Ecthyma

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QUESTIONS:

1. What is the moste likely diagnosis?

   1. Candida

   2. Ecthyma

   3. Insect bites

   4. Porphyria cutanea tarda

   5. Venous stasis ulcers

      
      

2. What is the recommended plan of care?

   1. Nystatin cream

   2. Permethrin cream

   3. Phlebotomy and low-dose hydroxychloroquine

   4. Wound debridement, barrier creams and multilayered compression bandages

   5. Wound debridement and topical mupirocin

FIGURE 1:

Left anterior-upper arm

FIGURE 2:

Left cheek

FIGURE 3:

Left anterior-lateral chest wall

ANSWERS

1. What is the most likely diagnosis?

   The correct answer is:

   
   

2. What is the recommended plan of care?

The correct answer is:

THE BASICS OF IMPETIGO…WHAT IT IS, WHAT CAUSES IT, WHAT ARE THE TYPES:

Impetigo is a communicable skin infection that is more common in children, but can occur at any age.10 It exists in three main forms including bullous, non-bullous and ecthyma.10 Impetigo is contagious, and can be spread among individuals living in the same household.11

Ecthyma is an uncommon variant of the skin infection impetigo and is most commonly found on the distal extremities.5,10 It consists of punched-out, ulcerative lesions with surrounding erythema.5 While impetigo is most commonly caused by Staphylococcus aureus, the ecthyma variant is most often caused by group A Streptococcus.5 It is worth noting, however, that both conditions can be caused by either organism.2 While most frequently seen in children ages two to six years of age, this type of infection can be seen at any age.11 Infection often occurs after minor skin injuries or conditions such as abrasions, dermatitis, and insect bites.11 For this reason, it is often seen among the homeless population as well as individuals in third world countries without the ability to maintain proper hygiene.11

SYMPTOMS/DESCRIPTION

Both impetigo and ecthyma may cause mild pain and pruritis.7 Infections are often found in areas of skin that have recently been injured due to scratching or an insect bite.2 Scratching the lesions may spread the infection, and the development of satellite lesions is common due to autoinoculation.5 The diagnosis of the three variants of impetigo is made clinically based on appearance of the lesions.7 Those lesions exhibiting a honey-colored crust are characteristic of bullous and nonbullous impetigo.7 Interestingly, these two forms of impetigo infection occur in the superficial epidermis and do not extend below the dermal-epidermal junction.5

By contrast, ecthyma is often referred to as deep impetigo because it extends into the dermis.2 It begins with a small, pus-filled blister and red border, which eventually leaves a crusty ulcer underneath.2 Ecthyma is characterized by purulent, shallow ulcers with a punched-out appearance.7 Overlying the ulcer is a thick, brown-black crust and surrounding erythema.7 Cultures of ecthyma lesions are indicated only when empiric antibiotic therapy fails to resolve the problem.7 In this case, patients should have a nasal culture and wound culture performed to identify Methicillin Resistant Staphylococcus aureus.7

Important diagnoses to include in a differential include excoriated insect bites, Porphyria cutanea tarda, venous stasis and ischemic ulcers of the legs.6 For any patient with a history of recent travel or relevant exposures, alternative diagnoses such as cutaneous anthrax and other potentially serious zoonotic infections must be considered.12 Ecthyma, as a variant of impetigo, should not be confused with Ecthyma gangrenosum, a bacterial infection caused by Pseudomonas aeruginosa and most commonly seen in immuno-compromised patients.12 Ecthyma gangrenosum involves vesicles and pustules that hemorrhage and ulcerate into a necrotic eschar.12

TREATMENT

In order to treat both ecthyma and impetigo, the lesions must be debrided.1,5 By removing the crusted exudate from the lesions, topical antibiotics are better able to penetrate the skin and treat the underlying infection.5 Mupirocin has been shown to be highly effective against gram-positive bacteria, such as Staphylococcus aureus and group A streptococcus.5 For effective treatment, mupirocin should be applied three times daily for a period of seven to ten days.1,5 Alternatively, retapamulin or fusidic acid can also be used.7,8 While penicillin is usually an effective oral agent, antistaphylococcal agents such as dicloxacillin, cephalexin, clindamycin, etc. may be necessary for extensive lesions or lesions that are resistant to treatment.7,8

Several measures can be taken to prevent infection.11 Patients should be encouraged to practice good hygiene with use of soap and water, to avoid sharing towels and to wash their clothes regularly.11 For individuals diagnosed with impetigo, family members of the individual should be checked for signs of infection.6 If there are concerns regarding exposure to impetigo or ecthyma, further preventive measures such as benzoyl peroxide wash and ethanol or isopropyl gel for hands/involved sites can be taken.6

Timely treatment of impetigo generally leads to prompt recovery.6 Failure to treat the infection can lead to more extensive spread of disease.6 Lesions can progress to infections deeper in the skin and soft-tissues.6 Complications of group A strep (GAS) induced impetigo include guttate psoriasis, scarlet fever and glomerulonephritis.6 Recurrent infections can occur due to either failure to eradicate the pathogen or by recolonization.6 Scarring may be seen upon healing of ecthyma lesions.6

REFERENCES

1. Bolognia, Jean, Joseph L. Jorizzo, and Julie V. Schaffer. Dermatology. Philadelphia: Elsevier Saunders, 2012. Web.

2. Berman, K. (2013, May 15). Ecthyma. Retrieved July 30, 2015, from http://www.nlm.nih.gov/medlineplus/ency/article/000864.htm

3. Singal, Ashwani K., Csilla Kormos–Hallberg, Chul Lee, Vaithamanithi M. Sadagoparamanujam, James J. Grady, Daniel H. Freeman, and Karl E. Anderson. "Low-Dose Hydroxychloroquine Is as Effective as Phlebotomy in Treatment of Patients With Porphyria Cutanea Tarda." Clinical Gastroenterology and Hepatology: 1402-409. Web. 7 Dec. 2015.

4. Aaron, Denise M., MD. "Candidiasis." Merck Manuals Consumer Version. Merck & Co., Inc. Web. 24 Jan. 2016. <http://www.merckmanuals.com/ home/skin-disorders/fungal-skin-infections/candidiasis>.

5. Norman, R., & Nodine, S. (n.d.). Impetigo and Poor Hygeine. Journal of the American Osteopathic College of Dermatology, 12(1), 16-16. Retrieved July 19, 2015.

6. Wolff K, Johnson R, Saavedra A.P. (2013). Section 25. Bacterial Colonizations and Infections of Skin and Soft Tissues. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology, 7e. Retrieved July 30, 2015 from http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/content.as px?bookid=682&Sectionid=45130158.

7. Dhar, A. (2013, May 1). Impetigo and Ecthyma. Retrieved July 30, 2015, from http://www.merckmanuals.com/professional/dermatologic- disorders/bacterial-skin-infections/impetigo-and-ecthyma

8. DermNet NZ: author: Vanessa Ngan, staff writer, 2003. Updated by Dr Jannet Gomez, Postgraduate student in Clinical Dermatology, Queen Mary University London, UK, January 2016.

9. "Medications." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 09 Sept. 2015. Web. 24 Jan. 2016. <http://www.cdc.gov/parasites/scabies/health_professionals/meds.html>.

10. Pallin, Daniel, Nassisi, Denise. Skin and Soft Tissue Infections. Rosens Emergency Medicine. 8th Edition. Copyright 2014. Retrieved 9/2/2015 on VCOM Library Website

11. Usatine R.P., Smith M.A., Chumley H.S., Mayeaux E.J., Jr. (2013). Chapter 116. Impetigo. The Color Atlas of Family Medicine, 2e. Retrieved July 30, 2015 from http://accessmedicine.mhmedical.com.vcom.idm.oclc.org/ content.aspx?bookid=685&Sectionid=45361173.

12. Orbuch, D., Kim, R., & Cohen, D. (2014). Ecthyma: A potential mimicker of zoonotic infections in a returning traveler. International Journal of Infectious Diseases, 29, 178-180. http://dx.doi.org/10.1016/j.ijid.2014.08.014