CUTANEOUS INFECTIONS AND INFESTATIONS DR. MOHAMMED ALSHAHWAN MD

OBJECTIVES 1. General understanding of the causative organisms of common skin infection(CSI). 2. Focus on CSI clinical presentation. 3. Overview of the basic investigations done and general knowledge of first line therapy.

BACTERIA (impetigo , erysipelas &cellulits ) VIRUS (wart ,herpes simplex & herpes zoster) FUNGUS (Tinea , candidasis) PARASITE (Lieshmaniasis ,scabies & pediculosis)

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

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

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.

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

CUTANOUS ( HPV 1 and 3 ) common wart flat wart planter wart GENITAL (HPV 6 and 11) classic condyloma acuminata

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

* Tissue destructive modalities TREATMENT * Tissue destructive modalities Keratolytic (salicylic acid and podophyllin) Cryotherapy ( Liquid nitrogen) Electrotherapy CO2 laser * Immunotherapy

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

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

Incubation period : 7- 10 days 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.

Tzank smear Direct fluorescent antibody test Viral culture Blood serology

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

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

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.

SERIOUS involvement 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.

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

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

Tinea corporis / Tinea cruris 1. Hyperkeratotic type (T 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

Tinea Capitis 1. Hyperkeratotic (black dot) usually due to T 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 .

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

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

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

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

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

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

Topical Antifungal Nystatin preparation (oral thrush) Imidazoles e. g 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

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

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

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

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

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

When to suspect scabies. 1. pruritus mainly at night 2 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

Permethrin cream Lindane cream Malathion lotion 2.5% sulphur ointment

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

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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