulitis, suppurative myositis and myonecrosis (gas gangrene)
• Gas gangrene- is a life-threatening infection following trauma or surgery and is characterized by
massive tissue necrosis with gas formation, shock, renal failure, and death within 2 days of onset.
LABORATORY DIAGNOSIS
• Microscopic detection of gram-positive bacilli and culture under an anaerobic conditions.
TREATMENT AND PREVENTION
• Surgical wound debridement and high-dose penicillin therapy are the main approaches to the
management of the diseases.

3. Bacillus anthracis
• gram-positive bacilli
• aerobic
• sporeforming
• encapsulated
• arranged in long chains
• characteristics: bamboo rod or medusa head appearance .
MODE OF TRANSMISSION

• inoculation of B. anthracis through break in the skin from either the soil or infected animal
products
CLINICAL FINDINGS
• Anthrax is a disease of herbivores.
• The skin infection cutaneous anthrax, is the most common form
• characterized by painless papules at the site of inoculation that becomes ulcerative, and later
develops into necrotic eschars.
LABORATORY DIAGNOSIS
• Microscopic examination and culture
TREATMENT AND PREVENTION
• Antibiotics like penicillin or doxycycline are the drugs of choice.
FUNGAL SKIN INFECTIONS
A. Superficial mycoses

1. Tenia versicolor (pityriasis versicolor)

- Caused by Malassezia furfur (Pityrosporum orbiculare)

- M furfur is part of a normal flora of parts of the body in which the skin is particularly rich in
sebaceous glands.
-Diagnosis is made by microscopic visualized of “spaghetti” and meatballs”appearance of
M.furfur with alkaline stain.

2. Tinea Nigra

-This infection caused by Exophiala werneckki, a fungus produces melanin.

- Diagnosis is made by direct microscopic examination of skin scrapings with potassium
hydroxide and culture using Sabouraud’s dextrose agar medium.
-Treatment same as tinea versicolor

B. CUTANEOUS MYCOSES OR DERMATOPHYTOSES

• Fungal infection involving the keratinized structure of the body such as like the skin, hair and
nails.

Three genera cause infection:

1. Microsporum- infect the hair and nails only

2. Trichophyton- infect the skin hair and nails

3. Epidermophyton- infect the skin and nails only.

The names of the infection reflect the anatomic sites :

• Tinea pedis also known as athlete foot
• Tinea capitis- scalp
• Tinea corporis- body
• Tinea cruris or jock itch- groin
• Tinea manus- hands
• Tinea barbae – beard
• Tinea unguium- known as onychomycosis nails

-Diagnosis direct microscopic examination

-Treatment administration of anti-fungal drugs like azoles (miconazole, clorimazole, econazole)

C. SUBCUTANEOUS MYCOSES

• The infection initially involves the deeper layer of the dermis and subcutaneous tissue later bones.
• The infection are relatively rare exception of sporotriochosis
Other infections:
• Chromoblastomycosis
 • Phaeohyphomycosis
• Zygormycosis
• Mycetoma (MADURA FOOT)

VIRAL INFECTIONS

1. Human Papillomarvirus

• Warts- caused by a DNA virus, the human papillomavirus (family Papovaviruses)

• 70 serotypes
• Capable of transforming infected cells into malignancy
Mode of transmission
• Direct contact through mucousal or skin breaks
• Sexual contact
• Passage through infected birth canal
• Childhood habit of chewing warts
Clinical findings
• Skin warts- benign, self-limiting, proliferations of the skin that regress in time. It may be flat,
dome-shaped, or plantar.
• Genital and anogenital warts- known as condylomata acuminata, STD
Laboratory diagnosis
• Based on gross appearance of the lesions and histologic appearance on microscopic examination
that includes hyperkeratosis
Treatment and prevention
• Removal of lesion by: Surgical excision, cryosurgery, electrocautery, application of caustic agents
like podophyllin, interferon for genital warts. Prevention is to avoid contact with infected tissue.

2. Herpes simplex

Etiologic agent
• Herpes simplex virus types 1 and 2
• DNA viruses under the family of herpesvirus
• Capable of latency in the neurons and are capable of recurrent infections
Mode of transmission
• HSV is present in oral and genital secretions and vesicle fluid.
• Transmitted through: oral contact (kissing), fomites (sharing of glasses, toothbrushes and other
saliva-contaminated materials), sexual contact, transplacental (during pregnancy), during
childbirth
Clinical findings
a) Gingivostomatitis

ü Primary infection
ü Caused by HSV-1
ü Presents as vesicles that rupture and ulcerates
ü Lesions- located in the buccal mucosa, palate, gingivae, pharynx, and the tounge
b) Herpes labialis (fever blister or cold sore)
 ü Represents recurrent mucocutaneous HSV infection
ü Caused by HSV-1 & 2
ü Lesions- located at vermillion borders of lips
c) Herpetic whitlow

ü Involving the fingers

ü Caused by both HSV types 1 & 2
d) Eczema herpeticum

ü Occurring in children with eczema

e) Herpes gladiatorum

ü Infection of the body

ü Acquired during wrestling or playing rugby
Laboratory diagnosis
• Based mainly on the clinical presentation of the infection
• Can be made using the Tzanck smear to demonstrate the characteristics inclusion bodies known
as the Cowdry type A inclusions and other histopathologic changes
• Cell culture but seldom requested
Treatment and prevention
• ACYCLOVIR- drug of choice
• No available vaccine for HSV