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Skin and Soft Tissue Infections Sanjaya Gihan Weerasinghe

Skin and Soft tissue infections

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Page 1: Skin and Soft  tissue  infections

Skin and Soft Tissue Infections

Sanjaya Gihan Weerasinghe

Page 2: Skin and Soft  tissue  infections

• Infections in,– Skin– Subcutaneous tissue– Fasciae – Muscles

Page 3: Skin and Soft  tissue  infections
Page 4: Skin and Soft  tissue  infections

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

Page 5: Skin and Soft  tissue  infections

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.

Page 6: Skin and Soft  tissue  infections

• It has two forms:1. Non-bullous

Streptococcus pyogenes "honey-crust" lesions

2. BullousStaphylococcus aureusrupture of the bullae

"varnish-like" crust

Page 7: Skin and Soft  tissue  infections
Page 8: Skin and Soft  tissue  infections

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

Page 9: Skin and Soft  tissue  infections

• 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

Page 10: Skin and Soft  tissue  infections

Folliculitis

• Infections of the superficial part of the hair follicle

• itchy or tender papules and pustules.

• Staphylococcus aureus

Page 11: Skin and Soft  tissue  infections

• 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.

Page 12: Skin and Soft  tissue  infections

Treatment

• topical antiseptics• topical sodium fusidate • mupirocin containing ointment• oral antibiotics –flucloxacillin or erythromycin

• If chronic – Detect and treat carrier state

Page 13: Skin and Soft  tissue  infections

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

Page 14: Skin and Soft  tissue  infections

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

Page 15: Skin and Soft  tissue  infections

Ecthyma

• By both streptococci and staphylococci

• Ulcer forms under a crusted surface of the infection

• Heals with scarring

Page 16: Skin and Soft  tissue  infections

• 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)

Page 17: Skin and Soft  tissue  infections

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

Page 18: Skin and Soft  tissue  infections

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

Page 19: Skin and Soft  tissue  infections
Page 20: Skin and Soft  tissue  infections

Predisposing factors

DiabetesAlcoholismMalignancyDrug abusevenous stasislymphoedema

Page 21: Skin and Soft  tissue  infections
Page 22: Skin and Soft  tissue  infections

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)

Page 23: Skin and Soft  tissue  infections

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

Page 24: Skin and Soft  tissue  infections

Complications-Local

• Blisters• Skin necrosis• Thrombophlebetics • Lymphadenitis• Abscesses

Page 25: Skin and Soft  tissue  infections

• Bacteremia• Septicemia • Osteomyelitis• Meningitis

Complications-Systemic

Page 26: Skin and Soft  tissue  infections

Skin abscess

• Subcutaneous• localized collection

of pus • surrounded by

granulation tissue• Hx of – penetrating injury– infection of haematoma

Page 27: Skin and Soft  tissue  infections

• S. aureus is the common infecting organism• Poor hygiene is predisposing• Rx- incision and drainage

Features:

Cellulitis present

Swollen

Soft center

feels like fluid underneath

Painful

TenderCellulitis

Abscess

Page 28: Skin and Soft  tissue  infections

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%

Page 29: Skin and Soft  tissue  infections
Page 30: Skin and Soft  tissue  infections

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

Page 31: Skin and Soft  tissue  infections

Diagnose on signs and symptoms.

Imaging- air in the tissues.

Page 32: Skin and Soft  tissue  infections

Clinical findings in necrotising fasciitisEarly findings1. Pain2. Cellulitis3. Pyrexia4. Tachycardia5. Swelling6. Skin anesthesia

Late findings1. Severe pain2. Skin discoloration (purple or

black)3. Blistering4. Hemorrhagic bullae5. Crepitus6. Discharge of “dishwater” fluid7. Severe sepsis or systemic

inflammatory response syndrome8. Multi-organ failure

Page 33: Skin and Soft  tissue  infections

• Treat aggressively and promptly• antibiotics –Type 1- –Broad-spectrum combination (amoxicillin , imipenem, levofloxacin)

–Type 2 • benzylpenicillin and clindamycin

Page 34: Skin and Soft  tissue  infections

• urgent surgical exploration– Extensive debridement or– amputation (if necessary)

Necrotizing fasciitis after debridement

Page 35: Skin and Soft  tissue  infections

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

Page 36: Skin and Soft  tissue  infections

• 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.

Page 37: Skin and Soft  tissue  infections

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

Page 38: Skin and Soft  tissue  infections

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

Page 39: Skin and Soft  tissue  infections

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

Page 40: Skin and Soft  tissue  infections

• Fever, Sepsis, Localized inflammation

• Muscle pain• Predisposing factors-

Immunodeficiency, IVDAs, Trauma and malnutrition

• Complications- Abscess, sepsis

• Rx- Drain surgically and antibiotics

Page 41: Skin and Soft  tissue  infections

Gangrene• Clinical situation where extensive tissue

necrosis is complicated by bacterial infectionDry gangreneWet gangreneGas gangrene

• Predisposing factors– Serious injuries – Ischemia due to atherosclerosis and PVD –Diabetes

Page 42: Skin and Soft  tissue  infections

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

Page 43: Skin and Soft  tissue  infections

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 organsE.g. Diabetic gangrene of foot

Gangrene of bowel

Page 44: Skin and Soft  tissue  infections
Page 45: Skin and Soft  tissue  infections

Gas Gangrene (Clostridial myonecrosis)

• Clostridium perfringens

• Extensive tissue destruction

• gas production by fermentative action of bacteria.

• Swollen reddish-black foul smelling tissue with crepitus.

Page 46: Skin and Soft  tissue  infections

Treatment

• usually surgical debridement• amputation (if necessary) • Antibiotics alone are not effective

Page 47: Skin and Soft  tissue  infections

Thank you!