|
|
|
|
Viral
Warts: These are benign tumors of the skin caused by
Human Papilloma Virus (HPV). They can occur at
any age but are unusual in infancy. It is spread by
direct or indirect contact. Impairment of the epithelial
barrier by trauma, xerosis (dry, cracked skin) or
maceration (excessive moisture) are pre-requisites for
the infection. Warts are commonly seen around the nails,
hands, face, feet and genital area. They can spread to
other parts of the body through scratching and trauma.
Clinically they are seen as asymptomatic, raised, round
lesions with rough or velvety surface. On the face, they
are seen as fleshy, finger like projections. Patients
with defective immunity and those belonging to families
with atopy usually develop large number of warts,
sometimes resistant to treatment.
Treatment includes
- Chemical
cautery - by using chemicals such a salicylic acid and
lactic acid, gluteraldehyde, trichloroacetic acid
etc.
- Electrosurgery
- Cryotherapy
using liquid nitrogen
- Immunomodulators
like podophylline, alpha interferon, 5 fluorouracil,
imiquimod
- CO2
laser
|
|
Herpes
Infections: These are one of the commonest viral
infections of the mucocutaneous surfaces caused by Herpes
Simplex Virus (HSV) Type 1 and HSV Type 2. Herpes
viruses cause primary mucocutaneous infection on
contact with mucosal surfaces or abraded skin following
which they replicate and enter the cutaneous neurones.
Here they remain dormant and cause recurrent disease
whenever the viral reactivation occurs.
|
HSV Type 1 usually affects the oral cavity and
occasionally the eyes. It presents as primary
infection or recurrent infection.
Primary infection usually occurs at younger age and
most of the time, goes unnoticed. It is characterised
by fever and grouped, fluid filled lesions inside the
mouth, leading to multiple, tiny ulcers.
Recurrent
herpes labialis is the commonest presentation. It is
characterised by a few grouped fluid filled lesions in and
around the mouth. It can occur in any individual who had a
primary infection (clinical or subclinical) in the past
and may be precipitated by fever, stress, UV radiation,
dental treatment, surgeries on the face including chemical
peeling.
|
Recurrent
herpes labialis |
Herpes
simplex Type 1 spreads from one to another by direct
contact. |
 |
Herpes
Simplex Type 2 infection occurs over the genitals and
is usually sexually transmitted. It also presents as
primary and recurrent infection. Primary infection is seen
5-12 days after sexual contact and is clinically
characterised by multiple, tiny, grouped, fluid filled
lesions which rupture, leaving behind multiple, tiny ulcers
over the genitals and is associated with fever and
lymph node enlargement. The person with a primary
infection will be shedding the virus for about 11-14 days
and should avoid sexual contact during this period. Healing occurs in 18-21
days.
Recurrence with HSV 2 infection is more common than HSV 1
infection. However the recurrent attacks are less severe
than the primary infection. Recurrence is precipitated by
stress, trauma and immunocompromised state. In a
recurrence, the viral shedding lasts for 3-4 days and
healing occurs in 9-10 days.
Primary genital infection during the third trimester of
pregnancy will lead to herpes infection in the neonates
which can be severe. With recurrent genital infection, the
risk of transmission to the newborn is lower.
Treatment:
It should be started early for better results. In addition
to the local measures to prevent the infection, acyclovir
should be given in appropriate dose for appropriate
duration.
|
|
|
|
Chicken
Pox (Varicella):
It is an acute infectious disease caused by the Varicella
zoster virus. It spreads by inhalations of the
viral particles. The duration between the infection and
onset of eruption is usually 14-21 days. Most commonly it
occurs during childhood when it is less severe and
sometimes subclinical. Those who did not have the
infection during childhood may develop it later, which
might be severe.
Clinically
it is characterised by fever, body ache and rash,
consisting typically of clear, fluid filled (dew-drop)
lesions starting on the trunk and extending on to the
face. The lesions crust in 2-4 days and new lesions appear
in crops over a period of one week. Patients with varicella are infectious to others when they are having
these clear, fluid filled lesions. The lesions of chicken
pox usually get secondarily infected resulting in
scarring.
Treatment
includes rest, use of drying preparations (calamine) in
the presence of fluid filled lesions, antibacterial creams
for ruptured lesions and antipyretics. Acyclovir is the
drug of choice and should be given as early as possible
(within 48 hours).
| |
|
|
Herpes
Zoster: It is a manifestation of reactivation of the Varicella
zoster virus that usually remains dormant in a sensory
ganglion following chicken pox. It occurs commonly in the
elderly, diabetics, immunocompromised and following stress
and trauma.
It
presents clinically as severe pain along the affected
nerve, followed by rash consisting of grouped, fluid filled
lesions along the affected nerves. A person with herpes
zoster can cause the spread of chicken pox in the family
members who did not suffer from it earlier.
Treatment
is the same as for chicken pox.
|
 |
| Prevention
of varicella is very important in neonates and
immunocompromised individuals. Passive immunization is by
administering varicella zoster immunoglobulin (VZIg) to
abort or modify the clinical infection and should be
administered within 4 days of exposure to the infected
case. Active immunization with a live attenuated VZ virus
reduces the risk of acquiring infection; however it should
be given within 48 hours to high risk individuals. |
| |
|
|
|
|
Bacterial Infections |
|
|
|
Bacterial infections of the skin are commonly referred
to as pyoderma, which literally means pus in the skin.
Pathogenic bacteria most commonly causing infections
of the skin are coagulase positive Staphylococcus aureus
and Streptococcus pyogenes. Conditions
predisposing for bacterial infections are moisture,
damage to the skin, pre-existing skin disease etc.
While
damage to the skin is a pre-requisite for
Streptococcal infections, Staphylococcal infections
can occur even on intact skin.
Disinfection of the skin using antiseptics can remove
the resident flora (non-disease causing bacteria
normally present on the skin) that provide defense
against infection and hence can predispose to more
frequent infections by Staphylococcus aureus.
On the other hand, as resident flora do not hinder the
growth of Streptococcus pyogenes, disinfecting
the skin does not offer protection against this
organism either. |
|
|
|
Impetigo
It is a common, contagious, superficial infection of
the skin caused by either Streptococcus pyogenes
or Staphylococcus aureus or both. It is
commonly seen in children and young adults. It is
common in lower socio-economic groups due to poor
hygiene, poor nutrition and over-crowding. The
peak incidence is seen in late summer. Precipitating
factors include breach in the skin due to trauma,
insect bite or any other skin diseases like eczema,
infestations (Scabies)
Common sites include face, especially around the
nose and mouth, scalp and legs.
Treatment:
Compresses to remove the crusts followed by
application of antibacterial creams.
For
mild and localised infections, topical antibiotics
like mupirocin, fucidic acid, neomycin and
bacitracin combination may suffice.
In
the presence of wide spread and severe infections
or with associated lymphadenopathy, oral
antibiotics are indicated.
Once
the infection is controlled, the underlying skin
disease should be identified and treated. |
|
 |
Bullous
Impetigo |
|
|
|
 |
Non-Bullous
Impetigo |
|
|
|
|
Info on Bacteria here:
www.typesofbacteria.co.uk/home.htm |
|
|
| |
|
|
 |
Carbuncle
Carbuncle
is a deep seated infection of the skin, produced by
the infection of neighbouring hair follicles, caused by
Staphylococcus aureus. It is predominantly seen
in middle aged and elderly men with predisposing causes
like diabetes, malnutrition, immunocompromised state
(diseases and drugs) and debility. Clinically it
presents as painful, hard, red lump with multiple
openings discharging pus. Common sites include back of
the neck, shoulders, hips and thighs. It is usually
associated with fever and generalised weakness. In
elderly and debilitated individuals, if not treated in
time, it can lead to toxemia and could even be fatal.
Treatment: Pus should be drained. Antibiotics
against Staphylococcus aureus should be started
as early as possible, drug of choice being cloxacillin
or penicillinase resistant antibiotics. Underlying cause
should be sought and treated. |
| |
|
|
|
Erysepelas:
It is the infection of the
dermis and the subcutaneous tissue including lymphatics, caused by Streptococcus pyogenes.
Clinically it is seen as sharply demarcated, painful, raised, red
lesions with orange peel (peau-de-orange) appearance. It is
usually associated with fever and lymphadenopathy. The common sites are
face and legs. In the presence of lymphatic obstruction secondary to
surgery and radiation, it can occur on the upper limbs also. Most
important predisposing cause is lymphatic obstruction (filarial
lymphedema, varicose veins with chronic edema of limb). It can also
occur following injuries, insect bites etc., that act as portal of entry
to Streptococcus pyogenes.
Without effective
treatment, complications like subcutaneous abscess, cellulitis and
septicemia can occur. Sometimes, systemic reactions like nephritis and
scarlet fever can follow.
Treatment:
Penicillin is the drug of choice. In the
presence of severe infection with systemic reaction, injectable
penicillin or first generation cephalosporins are indicated. In very
early infections and in patients allergic to penicillin, erythromycin is
the alternative. Vancomycin can also be used for penicillin sensitive
patients with severe infection. Foot end elevation may help in patients
with lymphedema. Recurrent erysepelas can occur in patients with chronic
lymphedema. In recurrent cases, long term penicillin (Penicillin LA 12L
Units once in 3 weeks) can be given. Supportive stockings may also help. |
|
|
|
|
|
|
|
|
Fungal
Infections |
|
|
|
|
|
Superficial fungal infections of the skin are the
most commonly encountered, curable skin diseases. They
are caused by fungi belonging to three groups:
dermatophytes, Candida species and Malassezia
furfur. The fungi affect the skin, hair and nails.
Dermatophytes cause the skin disease known as
Tinea (Ring Worm). Dermatophytes infecting the
skin could be anthropophilic (human to human), zoophilic
(animal to human) or geophilic (soil to human). Most
commonly encountered infections are caused by the anthropophilic species. Predisposing factors for
dermatophytoses include excessive sweating, occlusive
dressing, topical and systemic steroids, underlying skin
diseases like ichthyosis and atopic dermatitis,
immunocompromised state and environmental factors like
high humidity.
The
clinical presentation depends upon factors like site of
infection, immunological response of the host and
species of the fungus (anthropophilic cause less severe
and zoophilic cause more severe inflammatory response).
Commonly it is seen as ring like lesions with peripheral
activity and central clearance. Common sites are the
scalp in case of children (Tinea capitis) and body folds
(intertriginous) in adults. Itching is a characteristic
feature of tinea.
The
diagnosis of tinea is to a large extent based on the
clinical features. Difficulty arises when the patient
presents with tinea incognito (hidden tinea)
which results from misdiagnosis and mistreatment with
topical steroids, over-the-counter products and home
remedies. Tinea is one skin disease that, when diagnosed
right and treated right (proper antifungals for proper
duration), is curable. Treatment with topical steroids
leads to chronic disease.
Differential Diagnosis: Clinically tinea has to be
differentiated from common skin diseases like subacute
and chronic eczema, psoriasis etc. The points that
favour tinea are:
In case of
doubt, scrapping for fungal elements should be done (if
scales are present). If the patient has already used
topical steroids, they should be stopped and lesions
should be observed or plain antifungals could be
advised. |
|
|
|
|
|
|
|
|
Tinea
Capitis resulting in alopecia |
|
Tinea
Capitis resulting in alopecia |
|
|
|
|
|
|
|
Kerion |
|
Tinea
Concentricum |
|
|
|
|
|
Treatment
of Tinea: Treatment of tinea includes local
application of medicines and oral medications. When the
disease is of short duration and localised, local
application of medicines is usually sufficient. Long
term disease, extensive disease and recurrent infection
should be treated with oral medications.
The
antifungals used in the treatment of tinea are of two
types:
-
Fungistatic agents (inhibit the multiplication of the
fungus): Azoles like clotrimazole, miconazole,
ketoconazole, oxyconazole etc.
-
Fungicidal
agents (kill the fungus): Allylamines like terbinafine,
butenafine, naftifine, griseofulvin.
Drugs of
choice for dermatophytes are allylamines and griseofulvin.
Duration of
treatment depends upon the site of infection. Skin
infection usually requires treatment for 4-6 weeks, hair
infection for 6-8 weeks and nail infection for months (3-4
months for finger nails, 6-12 months for toe nails).
Treatment
should not be discontinued once the itching subsides; it
should be continued for the recommended duration to ensure
fungal clearance and prevention of immediate relapse.
Preventive measures like keeping the area dry, avoiding
wet clothes and avoiding friction should be practiced. |
| |
|
|
|
Candidiasis:
It is the infection of the skin and mucous membranes by
yeast like fungus Candida albicans and other
species. Cutaneous candidiasis usually affects the web
spaces of the fingers and toes, around the nails, body folds and angles of
the mouth and genitals.
Cutaneous candidiasis: The factors that favour
cutaneous candidiasis are
-
High moisture levels (sweat and prolonged immersion
in water)
-
Mechanical trauma (maceration)
-
Obesity
-
Diabetes
-
Immunocompromised states (HIV/AIDS, other causes)
-
Nutritional deficiencies (vitamin, iron deficiency)
-
Cushing's syndrome (drug induced or neoplastic)
-
Pregnancy
-
Extremes of age
|
|
 |
Clinically, cutaneous candidiasis is characterised by
erythema (redness) and maceration with sodden white scales at
the periphery of the erythema. In severe cases, there may
be tiny, pus filled lesions in the surrounding skin
(satellite lesions). There may be associated symptoms of
itching and burning.
It has to
be differentiated from other types of fungal infections of
the folds like tinea and seborroeic dermatitis,
Pseudomonas infections of the web spaces, bacterial
intertrigo and psoriasis (flexural). Diagnosis can be
confirmed by KOH mount.
Treatment: The precipitating factors should be
corrected. Topical and systemic antifungals can be used; the drugs
of choice would be antifungals belonging to azoles like
clotrimazole, miconazole, oxyconazole topically or
fluconazole orallly. |
|
|
|
|
|
Mucosal
Candidiasis: It is the Candidal infection of oro-pharyngeal
and genital mucosa. It is commonly seen in neonates,
elderly, diabetics, immunocompromised (HIV/AIDS),
following intake of steroids or of broad
spectrum antibiotics, in those wearing dentures,
nutritional deficiency etc.
Clinically
it presents with curdy white patches on the background
of erythema (redness) along with a burning sensation. It
can affect any part of the oral mucosa or genital
mucosa. The most common variety is called the thrush.
Following intake of antibiotics, oral candidiasis
presents as red mucous membranes with pain, without any
white patches. Candidal infection at the angles of the
mouth is seen in the elderly due to sagging of the
angles and in denture wearers due to ill fitting dentures.
It is characterised by erythema, maceration, fissuring
and crust formation. |
|
|
|
It should
be differentiated from other causes of white patches
such as leukoplakia, oral lichen planus, lupus
eythematoses, frictional keratosis etc. |
|
Oral
Candidiasis - Thrush |
|
|
|
Treatment: The precipitating factors should be
corrected. Topical and systemic antifungals can be used.
Nystatin suspension, clotrimazole mouth paints/vaginal
tablets topically or fluconazole and itraconazole orallly
are used.
|
|
Oral
Candidiasis |
|
|
|
|
|
|
|
Tinea
versicolor: It is a common, chronic, non-inflammatory,
superficial infection caused by the fungus variably known
as Pityrosporum orbiculare, Pityrosporum ovale or
Melassezia furfur. It is very common in places with
high humidity (tropical climate), affecting 40% of the
population. The fungus causing this infection belongs to
the normal flora of the skin and the manifestations of the
disease occur when there is an increase in the number of the
fungi and/or change in the form of the fungi under favourable conditions in the host. The precipitating
factors include:
-
Genetically determined susceptibility
-
Increased humidity (excessive sweating)
-
Increased sebum secretion (oily complexion)
-
Chronic illness
-
Immunocompromised state
-
Cushing's syndrome or prolonged use of glucocorticoids
-
Excessive use of oils
-
Pregnancy
|
|
Tinea
versicolor |
|
|
Clinically it is characterised by asymptomatic, hypo
and/or hyper pigmented tiny patches with fine scaling
which becomes prominent on rubbing. The common sites
affected are upper trunk, upper arms, neck, axillae (arm
pits), face and thighs.
The
diagnosis is made on the basis of the clinical
presentation and the sites involved. Sometimes it may have
to be differentiated from Pityriasis alba (dry, white
patches), early vitiligo, indeterminate leprosy, post
inflammatory hypopigmentation etc. In case of doubt KOH
examination of the scales should be done.
Treatment: Common antifungal agents used are
-
Selenium sulfide 2.5%
-
Topical azoles like clotrimazole, ketoconazole
- Oral
medications like ketoconazole, itraconazole, fluconazole
Duration
of treatment is 3 weeks. Repigmentation may take a few
months. Relapses are very common and need re-treatment with
same drugs. |
| |
|
|
|
