SDNP dcnp infections Flashcards
Cellulitis pathogen
Group A streptococcus, S. aureus: adults
Haemophilus influenzae B: children under 3
Cellulitis treatment
Management: Systemic abx for staph and strep organisms: 1st gen cephalosporins, dicloxacillin
severe cases IV nafcillliin
* Children: IV ampicillin with chloramphenicol, cefuroxime, ceftriaxone
* Consider Rifampin ppx for families w susceptible a child under 4 years, or day-care where systemic H. influenza B has occurred
Erysipelas etio/presentation
- Acute inflammatory form of cellulitis
- May originate in a traumatic or surgical wound
- Group A streptococci most responsible organisms
- Prodrome: flu-like symptoms; develop red, tender, firm spots that rapidly increase in size, uniformly elevated, shiny patch w raised border
Erythrasma pathogen
- Cornybacterium minutissimum
Erythrasma therapies
- Imidazole creams bid x 2 wk: miconazole, clotrimazole, econazole
- Topical abx: erythromycin, clindamycin, fusidic acid cream
- Severe cases: Erythromycin 250mgqidx2weeks
Erythrasma tests
- Woods lamp (UVA): coral red fluorescence
- Potassium hydroxide (KOH): concomitant yeast/fungus: stain w methylene blue: chains of bacilli
- Extensive: screen for diabetes mellitus: fasting glucose, hemoglobin A1c
Furuncle: abscess/boil
- Involves a hair follicle
- S. aureus most common pathogen
- Pearl: no fever or systemic symptoms
Carbuncles: aggregates of infected follicles
Involves mult hair follicles; deep dermis and subq tissue
* abx/antiseptic cleansers, mupirocin inside nostrils
Recurrent/resistant infection: tx all family members, culture for MRSA, clindamycin, rifampicin, cephalosporins
Pearl: Malaise, chills, fever precede or occur during active phase
Bullous impetigo
- Most common in infants and children
Non-bullous impetigo
Children> adults
Impetigo therapy (may resolve spontaneously)
- Topical mupirocin: effective for both staphylococci and streptococci.
- Topical retapamulin (Altabax) approved for infections caused by S. aureus; not MRSA.
- Widespread infections> oral antibiotics.
- Cloxacillin, dicloxacillin, or cephalexin for 5-10 days for rapid healing
- Azithromycin for 5 days once daily is effective and better tolerated than erythromycin or cloxacillin; may improve compliance.
Impetigo tx that’s NOT effective
- Erythromycin not effective d/t strains of resistant staph
- Penicillin inadequate since many
infections have mixed staph and strep
Impetigo info
- NCAA/NFHSS return to play guidelines: No moist, exudative or draining lesions
- Poststreptococcal glomerulonephritis: rare, may occur 1-3 weeks after infection of streptococcal impetigo
- Most commonly asymptomatic
- Occurs between 6-10 years of age
- Strep infections are precursors of guttate psoriasis
Herpes zoster complications
- Ramsay-Hunt syndome: vestibulocochlear nerve
- Ophthalmic branch of trigeminal nerve: HZ ophthalmic
- Herpes zoster multiplex: occurs along 2 noncontiguous dermatomes
- Herpes zoster multiplex: more than 2 dermatomes
- Postherpetic neuralgia: neuropathic sx one or more months beyond resolution
Herpes zoster therapy
- Acyclovir 800 mg q 4 h x7-10days
- Famciclovir 1000mg q 8 h x 7 days (not in
immunosuppressed) - Valacyclovir 1000 gm q 8 h x 7 days
- Foscarnet 40 mg/kg IV: resistant to Acyclovir
Staphylococcal Scalded Skin Syndrome (SSSS) presentation
- Acute onset of tender erythema, quickly develops large, thin, superficial bullae in periorificial and flexural areas.
- Desquamation and fissures around the
mouth/eyes: “sad old man” facies - Oral mucosa and conjunctiva not involved
Herpes zoster pearls
- Burrows soaks alleviate cutaneous symptoms
- Patients with active vesicular lesions can spread infection
- Consultations: neurology, ID, ophthalmology
- Shingrix: decreases r/o zoster & PHN
- Ppx in immunocompromised: 3-6 months acyclovir prophylaxis for transplant patients
- Patients w AIDS: acyclovir prophylaxis not recommended
SSSS course
- Oral mucosa & conjunctiva NOT involved
- Children < 6 y/o, d/t lack of immunity to the toxins and renal immaturity causes poor clearing of toxins; also seen in immunocompromised adults with renal impairment.
- Children are seldom septic
- Desquamation and healing in 7-10 days
- Skin & blood cultures are usually negative in children and positive in adults.
SSSS diagnostics
- Nikolsky’s sign +: extension of a bullae resulting from lateral pressure induces skin separation.
- Biopsy to rule out TEN if uncertain; SSSS biopsy shows splitting of the granular layer of the epidermis
SSSS antibiotics
Oral antibiotics
* Dicloxacillin
* Erythromycin
* Cephalosporins
* Clindamycin
* Sulfamethoxazole/trimethoprim
* Vancomycin
* Corticosteroids are contraindicated
SSSS Pearls
- Avoid wet dressings: may cause drying & cracking of skin
- Refer to nephrology for immunocompromised adults with renal involvement
- +Nikolsky sign
- Spares mucous membranes
- Resolves without scarring
Hansen’s Disease
- Leprosy, mycobacterium leprae
Acral neuropathy
5 disease types:
Tuberculoidleprosy (TT)
Borderlinetuberculoidleprosy(BT)
Midborderlineleprosy(BB)
Borderline lepromatousleprosy (BL)
Lepromatous leprosy (LL)*
Hansen’s Disease Pearls
- M. leprae cannot be grown in culture
- No serologic test for diagnosis
- Stigma may be worse than disease
- Can lead normal lives with appropriate therapy
- Non-infectious within 72 hours of beginning therapy
Condyloma acuminata (HPV)
- HPV types 6 and 11 can cause laryngeal papillomatosis in infants; treating the pregnant mother with Cryotherapy consistently may help reduce the number of warts.
Condylomata acuminata tx pregnancy
- Cryosurgery: LN2 is effective in treating smaller lesions, and safe during pregnancy.
- Laser therapy, YAG or CO2: good for primary and recurrent lesions, safe for pregnant patient who have failed LN2 and trichloracetic therapies..
Condylomata acuminata tx NOT pregnancy
- Podoflox 0.5% (condylox): not in pregnancy
- Interferon alfa-2b: Not for use during pregnancy
- 5-fluorouacil 5%:. Not to be used during pregnancy.
- Imiquimod: Lowest recurrence rate; not first-line therapy
- Sinecatechins 15% (Veregen): MoA unknown
Pregnancy can cause warts to grow d/t hormone changes and immune suppression; should be treated after the first trimester.
Gardasil
- The CDC Advisory Committee on Immunization Practices recommends the HPV vaccine Gardasil for M/F between ages of 11-16 years. Effective in prevention of HPV types 6,11,16, and 18.
Condylomata acuminata education
- Transmission is through sexual contact
- Educate patients about risk factors including infection and cancer
- Condoms should be used when warts are visible or during treatment, or abstinence is advised
- Patients should notify all sexual contacts to be evaluated
- Patients should be followed every 2-4 weeks during treatments until no lesions are noted, then every 3-6 months
- Appropriate PAP smears and STD tests should be performed
Condylomata acuminata pearls
- Frustrating disease characterized by frequent recurrences
- Patients should be treated respectfully and non- judgmentally
- Application of a gauze- soaked pad over suspicious lesions for 5-10 minutes reveals sharply demarcated lesions with white opacity
Gianotti-Crosti Syndrome (Papular Acrodermatitis of Childhood)
Self-limiting dermatitis triggered by viral infections:
* most often Epstein-Barr
* Hepatitis B
* CMV
* RSV
* Parvovirus 19
Spring, early summer, children 6 months to 14 years
* Often prodrome low-grade fever, URI
* Resolves in 3-8 weeks
Gianotti-Crosti presentation
- Symmetric, pink/brown flat- topped papules or vesicles on buttocks and spread to face and extensors. Trunk typically spared
- May be pruritic
- Koebner phenomenon reported
Molluscum contagiosum (DNA poxvirus)
- Palms and soles not involved
- Genital only lesions in children: high suspicion of child abuse
- Red halo: BOTE sign (beginning of the end)
Molluscum education
- Tx takes multiple visits over 1 month or +
- Do not share bath or towels.
- Children may attend school and daycare
- Cover lesions likely to come in contact w others
- Avoid sexual activity until lesions resolved.
- Maintain skin integrity, prevent auto-inoculation
- NCAA return to play: lesions curetted or removed; site covered
- NFHS return to play: 24 hours post curettage; site covered
Molluscum contagiosum tx
- Individualize tx
- Tx mult lesions in children conservatively to prevent scarring
- Genital lesions in adults should be treated to prevent transmission through sexual contact.
- Cantharidin: generally tolerated. Gently drop cantharidin on lesion, cover with tape, wash with soap and water in 2-24 hours.
- Liquid Nitrogen: Usually not tolerated in cases with multiple lesions, especially in children.
- Curettage: In the presence of few lesions, gently curette papules. This may result in scars and should not be utilized in cosmetic areas. Topical anesthesia may be needed in children.
- Salicylic acid 2% applied daily without occlusion
- Trichloracetic acid 35-50%
- Off-label: Tretinoin, imiquimod
Molluscum contagiosum pearls
Pearls
* Usually self-limited.
* Goal of treatment is to avoid scarring
* Often a tincture of time is the only
treatment needed
* Refer to ophthalmology for lesions in the
periocular area
Measles (Rubeola)
- Prodrome: fever, malaise, cough, conjunctivitis. Ill-appearing
- Koplik’s spots: bluish-white elevations on buccal mucosa
- Exanthem: erythematous maculopapular eruption, from scalp to forehead,
posterior ears, face, neck, to trunk and extremities. Fades in same progression - Incubation: 10-12 days
Measles (Rubeola) ddx
- Other morbilliform eruptions: Rubella, erythema infectiosum, pityriasis rosea, infectious mono
- DRUG
- Papulosquamous disorders: psoriasis, guttate psoriasis
Small pox (variola virus)
- Variola Major: mortality 30%
- Variola Minor: mild illness, mortality <1%
- Prodrome: fever, malaise, abd pain, chills, HA, vomiting
- 2-4 days: macules and papules in mouth, face, extremities, spread to trunk, including palms and soles
- Lesions all same stage of development
Small pox (variola virus)
- Contact local public health officials for handling and evaluation
- Supportive therapy
- TPOXX (tecovirmat) app by FDA in 2018: Emergency Use authorization
*Strict standard, contact, and Airborne precautions - Category A bioterrorism agent
Verrucae
- Benign epidermal neoplasms caused by HPV
- Affects 10% of children. Peak incidence 12-16
- Most are transient but recurrence common, especially in immunocompromised patients
- Lesions may koebnerize
- Risks: close personal contact: lesions spread by skin-to-skin contact or skin-to-mucosa contact; indirectly by contact with contaminated surfaces: wrestling mats, swimming pools, showers
Wart sub-types
- Common warts: Hands most commonly involved, but may appear anywhere
- Filiform warts: Single or multiple projections, most common around the mouth and face
- Flat warts: Flesh colored to pink flat or slightly elevated; few to multiple; usually on the face and areas that are shaved: beard area in males and legs in females
- Plantar warts: on the plantar surface (palms and soles); usually on pressure points: head of the metatarsal bones or heels
- Mosaic warts: Cluster of many warts, usually flat with black dots; usually on the heels
- Periungual and subungual warts: around and under the nail
Warts treatment
- Salicylic acid: OTC, available in liquid form and patches, removes surface keratin; preg cat C, therefore avoid during pregnancy
- Cryotherapy: LN2 most common office procedure; poorly tolerated in young children; requires mult tx spaced 2-3 wks apart; TOC during pregnancy
- 35-50% trichloroacetic acid: causes immediate superficial tissue necrosis
- Cantharidin: extract of the blister beetle causes epidermal necrosis and blistering;
painless application, but can form painful blister; often referred to as “Blister Juice” - Retinoids: useful for flat warts; tx may take months
- IL immunotherapy: Bleomycin: high risk for infection and scar; do not use during pregnancy
- Surgical excision ablative laser
- Curettage and desiccation
- Snip or shave excision for filiform warts
- Off-label Therapies: Imiquimod cream, 5-fluorouracil, intralesional squaric acid and Candida, duct tape, cimetidine 30 mg/kg/day
Warts management
- Often spontaneous resolution in 1-2 years: do not necessarily need to be treated
- Treat if lesions are painful, interfere with daily activities, or are multiplying
- In-office therapies most effective when combined with home treatment
- NCAA (National Collegiate Athletic Association) and NFHS (National Federation of State High School Associations) return to play rules for athletes: face: cover with mask; Nonface: cover or curette
Warts pearls
- Don’t make the tx worse than the condition: don’t leave a scar
- Tx take consistent tx for wks or mons
- Home tx are most effective after soaking lesion in warm water to soften skin and allow better penetration of medications; paring with pumice weekly removed keratotic skin
Fungal infections (candidiasis)
- Increased risk with TH17 biologic use, immunocompromised
- Dx based on clinical presentation
- Microscopy w KOH: budding hyphae, pseudo yeast cells; quickest and least expensive
- Fungal culture: gold standard to diagnose
fungal infections can take 2-6 weeks for results
*Biopsy with Periodic acid- Schiff (PAS): helpful to rule out tinea if clinical presentation and microscopy are not conclusive
Candidiasis tx
- Maintaining dryness necessary for intertriginous candidiasis
- Burrow’s compresses
- Absorbent powders (Zeasorb AF 1%)
- Loose-fitting clothes, frequent diaper
changes - Antifungal topical medications: Polyenes,
and azoles. - Nystatin, miconazole, clotrimazole,
ketoconazole, Econazole - Oral medications: fluconazole (Diflucan),
itraconazole (Sporonox)
Candidiasis pearls
- Refer to ID specialist for wide-spread infections
- Examine every pt w candidiasis for oral thrush
Education - Teach pts the risks of recurrence.
- Keep skin dry w powders & frequent clothing changes
- Pts should be re- evaluated if there is no
response to tx in 10-14 days
Fungal infections (Tinea)
- Dermatophyte infection most commonly caused by Trichophyton, Microsporum, and Epidermophyton
- Advancing erythematous border with scale and central clearing
Majocchi Granuloma
dermatophyte invasion of hair follicles
Tinea Barbae
Terbinafine 250mg/day x 2-4 weeks
Griseofulvin 500 mg/day x 2-4 weeks or 150 mg weekly x3- 4 weeks
Fluconazole 200 mg daily x 1-2 weeks
Tinea Capitis
NCAA/NFHS return to play: Oral antifungal>14days
Griseofulvin: 15 mg/kg/day ultramicrosized x3-6 wks
Terbinafine 3-6 mg/kg/day x 6 weeks
Itraconazole 25-200 mg/kg x 23 days
Tinea with Kerion
NCAA return to play: Oral antifungal>14days
Appropriate abx w + culture
Off-label oral prednisone 0.05-1 mg/kg/day x 10-14 days
Tinea Cruris
Topical antifungals
Tinea Manuum and Tinea Pedis
NCAA/NFHSReturntoPlay: Norestriction
Topical antifungals
Terbinafine 250 mg/day x 6 weeks
Itraconazole 400 mg/day x 4 weeks
Fluconazole 150 mg /week x 3-4 weeks
Tinea Unguium (Onychomycosis)
Systemic antifungals treatment of choice
Topical meds high noncompliance rate
Majocchi Granuloma
Terbinafine125-250 mg/day x 2-4 weeks Itraconazole 25-200 mg/kg x 2-4 weeks
