CUTANEOUS INFECTIONS AND INFESTATIONS

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CUTANEOUS INFECTIONS AND INFESTATIONS

• DR. MOHAMMED ALSHAHWAN MD

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• BACTERIA
• MYCOBACTERIA
• VIRUS
• FUNGUS
• PARASITE Worm
• Arthropod
• Protozoa
• STD (SEXUALLY TRANSMITTED DISEASE)

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• BACTERIAL
• I. Impetigo
• Superficial non-follicular infection due to
  staphylococcus and streptococcus
• Children
• not sick
• pustule (honey-colored crust )
• Face and Acral areas
• Primary or secondary

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• II. Erysipelas
• deep cutaneous infection (Dermal)
• due to streptococcus after penetrating trauma (
  CHRONIC LYMPHEDEMA)
• sick
• Face and Acral areas
• Unilateral sharply demarcated edematous red
  plaque

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• III. Cellulitis
• deep cutaneous infection (up to SC FAT)
• due to streptococcus after penetrating trauma (
  CHRONIC LYMPHEDEMA)
• sick
• Face and Acral areas
• Unilateral Diffuse (NOT well demarcated)
  edematous red plaque
• Blood Culture in immuocompramized pts.

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• IV. Erythrasma
• Corynebacterium minutissimum
• (not contagious)
• Asymptomatic
• Flexures
• well demarcated scaly reddish-brown patch with
  advancing edge.
• Coral-red fluorescence

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• MYCOBACTERIAL
• I.TUBERCULOSIS
• Exogenous
• tuberculosis chancre
• Direct extension
• scrofuloderma
• Hematogenous spread
• lupus vulgaris

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• Lupus vulgaris
• Most common type of Cutaneous TB
• Children
• Female
• Head and neck only
• Red-brown nodules and plaques
• (apple-jelly nodules) when it ulcerate it heal
  with unhealthy scar

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• II. LEPROSY
• M.leprae
• faceoral transmition
• Close contact in endemic area (India)
• Delay in presentation ( 20 years)

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• Classification of leprosy
• Indeterminate stage
• ill-defined hypopigmented anesthatic hairless
  dry patch
• Tubercaloid leprosy
• Few ( lt 3) well demarcated scaly red anesthatic
  hairless dry annular plaques with central
  clearing
• Adjacent nerve swelling

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• Lepromatous leprosy
• Multiple diffuse symmetrical skin-colored to
  red-brown plaques and nodules
• Leonine face
• blindness
• Peripheral neuropathy
• Borderline leprosy

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• VIRAL INFECTION
• WART
• Human papilloma virus (HPV)
• Direct contact
• Asymptomatic transmition
• Delay in presentation
• Oncogenic potential (HPV 16 and 18)
• High recurrence rate

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• CUTANOUS ( HPV 1 and 3 )
• common wart
• flat wart
• planter wart
• GENITAL (HPV 16 and 18)
• classic
• condyloma acuminata

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• GENITAL WART
• STD
• Oncogenic HPVs ( Cervical cancer)
• Usually more persistent and difficult to treat .

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• TREATMENT
• Tissue destructive modalities
• Keratolytic (salicylic acid and podophyllin)
• Cryotherapy ( Liquid nitrogen)
• CO2 laser
• Pulse-dye laser
• Immunotherapy

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• MOLLUSCUM CONTAGIOSUM
• POX virus
• Direct contact
• Asymptomatic transmition
• Children
• Genital type is STD

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• Multiple UMBLICATED skin colored or reddish
  papule affecting the face and extremities.
• CURETTAGE is the treatment of choice for few
  lesions
• KOH is the treatment of choice for multiple
  lesions.

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• ORF
• POX virus
• Contact with infected cattle or sheep
• After 2 weeks of incubation a solitary expanding
  red papule with vesicle at the center which
  become necrotic at the end.
• Patient develop IMMUNITY afterward

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• HERPES SIMPLEX
• Human Herpes virus I and II
• Direct contact
• Asymptomatic transmition
• Latency
• High recurrence rate

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• CUTANEOUS ( HSV I )
• orolibialis Initial
• Herpatic whitlow Recurrence
• herpes ophtalmicus
• GENITAL ( HSV II )
  
  
• Initial
  
• 
  Recurrence
• 
  

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• Incubation period 7- 10 days.
  After 24-48 hours of burning and tingling
  sensation the patient develop grouped vesicles on
  erythematous base which ulcerate within 24 hours.
• The whole illness is around 7-10 days.

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• Tzank smear
• Direct fluorescent antibody test
• Viral culture
• Blood serology

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• VARICELLAE ZOSTER VIRUS (VZV)
• FACEORAL
  CHICKENPOX ( Children)
• HERPES ZOSTER (Adult) is due to reactivation
  of VZV which was dorminant in nerve root
  ganglion
  

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• CHICKENPOX
• Incubation period 2 weeks
• Prodrom of respiratory coryza followed by
  disseminated red macules with central vesicles.
• The whole illness 3 weeks
• The patient contagious 5 days before and 5 days
  after skin eruption

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• HERPES ZOSTER
• After 24-48 hours of burning and tingling
  sensation the patient develop grouped vesicles on
  erythematous base which ulcerate within 24 hours.
• The whole illness is around 7-10 days.
• Post-herpetic neuralgia (PHN) which usually
  persist for around 4 weeks.

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• It is almost always DERMATOMAL
• SPINAL (Thoracic )
• CRANIAL ( Trigeminal)
• SERIOUS involvement
• 1.Ophthalmic division of trigeminal nerve.
• 2. Geniculate ganglia (Ramsey-hunt syndrome)
• 3.Sacral ganglia.

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• Treatment
• HERPES SIMPLEX
• Acyclovir 200 mg five time a day for a week
• HERPES ZOSTER
• Acyclovir 800 mg five time a day for a week

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• FUNGAL
• DERMATOPHYTE
• Tinea Pedis (most common)
• 1.Erosive interdigitalis
• 2. Hyperkeratotic type(T. rubrum)
• 3. Inflammatory type(T.mentagrophyte)

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• Tinea corporis / Tinea cruris
• 1.Hyperkeratotic type (T. rubrum)
• well-demarcated annular red hyperkeratotic
  plaque with central clearing (Ring worm)
• 2.Inflammatory type (T.mentagrophyte)
• well-demarcated edematous red plaque with
  superimposed pustules

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• Tinea Capitis
• 1.Hyperkeratotic (black dot)
• usually due to T. tonsurans
• 2. Inflammatory (Kerion)
• usually due to M. canis complex
• 3. Favus
  
• Due to T. schoenleinii
• it characterized by the presence of
  Scutulae .

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• YEAST
• Candidosis
• Due to candida albicans
• It is a commensal flora of the gut which become
  pathogenic when the immune status of the person
  changed

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• physiological (old age , neonate and pregnancy)
• pathological ( DM, HIV and organ transplant)
• Itrogenic (long course of Antibiotics)

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• MUCOSAL
• 1. Oral
• oral thrush
• angular chilitis
• 2. Genital
• valvuvaginitis

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• CUTANEOUS
• it favor wet areas
• Candidal intertrigo ( Napkin rash)
• peripherally spreading glazed red patch with
  scaly border and satellite pustules
• Candidal paronychia

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• pityriasis versicolor
• Due to Malassezia furfur
• Asypmtomatic
• Well-demarcated brown patches with branny over
  the trunk and upper extremities

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• 1. Scraping,Clipping and Hair blucking
• KOH/microscopy
  Culture
• 2. Skin biopsy
  Histopathology with PAS stain
• Culture

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• Topical Antifungal
• Nystatin preparation (oral thrush)
• Imidazoles e.g. cotrimazole and miconazole
• Systemic Antifungal
• Imidazoles e.g. Itraconazole and fluconazole
• Allylamine e.g. Terbinafine
• Griseovulvin

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• Indication of systemic treatment
• 1.Tinea Capitis
• 2. Paronychia and Onychomycosis
• 3. Failure to respond to topical treatment
• 4. Immunocompramized pts.
• 5. Atypical presentations.

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• PROTOZOA
• Lieshmaniasis
• Protozoa called Lieshmania
• Sand fly (premastigote)
• Macrophage (Amastigote)
• Lieshman-Donovan bodies

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• Localized Cutaneous
  Well-demarcated ulcerated nodule over the exposed
  areas after a trip to an endemic area ( H/o of
  insect bite)
• Disseminated Cutaneous
• Mucocutaneous
• Visceral

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• Skin biopsy
• Histopathology with Gimsa stain
• Lieshman-Donovan bodies
• Culture
• PCR for DNA
• Liesmanin test

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• Resolve spontaneously leaving a scar
• Antimony(Pentostam) either Intralesional or
  Intramuscular to shrink the lesion

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• Scabies
• Mite called sarcoptes scabei
• which residue in burrows in the stratum
  corneum laying eggs then dieing and the eggs will
  maturate 2 weeks period and the cycle repeated.
• Skin lesions are Secondary eczematous eruption
  due to immune reaction to the mite and eggs

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• When to suspect scabies ?
• 1.pruritus mainly at night
• 2. Other member of the family also having
  severe pruritus
• 3. Pruritus and skin eruption is more severe in
  the flexors
• Document See the mite or eggs

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• Permethrin cream
• Lindane cream
• Malathion lotion
• 2.5 sulphur ointment

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• PEDICULOSIS
• Head lice (Pediculosis Capitis)
• Children
• Body lice (Pediculosis Corporis)
• Homeless people and vagrants
• Pubic lice (Pediculosis Pubis)
• STD ( partner should be treated)

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• The diagnosis can be conformed by seeing the lice
  eggs ( NITs)
• Best treatment is SHAVING for head and pubic
  lice. Alternatives
  
• Permethrin creame rinse
• Malathion lotion

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• STD
• Syphilis
• Spirochete called Treponema Pallidum
• After 1-4 weeks of Sexual contact
• A third develop 1ry syphilis
• After 4-8 weeks A third develop 2ry syphilis
• After months to years A third develop 3ry syphilis

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• 1ry syphilis ( 1ry chancre)
• Painless well-demarcated indurated genital ulcer
  with lymphadenopathy.
• Serology is negative
• Smear for
• Dark filed examination
• Direct fluorescent antibody test

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• 2ry syphilis
• Asymptomatic generalized monomorphic eruption
  with lymphadenpathy with characteristic
  involvement of the palms/soles and mucous
  membrane.
• Serology is positive ( VDRL / RPR)
• Skin biopsy for
• Histopathology and stain
• Culture

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• 3ry syphilis
• Cuatneous
• Well-demarcated nodules with or without
  ulceration mainly over the trunk GUMMA . Severe
  mutilation can happen when it involve the face
• Serology is not reliable
• Diagnosis can be made through skin biopsy

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• HUMAN IMMUNODEFICIENCY VIRUS
• (HIV)
• Retrovirus that affect the CD-4
  T-helper cells
• Stages
• 1. Viral prodrome ( usually Asymptomatic)
• 2. ARC ( AIDS related complex)
• 3. AIDS

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• When to Suspect HIV ?
• Generally, in case of severe Atypical
  disseminated stubborn Infection/Neoplasm.
• 1.severe seborrhoeic dermatitis/psoriasis
• 2.Oral hairy leukopakia.
• 3. Proximal Subungual onychomycosis.
• 4. Kaposi sarcoma
• 5. Eosinophilic folliculitis

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THANK YOU