Bacterial Skin Infections

Basic Dermatology Curriculum

Last updated December, 2018

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 Goals and Objectives
 The purpose of this module is to help medical students
develop a clinical approach to the evaluation and initial
management of patients presenting with cutaneous
bacterial infections.
 By completing this module, the learner will be able to:
• Describe the morphology of common cutaneous bacterial
infections
• Discuss the bacterial etiologies of cellulitis and erysipelas
• Recognize clinical patterns and risk factors that suggest MRSA
• Recommend initial steps for the evaluation and treatment of
common cutaneous bacterial infections
• Recognize characteristic features of necrotizing fasciitis and
the need for emergent treatment, including surgical intervention

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Case One
Mr. Neal Tolson

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 Case One: History
 HPI: Mr. Tolson is a 55-year-old man who presents with 5
days of worsening right lower extremity pain and a red rash.
He reports recent fevers and chills since he returned from a
camping trip last week.
 PMH: arthritis
 Medications: occasional NSAIDs, multivitamin
 Allergies: no known drug allergies
 Family history: father with history of melanoma
 Social history: lives in the city with his wife, two grown
children
 Health-related behaviors: no alcohol, tobacco or drug use
 ROS: able to bear weight, no itching

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Case One: Exam
 Vital signs: T 100.2, HR 80, BP
120/70, RR 18
 Skin: erythematous plaque with ill-
defined borders over the right medial
malleolus that is tender to palpation.
 Tender, slightly enlarged right inguinal
lymph node
 Laboratory data: WBC 12,000 (75%
neutrophils, 10% bands)

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 Case One, Question 1
What is the most likely diagnosis?
a. Bacterial folliculitis
b. Cellulitis
c. Necrotizing fasciitis
d. Stasis dermatitis
e. Tinea corporis

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 Case One, Question 1
Answer: b
What is the most likely diagnosis?
a. Bacterial folliculitis (Would expect pustules and papules centered on hair
follicles. Without systemic signs of infection)
b. Cellulitis
c. Necrotizing fasciitis (Would expect rapidly expanding rash, usually
appears as a dusky, edematous, red plaque. In this setting, it is always
appropriate to ask the question, “Could this be necrotizing fasciitis?”)
d. Stasis dermatitis (Although found in similar location, stasis dermatitis
often presents on both legs with itch, some pain, and scale, which may
erode or crust. There should not be fever or elevated WBC)
e. Tinea corporis (Would expect annular plaque with elevated border and
central clearing. Painless, but itchy without fever or elevated WBC)

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 Diagnosis: Cellulitis
 Cellulitis is a very common infection occurring in up to 3% of
people per year
 Results from an infection of the dermis that often begins with some
entry portal such as a wound, maceration between toes or fungal
infection (e.g., tinea pedis)
 Presents as a spreading erythematous, non-fluctuant tender
plaque
 More commonly found on the lower leg
 Streaks of lymphangitis may spread from the area to lymph nodes
 Most do not require hospitalization unless IV therapy is required:
systemically signs of toxicity, rapid progression, inability to tolerate
oral therapy, proximity to an indwelling medical device, or
immunosuppressed

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 Differential of Lower Extremity Cellulitis
Redness
Entity Unilateral/ Painful Swollen Red disappears with Other Findings
Bilateral elevation

Stasis Dermatitis (acute flare Usually bilateral Erythema with Usually medial ankle
of chronic venous chronic problem yellowish or light area; assoc with
insufficiency but may have No, itchy Little if any brown No papules, vesicles,
unilateral flare pigmentation; weeping, crusting
sharply demarcated
redness
Acute Usually unilateral Yes, but develops Usually medial ankle,
Lipodermato- sclerosis but may have over weeks to months No Red-purple No lower calf; indurated
bilateral plaque and warm

Asteatotic Bilateral No, may be itchy No Reticular pattern No Lower legs; not hot;
Eczema: dryness in net-like can be oozing,
pattern crusting, fissuring

Acute Allergic Depends on No, itchy Yes Yes No Well-demarcated;

Contact, as with neomycin exposure; at area scaling, blistering,
of contact weeping

Acute Irritant Depends on Yes, painful, burning, Yes Yes No Well-demarcated;

Contact exposure; at area stinging bullae, weeping,
of contact crusting
Gout: uric acid level may be Unilateral Yes, severe Yes Yes, violaceous; No Affects lower
normal during attack extends beyond extremity, as great
joint involved toe the most, instep,
heel, ankle, knee
Lymphedema, primary or Almost always No, but Yes, including Yes Yes, usually May be warm but not
secondary as surgery, unilateral uncomfortable dorsal surfaces disappears hot
radiation, trauma of feet and
toes

Dependent Unilateral or No, usually; may have No Fiery red-dusky Yes Ischemic changes
Rubor bilateral pain at rest with erythema causal; not hot
arterial insufficiency

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 Cellulitis: Risk Factors
 Risk factors for cellulitis include:
• Local trauma (bug bites, laceration, abrasion,
puncture wound)
• Spread of a preceding or concurrent skin lesion
(furuncle, ulcer)
• Secondary cellulitis from blood-borne infection or from direct
spread of subjacent infections (e.g. osteomyelitis) is rare
• A preexisting skin infection due to compromise of skin
barrier (intrerdigital toe web infection, tinea pedis)
• Inflammation (local dermatitis, radiation therapy)
• Edema and impaired lymphatics in the affected area

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 Cellulitis: Etiology
 80% of cases are caused by Gram positive organisms
 Group A streptococcus is most common >>> other strep
 Staphylococcus aureus is less common but occurs with open
wound or penetrating trauma as with needle injection with drug
abuse
 Think of other organisms if there have been unusual
exposures or conditions:
• Pasteurella multocida (animal bites)
• Eikenella corrodens (human bites)
• MRSA (with concurrent MRSA elsewhere/illicit drug
use/purulent drainage)

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 Case One, Question 2
Based on Mr. Tolson’s history and findings, what
is the next best step in management?
a. Apply topical antibiotics
b. Apply topical steroids, compression wraps, and
encourage leg elevation
c. Begin oral antibiotics immediately with coverage
for Gram positive bacteria and encourage leg
elevation
d. Order an imaging study
e. Hospital admission for IV antibiotics

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 Case One, Question 2
Answer: c
What is the next best step in management?
a. Apply topical antibiotics (not effective)
b. Apply topical steroids, compression wraps, and encourage leg
elevation (this is the treatment for stasis dermatitis, not cellulitis)
c. Begin antibiotics immediately with coverage for Gram positive
bacteria and encourage leg elevation
d. Order an imaging study (radiographic examination is not
necessary for routine evaluation of patients with cellulitis)
e. Hospital admission for IV antibiotics (admission only with
differential including deeper/necrotizing infection; severely
immunocompromised or non-compliant patient; non-response to
oral outpatient treatment; signs of systemic toxicity)

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 Cellulitis: Treatment
 It is important to recognize and treat cellulitis early as untreated
cellulitis may lead to sepsis and death
 The following guidelines are for empiric antibiotic therapy for
outpatients with:
• Nonpurulent cellulitis: treat for β-hemolytic streptococci (group A
streptococcus)  cephalexin, amoxicillin, amoxicillin-clavulanate,
dicloxacillin, or clindamycin
• Purulent cellulitis (purulent drainage or exudate without drainable
abscess)/injection drug use/other penetrating trauma/MRSA
presence elsewhere: Treat for community-associated MRSA and
strep  clindamycin, TMP/SMX, or doxycycline + amoxicillin; work
with dermatology and infectious disease specialists
• Unusual exposures: treat for additional bacterial species based on
such exposure; work with dermatology and infectious disease
specialists
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 Cellulitis: Treatment (cont.)
 Monitor patients closely and revise therapy if there is a poor
response to initial treatment; usually a 5 day course of antibiotics is
sufficient
 Treat underlying dermatologic disorder/condition, if present
 Elevation of the involved area
 Treat tinea pedis, toe maceration (strep or Gram negative infection) if
present
 For hospitalized patients: empiric therapy for MRSA should be
considered
 Cultures from abscesses and other purulent skin and soft tissue
infections (SSTIs) are recommended in patients to be treated with
antibiotic therapy but if case has a typical presentation, they need not
be performed

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 MRSA Risk Factors
Healthcare-associated MRSA (HA-MRSA) and community-
associated MRSA (CA-MRSA) risk factors include:

• Antibiotic use • Proximity to others with MRSA

• Prolonged colonization or infection
hospitalization • Skin trauma
• Surgical site infection • Cosmetic body shaving
• Intensive care • Group facilities
• Hemodialysis • Sharing equipment that is not
• MRSA colonization cleaned or laundered between
users/body contact as in sports

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 Antibiotics Used to Treat MRSA

Dosage (adult
Drug dosing with normal Comments
renal function)
Excellent tissue and abscess penetration.
600 mg/kg IV Q8H
Clindamycin Risk for C. difficile
300-450 mg PO QID
Inducible resistance in MRSA
Trimethoprim- Unreliable for S. pyogenes (will need to
1 or 2 double-strength
Sulfamethoxazole combine with amoxicillin/equivalent to
tablets PO BID
(TMP/SMX) cover for group A strep)
Unreliable for S. pyogenes (will need to
Doxycyline, combine with amoxicillin/equivalent to
100 mg PO BID
minocycline cover for group A strep). Do not use in
children < 8 years old.
600 mg IV Q12H Expensive. No cross-resistance with
Linezolid
600 mg PO BID other antibiotic classes
30mg/kg/d in 2
Parenteral drug of choice for treatment of
Vancomycin divided
severe infections caused by MRSA
doses IV
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 Case Two, Question 1
Does this person have cellulitis?

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Yes- a type of cellulitis called
Erysipelas

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 Erysipelas
 Erysipelas is a superficial cellulitis with marked dermal
lymphatic involvement (causing the skin to be edematous or
raised)
• Main pathogen is group A streptococcus
• Also caused by Staph aureus, Haemophilus spp, and others
 Usually affects the lower extremities and face
 Presents with pain, bright erythema, and plaque-like edema
with a sharply defined margin to normal tissue
 Plaques may develop overlying blisters (bullae)
 May be associated with a high white count (>20,000/mcL)
 May be preceded by chills, fever, headache, vomiting, and joint
pain

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Example of Erysipelas

Large, shiny erythematous

plaque with sharply
demarcated borders located
on the leg

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Case Two, Question 2

What is the most appropriate

treatment?
a. Oral antibiotics
b. Oral steroids
c. Topical antibiotics
d. Topical moisturizers
e. Topical steroids

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Case Two, Question 2
Answer: a
What is the most
appropriate treatment?
a. Oral antibiotics
b. Oral steroids
c. Topical antibiotics
d. Topical moisturizers
e. Topical steroids
Oral antibiotics are the most appropriate
therapy in uncomplicated erysipelas.

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 Erysipelas: Treatment
 Immediate empiric antibiotic therapy should be
started (cover most common pathogen -
Streptococcus)
 Such as penicillin V, amoxicillin, clindamycin,
macrolide, and others
 Monitor patients closely and revise therapy if
there is a poor response to initial treatment
 Elevation of the involved area
 Treat tinea pedis, erythrasma, or strep of toe
spaces if present

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Case Three
Mr. Jesse Hammel

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 Case Three: History
 HPI: Mr. Hammel is a 27-year-old man with a history of “skin
popping” (subcutaneous or intradermal injection of drug) who
presents to the emergency department with a painful, enlarging
mass on his right arm for the last two days.
 PMH: History of skin and soft tissue infections, hospitalized with
MRSA bacteremia two years ago
 Medications: none
 Allergies: no known drug allergies
 Family history: father with diabetes, mother with hypertension
 Social history: lives with friends in an apartment, works in retail
 Health-related behaviors: IVDU (intravenous drug use), including
skin popping. No tobacco or alcohol use.
 ROS: no fevers, sweats or chills

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 Case Three: Skin Exam

 Erythematous, warm,
fluctuant nodule with
several small
pustules throughout
the surface
 Very tender to
palpation

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 Diagnosis: Abscess

 A skin abscess is a collection of pus within the

dermis and deeper skin tissues
 Present as painful, tender, fluctuant and
erythematous nodules
 May be have overlying pustule and be
surrounded by a rim of erythematous edema
 Spontaneous drainage of purulent material may
occur

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 Case Three, Question 1

What is the next best step in management?

a. Incision and drainage
b. Topical antibiotics
c. Offer HIV test
d. a and b
e. a and c

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 Case Three, Question 1

Answer: e
What is the next best step in management?
a. Incision and drainage (incision and drainage is the
treatment of choice for abscesses)
b. Topical antibiotics (not effective)
c. Offer HIV test (patients with risk factors for HIV
should be offered an HIV test, e.g. IVDU in this
patient)
d. a and b
e. a and c

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 Abscess: Treatment
 Abscesses require incision and drainage (I & D)
• Most experts recommend clearing pus and debris and probing the
entire cavity following incision and drainage
 Antibiotics are recommended for abscesses associated with:
• Severe or extensive disease (e.g., involving multiple sites)
• Rapid progression in presence of associated cellulitis
• Signs and symptoms of systemic illness
• Associated comorbidities or immunosuppression
• Extremes of age
• Abscess in an area difficult to drain (e.g., face, hand, or genitalia)
• Associated septic phlebitis
• Lack of response to I&D alone

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 Abscess: Treatment (cont.)
 Recommended oral antibiotics include:
clindamycin, TMP-SMZ, tetracyclines
 For hospitalized patients, consider vancomycin,
linezolid, daptomycin, or telavancin
 Wound cultures should be sent from
purulence and before antibiotics are started
 Patients with recurrent skin infections should
be referred to a dermatologist

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 Do you know the following
diagnoses?
HINT: Where are the bacteria and what are
they causing?

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What is the diagnosis?

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 Furunculosis

 A furuncle (boil) is
an acute, round,
tender,
circumscribed,
perifollicular
abscess that
generally ends in
central suppuration

35
What is the diagnosis?

36
 Carbunculosis

 A carbuncle is a
coalescence of
several inflamed
follicles into a single
inflammatory mass
with purulent
drainage from
multiple follicles

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 Furuncle, Carbuncle
 Furuncles and carbuncles are a subtype of abscesses,
which preferentially occur in skin areas containing hair
follicles exposed to friction and perspiration
• Common areas include the back of the neck, face, axillae,
and buttocks
 Usually caused by Staphylococcus aureus
 Patients are commonly treated with oral antibiotics
 For a solitary small furuncle: warm compresses to promote
drainage may be sufficient
 For larger furuncles and carbuncles: manage as you would
an abscess

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 More Examples:
Furuncle and Carbuncle

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Case Four
Mr. Jeffrey Anders

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 Case Four: History
 Mr. Anders is a 19-year-old man who
presents to dermatology clinic with two
weeks of multiple “pimples” in his groin.
He is concerned he has an STD.
 When asked, he reports occasionally
shaving his pubic hair
 Sexual history reveals one female partner
in the last year

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 Case Four: Skin Exam

 Multiple follicular
pustules with
surrounding erythema
in the right groin

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 Case Four, Question 1
Which of the following recommendations
would you provide Mr. Anders?
a. Prescribe oral antibiotics
b. Stop shaving that area
c. Wash the area (antibacterial soap may be
used)
d. Check with his girlfriend to see if she has
any breakout
e. All of the above

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 Case Four, Question 1
Answer: e
Which of the following recommendations
would you provide Mr. Anders?
a. Prescribe oral antibiotics
b. Stop shaving that area
c. Wash the area daily (antibacterial soap may
be used)
d. Check with his girlfriend to see if she has
any breakout
e. All of the above

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 Folliculitis
 Folliculitis is a superficial bacterial infection of the hair
follicles
 Presents as small, raised, erythematous, occasionally
pruritic pustules less than 5 mm in diameter
 Genital folliculitis may be sexually transmitted
 Pathogens:
• Majority of cases are due to Staphyloccus aureus
• If there has been exposure to a hot tub or swimming pool,
consider Pseudomonas as a possible cause
• Pustules associated with marked erythema in the groin
may represent candidiasis

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 Folliculitis: Management
 Cleanse with antibacterial soap
 Superficial pustules will rupture and drain
spontaneously
 Oral or topical anti-staphylococcal agents
as mupirocin or retapamulin ointment;
topical clindamycin solution/lotion may be
used
 Deep lesions of folliculitis represent small
follicular abscesses and should be drained

46
More Examples of Folliculitis

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Case Five
Mr. Danny Holden

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 Case Five: History
 Mr. Holden is a 17-year-old man who
presents to his primary care provider with
a three-week history of a facial rash. The
rash is not painful, but occasionally burns
and itches.
 About a month ago he babysat his 2 year
old niece and she had “a rash on the face.”
 He tried over the counter hydrocortisone
cream with no relief.

49
 Case Five: Skin Exam
 Peri-oral vesicles, papules, and plaques
with overlying honey-colored crust
 Minimal surrounding erythema

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 Case Five, Question 1
What is the most likely diagnosis?
a. Acne vulgaris
b. Impetigo
c. Orolabial HSV
d. Seborrheic dermatitis
e. Tinea faciei

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 Case Five, Question 1
Answer: b
What is the most likely diagnosis?
a. Acne vulgaris (would expect comedones, papules, and pustules, but
not crusted plaques)
b. Impetigo
c. Orolabial HSV (would expect grouped and confluent vesicles with an
erythematous rim; can evolve to crusting and be confused with
impetigo)
d. Seborrheic dermatitis (would expect erythematous patches and
plaques with a greasy, yellow scale)
e. Tinea faciei (would expect erythematous, annular scaly plaques but
often are erythematous with slight scale)

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 Diagnosis: Impetigo
 Impetigo is a common superficial bacterial skin
infection
 Most commonly seen in children ages 2-5, but
older children and adults can be affected
 Impetigo is contagious, easily spread among
individuals in close contact
 Most cases are due to S. aureus with the
remainder either being due to Strep pyogenes or
a combination of these two organisms

53
Examples of Non-bullous Impetigo
 Also called impetigo
contagiosum; most
common form
 Lesions begin as papules
surrounded by erythema
 They progress to form
pustules that enlarge and
break down to form thick,
adherent crusts with a
characteristic honey-
crusted appearance
 Facial area is common
location

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 Example of Bullous Impetigo
 A form of impetigo seen in
young children is
characterized by flaccid
bullae with clear yellow
fluid, which later becomes
purulent
 Ruptured bullae leave a
thick brown crust
 Common locations are the
face, extremities, and
diaper area

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 Ecthyma
 Ecthyma is an ulcerative
papule or plaque which
extends through the
epidermis and into the
dermis
 Consist of “punched out”
ulcers covered with yellow
crust surrounded by raised
margins
 Heals slowly and may scar
 S. aureus and/or Strep
pyogenes may be the cause

56
 Back to Case Five
Danny Holdon was diagnosed with non-
bullous impetigo based on clinical findings

57
 Case Five, Question 2
Which of the following treatment
recommendations is most appropriate for
Danny?
a. Hand washing to reduce spread
b. Topical or oral antibiotics
c. Wash the affected area with antibacterial
soap
d. Check to see if his niece still has her rash
e. All of the above

58
 Case Five, Question 2
Answer: e
Which of the following treatment recommendations
is most appropriate for Danny?
a. Hand washing to reduce spread
b. Topical or oral antibiotics
c. Wash the affected area with antibacterial
soap
d. Check to see if his niece still has her rash
e. All of the above

59
 Impetigo: Treatment
 Topical therapy with mupirocin or
retapamulin ointment may be equally
effective to oral antibiotics if the lesions are
localized in an otherwise healthy patient
and there are not multiple outbreaks in a
family or group
 Otherwise, oral antibiotics are used

60
 Impetigo: Treatment (cont.)
 Oral antibiotics are used to treat impetigo when it is
extensive or affecting several people (close contacts)
and for treatment of ecthyma
 Effective antibiotics include:
• Dicloxacillin
• Cephalexin
• Erythromycin (some strains of Staphyloccocus aureus
and Streptococcal pyogenes may be resistant)
• Clindamycin
• Amoxicillin/clavulanate
• If concern for MRSA, clindamycin, trimethoprim-
sulfamethoxazole, or doxycycline can be used

61
Case Six
Mr. Rodney Gorton

62
 Case Six: History
 HPI: Mr. Gorton is a 68-year-old man who presented to outpatient
surgery for hernia repair. He reported that he had not been feeling well
yesterday but did not wish to cancel his surgery. On PE, he was febrile,
tachycardic, and found to have an expanding tender red rash on his left
thigh. He was admitted to medicine and the dermatology service was
consulted for evaluation of the rash.
 PMH: hypertension, diabetes mellitus type 2
 Medications: lisinopril, insulin, oxycodone
 Allergies: none
 Family history: noncontributory
 Social history: retired, lives with his wife
 Health-related behaviors: no alcohol, tobacco, or drug use
 ROS: fatigue, rash is very painful; deep bruise occurred last week while
cutting wood in area of rash; also had skin tear from branch

63
 Case Six: Exam
 Vital signs: T 102.5, HR 110, BP 90/50, RR 20
 General: ill-appearing gentleman lying in bed
 Skin: ill-defined, large erythematous plaque with central
dusky blue patches, which are anesthetic; upon re-
examination 60 minutes later the redness had spread; the
subcutaneous tissue had a woody induration

Andrews’ Diseases of the Skin Clinical Dermatology. 11 th ed. Philadelphia, Pa: Saunders
Elsevier; 2011. Image copyright Elsevier.

64
 Case Six, Question 1
Which of the following would the
dermatologist recommend for initial
management?
a. An urgent surgery consult
b. IV fluids and narrow antibiotic coverage
c. Schedule an MRI for tomorrow
d. Schedule a skin biopsy in am
e. All of the above

65
 Case Six, Question 1
Answer: a
Which of the following would the dermatologist recommend for initial
management?
a. An urgent surgical consult (necrotizing fasciitis is a surgical emergency)
b. IV fluids and narrow antibiotic coverage (do need IV fluids but also need
broad spectrum coverage initially)
c. Schedule an MRI for tomorrow (If MRI done, should be stat; could show
edema along fascial plane but sensitivity and specificity not well defined;
never delay surgery for MRI if necrotizing fasciitis is clinically suspected)
d. Schedule a skin biopsy in am (if biopsy done, should be an immediate deep
biopsy; if diagnosis is suspected and general surgeon is present, deep
tissue can be obtained during exploratory procedure; involved fascia would
be edematous and dull gray with areas of necrosis; should order Gram stain
and C&S
e. All of the above (no, only a)

66
 Necrotizing Fasciitis: Treatment
 Necrotizing fasciitis is a clinical diagnosis characterized by rapidly
progressing erythema, edema, fever, systemic symptoms, crepitus,
skin necrosis and ecchymosis. There is local anesthesia over the
plaque but overall severe pain out of proportion to exam findings in
some cases
 Poor prognostic factors include: delay in diagnosis, age>50, diabetes,
atherosclerosis, infection involving the trunk
 Necrotizing soft tissue infections can involve the skin, subcutaneous fat,
superficial or deep fascia, and/or muscle
 Considered a medical/surgical emergency with up to a 30-70% mortality
rate with group A Streptococcus
 If you suspect necrotizing fasciitis: consult surgery immediately
 Treatment includes widespread debridement and broad-spectrum
systemic antibiotics
 Do not delay treatment to obtain MRI

67
 Take Home Points
 Cellulitis is a bacterial infection of the dermis that often
begins with a portal of entry such as a wound, insect bite,
fungal infection (tinea pedis), or maceration between toes
 Untreated cellulitis may lead to sepsis and death
 The differential diagnosis of lower extremity cellulitis
includes non-infectious etiologies
 Erysipelas is a superficial cellulitis with marked dermal
lymphatic involvement
 A skin abscess is a loculated infection within the dermis
and deeper skin tissues and is best treated with I&D
 Furuncles and carbuncles are subtypes of abscesses,
which preferentially occur in skin areas containing hair
follicles exposed to friction and perspiration

68
 Take Home Points (cont.)
 Folliculitis is a superficial bacterial infection of the hair
follicles presenting as follicular pustules
 In impetigo, papules and vesicles progress to form
pustules that enlarge and break down to form thick,
adherent crusts with a golden or honey-colored
appearance; ecthyma is a deeper form of impetigo
and results in ulcers
 Necrotizing fasciitis presents as an expanding dusky,
edematous, red plaque with blue discoloration with
associated anesthesia
 Necrotizing fasciitis is a medical/surgical emergency

69
 Acknowledgements
 This module was developed by the American Academy of
Dermatology Medical Student Core Curriculum Workgroup from
2008-2012.
 Primary authors: Laura S. Huff, MD; Cory A. Dunnick, MD, FAAD.
 Contributor: Sarah D. Cipriano, MD, MPH.
 Peer reviewers: Timothy G. Berger, MD, FAAD; Susan K. Ailor, MD,
FAAD, Daniela Kroshinsky, MD, FAAD.
 Revisions and editing: Sarah D. Cipriano, MD, MPH, Alina Markova.
Last revised August 2011.
 Revisions and editing: Susan K. Ailor, MD. Last revised Dec 2014.
 2018 Review and Update by Karolyn Wanat, MD. Peer Reviewed by
Kevin Luk, MD, and Joslyn Kirby, MD, MEd, MS.

70
 References
 Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based
Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from:
[Link]/publication/462.
 Hirschman JV, Raugi GJ. Lower limb cellulitis and its mimics: Part I. Lower limb
cellulitis. J Am Acad Dermatol 2012 Aug, p163-175.
 Hirschman JV, Raugi GJ. Lower limb cellulitis and its mimics: Part II. Conditions that
simulate lower limb cellulitis. J Am Acad Dermatol 2012 Aug, p177-185.
 Drucker CR. Update on topical antibiotics in dermatology. Dermatologic Therapy
Jan/Feb 2012, 25(1), p 6-11.
 Paller AS, Mancini AJ, “Chapter 14: Bacterial, Mycobacterial, and Protozoal
Infections of the Skin. Hurwitz Clinical Pediatric Dermatology, 4 th ed, Elsevier, 2011.

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 RESOURCES

• Thanks to the American Academy of

Dermatology for allowing use of their
digital teaching library.

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