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Skin and Soft tissue infections

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Short notes on skin and soft tissue infections

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Skin and Soft tissue infections

  1. 1. Skin and Soft Tissue Infections Sanjaya Gihan Weerasinghe
  2. 2. • Infections in, – Skin – Subcutaneous tissue – Fasciae – Muscles
  3. 3. Erysipelas • Strep. Infections of dermis • Well demarcated, painful, erythematous • indurated plaques, Blisters & ulceration  • Abrupt fever with chills • Face, legs • common in very young, old, debilitated patients • lymphoedematous • erysipelas and Cellulitis overlap often • Treatment: Penicillin IV/IM
  4. 4. Impetigo • A contagious superficial infection of the skin • Staphylococci or β-haemolytic streptococci • common in children • usually involves the skin of the face, often around the mouth and nose. • spread by direct contact • Minor abrasions and other skin lesions predispose to infections • Prevention is by good personal hygiene , particularly hand washing with soap.
  5. 5. • It has two forms: 1. Non-bullous Streptococcus pyogenes "honey-crust" lesions 2. Bullous Staphylococcus aureus rupture of the bullae "varnish-like" crust
  6. 6. Treatment • Usually self-limiting • Avoid precipitating factor (e.g., exfoliation) • Localized – topical fusidic acid tds. (for MRSA) • mild and localized – Topical antibiotic e.g.; topical mupirocin • Extensive disease – oral flucloxacillin, Erythromycin
  7. 7. • Other close contacts should be examined • children should avoid school for 1week after starting therapy. • resistant to treatment or recurrent – take nasal swabs and check other family members. • Eradication of nasal carriage – Nasal mupirocin
  8. 8. Folliculitis • Infections of the superficial part of the hair follicle • itchy or tender papules and pustules. • Staphylococcus aureus
  9. 9. • Small pustules often pierced by a hair • Legs, face – (sycosis barbae) • commoner in humid climates and when occlusive clothes are worn. • Extensive, itchy folliculitis in HIV infection.
  10. 10. Treatment • topical antiseptics • topical sodium fusidate • mupirocin containing ointment • oral antibiotics – flucloxacillin or erythromycin • If chronic – Detect and treat carrier state
  11. 11. Boils (furuncles) • Staph. Infections of the deeper part of hair follicle • most common on the face, neck, armpit, buttocks, and thighs • On central face – danger of cavernous sinus thrombosis • Tender, red, cone shaped swelling • heal with scarring • Recurrences may occur • Exclude carrier state • Treatment: Antibiotics • If large – need incision
  12. 12. CARBUNCLE • Deep staph. Infection of several adjacent hair follicle • cluster of boils that form a connected area of infection • neck, back, thighs • In diabetics & debilitated • Treatment – Antibiotics, – Surgical incision
  13. 13. Ecthyma • By both streptococci and staphylococci • Ulcer forms under a crusted surface of the infection • Heals with scarring
  14. 14. • Poor hygiene and malnutrition are predisposing factors • Minor injuries and other skin conditions determine the site • Treatment- – Improved hygiene and nutrition – Antibiotics (phenoxymethylpenicillin and flucloxacillin)
  15. 15. Cellulitis • Infection of normal skin flora or exogenous bacteria (S. aureus and ß-haemolytic streptococci) • Deep skin or subcutaneous layer • Hx of Trauma and Ulceration • Organisms enter through breach in skin • Infection can spread to blood stream Bacteremia /septicemia. • lower leg , hand ,nose ,periorbital
  16. 16. Clinical features • Acute localised pain • Oedema • lymphangitis &lymphadenitis – Hot painful erythema streaking, progressing proximally from the affected area, tracking along lymphatics • +/- blister • Fever, Malaise, Leucocytosis
  17. 17. Predisposing factors Diabetes Alcoholism Malignancy Drug abuse venous stasis lymphoedema
  18. 18. Investigations • Swabs taken from relevant sites (from leading edge or aspirating blisters) • Gram stain and Blood cultures • Serological- – antistreptolysin O titre (ASOT) – antiDNAse B titre (ADB)
  19. 19. Management • Elevate limb. • Treat underlying Cause • Antibiotics – Phenoxymethylpenicillin – erythromycin – flucloxacillin (all 500 mg qds) – Vancomycin – Linezolid – Clindamycin • Widespread – IV antibiotics (3–5 days) ,2 weeks (oral) • Recurrent – low dose antibiotic prophylaxis (phenoxymethylpenicillin) MRSA Cellulitis
  20. 20. Complications-Local • Blisters • Skin necrosis • Thrombophlebetics • Lymphadenitis • Abscesses
  21. 21. Complications-Systemic • Bacteremia • Septicemia • Osteomyelitis • Meningitis
  22. 22. Skin abscess • Subcutaneous • localized collection of pus • surrounded by granulation tissue • Hx of – penetrating injury – infection of haematoma
  23. 23. Features: Cellulitis present Swollen Soft center feels like fluid underneath Painful Tender Cellulitis Abscess • S. aureus is the common infecting organism • Poor hygiene is predisposing • Rx- incision and drainage
  24. 24. Necrotizing fasciitis • Surgical emergency • Polymicrobial Infection of the fascia Type 1- E.coli, Pseudomonas, Proteus, Bacteroides, Clostridium Type 2- Streptococcus • May proceed rapidly to underlying muscle. • Diagnosis is often delayed • Primarily a clinical diagnosis • Rapid progression to septic shock • Mortality 30-50%
  25. 25. Clinical Features • Severe pain at the site of initial infection • Tissue necrosis. • spreading erythema • pain • soft tissue crepitus – (infection tracks rapidly along the tissue planes) • Fever ,Tachycardia
  26. 26.  Diagnose on signs and symptoms.  Imaging- air in the tissues.
  27. 27. Clinical findings in necrotising fasciitis Early findings 1. Pain 2. Cellulitis 3. Pyrexia 4. Tachycardia 5. Swelling 6. Skin anesthesia Late findings 1. Severe pain 2. Skin discoloration (purple or black) 3. Blistering 4. Hemorrhagic bullae 5. Crepitus 6. Discharge of “dishwater” fluid 7. Severe sepsis or systemic inflammatory response syndrome 8. Multi-organ failure
  28. 28. • Treat aggressively and promptly • antibiotics –Type 1- – Broad-spectrum combination (amoxicillin , imipenem, levofloxacin) –Type 2 • benzylpenicillin and clindamycin
  29. 29. • urgent surgical exploration – Extensive debridement or – amputation (if necessary) Necrotizing fasciitis after debridement
  30. 30. • Staphylococcal scalded skin syndrome • exfoliate or epidermolytic toxin. • rapidly spreading tender erythema • Dermonecrosis • Outer layer of the epidermis peel off • Blistering • Ritter's Disease of the Newborn - most severe form of SSSS
  31. 31. • Affects – infants, immunosuppressed , renal disease, Malignancy • Mortality – higher in adult • Diagnosis – Clinical – Culture – Frozen section examination of skin – shows split • Treatment: IV antibiotics & nursing care or Self limiting.
  32. 32. Hidradenitis suppurativa • Infection in Apocrine sweat glands • Common in Axillae and groin and in females • Multiple tender swellings • Enlarging and discharging pus • Recurrence • worse in obese individuals • Rx- – weight loss – oral retinoids (Vitamin A) – Zinc gluconate
  33. 33. Erythrasma • Chronic skin infection of Corynebacterium • Macular wrinkled, slightly scaly pink ,brown or macerated white areas • armpits ,groin or between toe webs • Coral pink under Wood’s light • prevalent among diabetics, the obese, and in warm climates • Rx – Topical fusidic acid ,Miconazole
  34. 34. Pyomyositis • S. aureus & Streptococcus infection of the skeletal muscles • pus-filled abscess • most common in tropical areas- “ myositis tropicans” • can affect any skeletal muscle • most often infects the large muscle groups e.g.-quadriceps or gluteal muscles
  35. 35. • Fever, Sepsis, Localized inflammation • Muscle pain • Predisposing factors- Immunodeficiency, IVDAs, Trauma and malnutrition • Complications- Abscess, sepsis • Rx- Drain surgically and antibiotics
  36. 36. Gangrene • Clinical situation where extensive tissue necrosis is complicated by bacterial infection Dry gangrene Wet gangrene Gas gangrene • Predisposing factors – Serious injuries – Ischemia due to atherosclerosis and PVD – Diabetes
  37. 37. Dry Gangrene • The result of ischaemic coagulative necrosis. • Black, dry, sharply demarcated • Secondary bacterial infection is insignificant E.g. Gangrene of extremities in thrombo-embolic occlusion of vessels
  38. 38. Wet Gangrene • Tissue necrosis is complicated by severe infection. • Swollen, reddish-black foul smelling tissue. • Extensive liquefaction of dead tissue occurs due to invasion of organisms & acute inflammation. • No clear demarcation between dead and viable tissue. • Occurs in extremities and internal organs E.g. Diabetic gangrene of foot Gangrene of bowel
  39. 39. Gas Gangrene (Clostridial myonecrosis) • Clostridium perfringens • Extensive tissue destruction • gas production by fermentative action of bacteria. • Swollen reddish-black foul smelling tissue with crepitus.
  40. 40. Treatment • usually surgical debridement • amputation (if necessary) • Antibiotics alone are not effective

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