SKIN INFECTIONS

What are the skin microflora?

• The skin microflora are

microorganisms that are resident on
our skin.

• Found in the upper parts of the

epidermis and congregated in and
around the hair follicles.
They include:

◾ STAPHYLOCOCCUS (S).

◾ MICROCOCCUS.

◾ CORYNEBACTERIUM.

◾ MALASEZZIA
Microorganisms are found all over the skin
surface but the species vary with anatomical
site.

Skin sites can be grouped into three types:

◾Dry
◾Moist
◾Oily
Dry body sites

Dry sites include the forearms, hands, legs

and feet. They have the most diverse
microbiota, due to high exposure to the
external environment.
Coagulase-negative staphylococci
predominate, eg S epidermedis and S hominis.

Moist body sites

Corynebacteria flourish in the moist skin of

the skin folds: elbow creases, beneath the
breasts, in-between the toes and the
groins.
Sebaceous sites

Sebaceous body sites include the head, neck

and trunk, where sebaceous glands secrete
an oily substance, sebum, allowing
propionibacteria to thrive.

Demodex (D) mites and the fungus

Malasezzia also congregate in the oily areas
of the face.
What is the role of microflora in human
health?
Micro-organisms can be grouped according to
their relationship with us:

◾Commensals – organisms that reside on our

skin, deriving benefit from us, but we do not
benefit from them.

◾Symbionts – the microorganism and humans

are mutually beneficial.

◾Pathogens – the microorganism benefits but

causes disease to the human.
Can the skin microbiota be harmful?

• Microorganisms are implicated in a number of

infectious and non-infectious skin
conditions affecting the epidermis, hair
follicles, dermis and subcutis.

• Whilst commensal organisms are harmless in

most people, they may cause minor or even
potentially fatal disease in another.

• The following factors make pathogenesis

more likely: :
1. A breach in the mechanical skin barrier due
to injury, a skin disease (eg dermatitis), or
an invasive medical device (eg central
venous line)

2. Immune suppressant medication.

3. Immunocompromise due to cancer or

human immunodeficiency virus infection
(HIV) .

4. Extremes of age (very young or very old).

5. Individual genetic factors.

BACTERIAL SKIN INFECTIONS
The most common bacteria to cause skin
infections are:

 STAPHYLOCOCCUS AUREUS

◾ Folliculitis
◾ Furunculosis (boils) and abscesses
◾ Impetigo (school sores)
◾ Staphylococcal scalded skin syndrome
◾ Toxic shock syndrome
 STREPTOCOCCUS PYOGENES

◾ Cellulitis
◾ Erysipelas
◾ Impetigo
◾ Necrotising fasciitis
◾Infectious gangrene
◾ Scarlet fever
◾ Rheumatic fever, erythema
marginatum
 Overgrowth of CORYNEBACTERIUM SPP.

• Erythrasma,
• Pitted keratolysis &
• Trichomycosis axillaris.
IMPETIGO
 Impetigo is the most common bacterial
infection in children.

This acute, highly contagious infection of the

superficial layers of the epidermis is
primarily caused by Streptococcus pyogenes
or Staphylococcus aureus.
 Occurs in individuals of all ages but is most
common in children 2-5 years of age

 Warm, humid conditions combined with

frequent cutaneous disruption via biting
insects favor its development.
 Crowded conditions or poor hygiene .

 Conditions such as HIV infection, post

transplantation, diabetes mellitus,
hemodialysis, chemotherapy, radiation
therapy, or systemic corticosteroid treatment
increase susceptibility.
 Secondary skin infections of existing skin
lesions (eg, cuts, abrasions, insect bites,
chickenpox) can also occur. (impetiginized)
Impetigo is classified as either :

 NONBULLOUS (IMPETIGO CONTAGIOSA) 70% of

cases . Can be caused by both S aureus {80%}and
GABHS{10%}.

 BULLOUS. { Is most common in neonates and

infants; 90% of cases occur in children younger than
2 years.}
Is caused almost exclusively by S aureus.
This strain of bacteria produces an
exfoliating toxin that causes subcorneal
epidermal cleavage and the condition known
as Staphylococcal scalded skin syndrome
(SSSS).
CLINICAL PRESENTATION
Nonbullous impetigo :

 Begins with a single erythematous macule

that rapidly evolves into a vesicle or pustule
and ruptures measuring less than 2 cm.

 The released serous contents then dry,

leaving a crusted, honey-colored exudate
over the erosion.

 Elevation of the crust reveals a moist

erythematous base.
 Rapid spread follows by contiguous
extension or to distal areas through
inoculation of other wounds from scratching.

 Skin on any part of the body can be involved,

but the face((around the mouth and the
nose) and extremities are affected most
commonly.

 Lesions are usually asymptomatic, with

occasional pruritus.

 Little or no surrounding erythema or edema

is present.
 As the lesions resolve, either spontaneously
or after antibiotic treatment, the crusts
slough from the affected areas and heal
without scarring.
IMPETIGO
Bullous impetigo :

o usually consists of Thin-roofed, flaccid, and

transparent bullae usually measure less
than 3 cm.

o Intact bullae are not usually present because

they are very fragile.

o Spontaneously rupture within 1-3 days, , and

drain so that only the remnants, or
collarettes, are seen at the time of
presentation.
o Bullous lesions occur on intact skin of
intertriginous areas such as the neck, the
axillary and crural folds, and the diaper area,
but they may appear on the face or
anywhere on the body.

o No surrounding erythema or edema is

present.

o In infants, extensive lesions may be

associated with systemic symptoms such as
fever, malaise, generalized weakness, and
diarrhea
 Management:

o Typically involves local wound care along

with antibiotic therapy.

o Antibiotic therapy with a topical agent alone

or a combination of systemic and topical
agents
o Frequent application of wet dressings to
areas affected by lesions.

o Good hygiene with antibacterial washes

may prevent the transmission of impetigo
and prevent recurrences

o Treat preexisting underlying skin diseases,

such as atopic dermatitis.
o Children with impetigo should avoid close
contact with other children if possible.

o Current recommendations call for the

exclusion of children with impetigo from
school or day care for 24 hours after the
initiation of antibiotics.
ECTHYMA
 It is a deep form of impetigo as the same
bacteria causing the infection are involved
but ecthyma causes deeper erosions of the
skin.

 Characterised by crusted sores beneath

which ulcers form.
  Streptococcus pyogenes and/or
Staphylococcus aureus.

 Children, elderly people and

immunocompromised patients (eg diabetes,
immunosuppressive medication,
malignancy, HIV) tend to have a greater
chance of infection.
• Ecthyma lesion usually begins as a vesicle
(small blister) or pustule on an inflamed area
of skin.

• A hard crust that is harder and thicker than

the crust of impetigo soon covers this.

• With difficulty, the crust can be removed to

reveal an indurated ulcer that may be red,
swollen and oozing with pus.

• The areas most affected are the buttocks,

thighs, legs, ankle and feet.
Treatment depends on the extent and
severity of infection.

 Soak crusted areas

 Topical antiseptics or antibiotics
 Oral antibiotics
ERYSIPELAS
• Erysipelas is a bacterial skin infection
involving the upper dermis that
characteristically extends into the superficial
cutaneous lymphatics.

• It is a tender, intensely erythematous,

indurated plaque with a sharply demarcated
border.

• Its well-defined margin can help differentiate

it from other skin infections (eg, cellulitis)
• Found in lower extremities in 80% of
patients; the face is affected in most of the
remainder of the cases.
• In erysipelas, the infection rapidly invades
and spreads through the lymphatic vessels.

• Regional lymph node swelling and

tenderness.

• Streptococci are the primary cause

• Most often affects infants and the elderly,
but can affect any age group.

Other risk factors ,Previous episode(s) of

erysipelas , injury , Diabetes ,
Alcoholism ,Obesity ,Pregnancy.
Management:

• Symptomatic treatment of aches and fever

• Cold compresses

• Elevation and rest of the affected limb.

• Penicillin, orally or intravenously is the
antibiotic of first choice.

• Erythromycin may be used as an

alternative in patients with penicillin allergy.

• Treatment is usually for {10-14 days}

• No scarring occurs.

Common complications
• include abscess, gangrene, and
thrombophlebitis
CELLULITIS
A non necrotizing inflammation of the
skin and subcutaneous tissues, a process
usually related to acute infection that does
not involve the fascia or muscles.
 Characterized by localized pain, swelling,
tenderness, erythema, and warmth.

 Cellulitis has been classically considered to

be an infection without formation of abscess
(nonpurulent), purulent drainage, or
ulceration
 Streptococcal species are the most common
causes of erysipelas and diffuse cellulitis.

 The elderly and individuals with diabetes

mellitus are at risk for more severe disease
 Most patients’ conditions respond well to
oral antibiotics.

 When outpatient therapy is unsuccessful,

or for patients who require admission
initially, IV antibiotics are usually effective.
 Cellulitis may progress to serious illness by
uncontrolled contiguous spread, including
via the lymphatic or circulatory systems.

 Complications include lymphangitis, and

abscess formation.
 FOLLICULITIS

 Folliculitis is an inflammation or infection of

the hair follicles of the skin.

 Any hair-bearing site can be affected, but the

sites most often involved are the face, scalp,
thighs, axilla, and inguinal area.
 Folliculitis divided into superficial and deep
forms; however, most superficial forms can
evolve into the deep form.

 The most common superficial form of

infectious folliculitis is known as impetigo of
Bockhart or barbers itch and is caused by
Staphylococcus aureus

 The lesions are seen in the beard area,

often on the upper lip near the nose, as
erythematous follicular-based papules or
pustules that may rupture and leave a yellow
crust.
 The pustule is often pierced by a hair that is
easily extracted from the follicle.

 This form of folliculitis occurs more

commonly in carriers of nasal staphylococci.
 When involvement of the follicle is more
extensive, a follicular-centered dermal
abscess results.

 When the condition occurs on the beard

areas of the face, it is referred to as sycosis
barbae (vulgaris), but if it occurs elsewhere, it
is referred to as a furuncle or boil.

A confluence of several furuncles results in a

carbuncle
 The causes of folliculitis are multiple and
include infection, friction, excessive
perspiration, and occlusion; however, many
cases remain idiopathic.

 Patients who have a reduced immune

status, prior skin injury, or dermatoses or
those who are obese may be more at risk.