Project in Microbiology

and Parasitology
BACTERIAL INFECTIONS
OF THE SKIN
• Cellulitis
• Folliculitis
• Furunculosis (Boils)
• Erysipelas
• Hidradenitis Suppurativa
• Rocky Mountain Spotted Fever
• Impetigo
• Staphylococcal Scalded Skin Syndrome
• Toxic Shock Syndrome
• Narcotizing Fasciitis
• Pitted Keratolysis
• Trichomycosis Axilliaris
• Erythrasma
 Cellulitis
Cellulitis is a diffuse inflammation of connective tissue
with severe inflammation of dermal and subcutaneous layers
of the skin. Cellulitis can be caused by normal skin flora or by
exogenous bacteria, and often occurs where the skin has
previously been broken: cracks in the skin, cuts, blisters,
burns, insect bites, surgical wounds, or sites of intravenous
catheter insertion. Skin on the face or lower legs is most
commonly affected by this infection, though cellulitis can occur
on any part of the body. The mainstay of therapy remains
treatment with appropriate antibiotics.
Causes
Cellulitis is caused by a type of bacteria entering the
skin, usually by way of a cut, abrasion or break in the skin.
This break does not need to be visible. Group A
Streptococcus and Staphylococcus are the most common
of these bacteria, which are part of the normal flora of the skin
but cause no actual infection while on the skin's outer surface.
Predisposing conditions for cellulitis include insect bite,
blistering, animal bite, tattoos, pruritic skin rash, recent
surgery, athlete's foot, dry skin, eczema, injecting drugs
(especially subcutaneous or intramuscular injection or where
an attempted IV injection "misses" or blows the vein),
pregnancy, diabetes and obesity, which can affect circulation,
as well as burns and boils, though there is debate as to
whether minor foot lesions contribute
Risk factors

The elderly and those with immunodeficiency (a weakened

immune system) are especially vulnerable to contracting cellulitis.
Diabetics are more susceptible to cellulitis than the general
population because of impairment of the immune system; they are
especially prone to cellulitis in the feet because the disease causes
impairment of blood circulation in the legs leading to diabetic
foot/foot ulcers. Poor control of blood glucose levels allows bacteria
to grow more rapidly in the affected tissue and facilitates rapid
progression if the infection enters the bloodstream. Neural
degeneration in diabetes means these ulcers may not be painful
and thus often become infected.
Incubation
Cellulitis can develop in as little as 24 hours or can take
days to develop.

Duration
In many cases, cellulitis takes less than a week to
disappear with antibiotic therapy.However, it can take months
to resolve completely in more serious cases and can result in
severe debility or even death if untreated. If it is not properly
treated, it may appear to improve but can resurface months or
even years later.

Treatment
Treatment consists of resting the affected limb or area,
cleaning the wound site if present (with debridement of dead
tissue if necessary) and treatment with oral antibiotics, except
in severe cases, which may require admission and
intravenous (IV) therapy. Flucloxacillin monotherapy (to cover
staphylococcal infection) is often sufficient in mild cellulitis, but
in more moderate cases or where streptococcal infection is
suspected then usually combined with oral
phenoxymethylpenicillin or intravenous benzylpenicillin, or
ampicillin/amoxicillin (e.g. co-amoxiclv in the UK).
 Pain relief is also often prescribed, but excessive pain
should always be considered relevant, as it is a symptom of
necrotising fasciitis, which requires emergency surgical
attention.
As in other maladies characterized by wounds or tissue
destruction, hyperbaric oxygen treatment can be a valuable
adjunctive therapy, but is not widely available.

Prevention
Any wound should be cleaned and dressed
appropriately. Changing bandages daily or when they become
wet or dirty will reduce the risk of contracting cellulitis. Medical
advice should be sought for any wounds that are deep or dirty
and when there is concern about retained foreign bodies
 Folliculitis
- is the inflammation of one or more hair follicles. The condition
may occur anywhere on the skin.

Folliculitis starts when hair follicles are damaged by friction from

clothing, an insect bite, blockage of the follicle, shaving or too
tight braids too close to the scalp traction folliculitis. In most
cases of folliculitis, the damaged follicles are then infected
with the bacteria Staphylococcus (staph).
 Different Types of Folliculitis
• Tinea barbae is similar to barber's itch, but the infection is
caused by the fungus T. rubrum.

• Malassezia folliculitis, formerly known as Pityrosporum

folliculitis, is caused by malassezia yeast.

• Pseudofolliculitis barbae is a disorder occurring primarily in

men of African descent. If curly beard hairs are cut too short, they
may curve back into the skin and cause inflammation.

• Hot tub folliculitis is caused by the bacteria Pseudomonas

aeruginosa often found in new hot tubs.The folliculitis usually
occurs after sitting in a hot tub that was not properly cleaned
before use. Symptoms are found around the body parts that sit in
the hot tub -- typically the legs, hips, and buttocks and
surrounding areas. Symptoms are typically amplified around
regions that were covered by wet clothing, such as bathing suits.
• Sycosis vulgaris, Sycosis barbae or Barber's itch is a
staphylococcus infection of the hair follicles in the bearded area of
the face, usually the upper lip. Shaving aggravates the condition.

• Eosinophilic folliculitis may appear in persons with impaired

immunity (AIDS, blood disorders).

• Herpetic folliculitis may occur when Herpes Simplex Virus

infection spreads to nearby hair follicles - mostly around the
mouth. It typically occurs in persons with AIDS.

• Gram negative folliculitis may appear after prolonged acne

treatment with antibiotics.

• Folliculitis decalvans or tufted folliculitis usually affects scalp.

Several hairs arise from the same hair follicle. Scarring and
permanent hair loss may follow. The cause is unknown.
 causes scars on the nape of the
• Folliculitis keloidalis
neck. It is most common among males of African
descent with curly hair.

• Oil folliculitis is inflammation of hair follicles due to exposure

to various oils and typically occurs on forearms or thighs. It is
common in refinery workers, road workers, mechanics, sheep
shearers. Even makeup may cause it.
Symptoms

• rash (reddened skin area)

• pimples or pustules located around a hair follicle
– may crust over
– typically occur on neck, axilla, or groin area
– may be present as genital lesions
• itching skin
• spreading from leg to arm to body through improper treatment
of antibiotics
Treatment

• Topical antiseptic treatment is adequate for most cases

• Topical antibiotics such as mupirocin or neomycin containing
ointment
• Some patients may benefit from systemic narrow-spectrum
penicillinase-resistant penicillins (such as dicloxacillin in US,
or flucloxacillin in UK)
What increases my risk of
developing folliculitis?
• You are more likely to get folliculitis if you:
• Use a hot tub, whirlpool, or swimming pool that is not
properly treated with chlorine.
• Wear tight clothes.
• Use antibiotics or steroid cream for long periods.
• Use or work with substances that can irritate or block the
follicles. Examples include makeup, cocoa butter, motor oil,
tar, and creosote.
• Have an infected cut, scrape, or surgical incision. The
bacteria or fungi can spread to nearby hair follicles.
• Have a disease such as diabetes or HIV that lowers your
ability to fight infection.
 Boil (furuncle)

Boil (or furuncle) is a skin disease caused by

the infection of hair follicles, resulting in the localized
accumulation of pus and dead tissue. Individual boils can
cluster together and form an interconnected network of boils
called carbuncles.
Causes

• Furuncles are very common. Furuncles are generally caused

by Staphylococcus aureus, but they may be caused by other
bacteria or fungi found on the skin's surface. Damage to the
hair follicle allows these bacteria to enter deeper into the
tissues of the follicle and the subcutaneous tissue.

• Furuncles may occur in the hair follicles anywhere on the

body, but they are most common on the face, neck, armpit,
buttocks, and thighs. Furuncles can be single or multiple.
Symptoms

Boils are red, pus-filled lumps that are tender,

warm, and extremely painful. A yellow or white point at the
center of the lump can be seen when the boil is ready to drain
or discharge pus. An abscess is also a contained collection of
pus; however, it can occur anywhere in or on the body. A boil
always involves a hair follicle.
Characteristics

• Is usually pea-sized, but may be as large as a golf ball

• May develop white or yellow centers (pustules)
• May join with another furuncle or spread to other skin areas
• May grow rapidly
• May weep, ooze, crust
Other symptoms may include:
• Fatigue
• Fever
• General ill-feeling
• Itching before furuncle develops
• Skin redness or inflammation around the lesion
Treatment
• Furuncles may heal on their own after an initial period of itching
and mild pain. More often, they increase in discomfort as pus
collects. They finally burst, drain, and then heal on their own.

• Furuncles usually must drain before they will heal. This most
often occurs in less than 2 weeks. Treatment by a health care
provider is needed if a furncle lasts longer than 2 weeks,
returns, is located on the spine or the middle of the face, or
occurs with a fever or other symptoms because the infection
may spread and cause complications.

• Warm moist compresses encourage furuncles to drain, which

speeds healing. Gently soak the area with a warm, moist cloth
several times each day. Deep or large lesions may need to be
drained surgically by a health care provider. Never squeeze a
boil or attempt to cut it open it at home because this can spread
the infection and make it worse.
• Meticulous hygiene is important to prevent the spread of
infection. Draining lesions should be cleaned frequently. You
should wash your hands very well The after touching a
furuncle. Do not re-use or share washcloths or towels.
Clothing, washcloths, towels, and sheets or other items that
contact infected areas should be washed in very hot
(preferably boiling) water. Dressings should be changed
frequently and discarded in a manner that contains the
drainage, such as by placing them in a bag that can be closed
tightly before discarding.

• Antibacterial soaps and topical antibiotics are of little benefit

once a furuncle has formed. Systemic antibiotics may help to
control infection in those with repeateda furuncles.
• Possible Complications
• Abscess of the skin, spinal cord, brain, kidneys, or other organ
• Brain infection
• Endocarditis
• Osteomyelitis
• Permanent scarring
• Sepsis
• Spinal cord infection
• Spread of infection to other parts of the body or skin surfaces
 Erysipelas

It is an acute streptococcus bacterial

infection of the dermis, resulting in inflammation.
Causes
Most cases of erysipelas are due to
Streptococcus pyogenes (also known as beta-hemolytic group
A streptococci), although non-group A streptococci can also
be the causative agent. Historically, the face was most
affected; today the legs are affected most often.

Erysipelas infections can enter the skin through

minor trauma, eczema, surgical incisions and ulcers, and
often originate from strep bacteria in the subject's own nasal
passages
Signs and symptoms
Erysipelas on an arm
Patients typically develop symptoms including
high fevers, shaking, chills, fatigue, headaches, vomiting, and
general illness within 48 hours of the initial infection. The
erythematous skin lesion enlarges rapidly and has a sharply
demarcated raised edge. It appears as a red, swollen, warm,
hardened and painful rash, similar in consistency to an orange
peel. More severe infections can result in vesicles, bullae, and
petechiae, with possible skin necrosis. Lymph nodes may be
swollen, and lymphedema may occur. Occasionally, a red
streak extending to the lymph node can be seen.
The infection may occur on any part of the skin
including the face, arms, fingers, legs and toes, but it tends to
favor the extremities. Fat tissue is most susceptible to
infection, and facial areas typically around the eyes, ears, and
cheeks. Repeated infection of the extremities can lead to
chronic swelling (lymphadenitis).
Risk factors

This disease is most common among the elderly,

infants, and children. People with immune deficiency,
diabetes, alcoholism, skin ulceration, fungal infections and
impaired lymphatic drainage (e.g., after mastectomy, pelvic
surgery, bypass grafting) are also at increased risk.
Hidradenitis suppurativa

It is a chronic skin inflammation marked by the

presence of blackheads and one or more red, tender bumps
(lesions). The lesions often enlarge, break open and drain
pus. Scarring may result after several recurrences

Considered a severe form of acne (acne

inversa), hidradenitis suppurativa occurs deep in the skin
around oil (sebaceous) glands and hair follicles. The parts of
the body affected — the groin and armpits, for example — are
also the main locations of apocrine sweat glands.
Signs and symptoms

• Small pitted areas of skin containing blackheads, often

appearing in pairs or a "double-barrel" pattern.
• One or more red, tender bumps (lesions) that fill with pus. The
bumps often enlarge, break open and drain pus. The drainage
may have an unpleasant odor. Itching, burning and excessive
sweating may accompany the bumps.
• Painful, pea-sized lumps that grow under the skin. These hard
lumps, which may persist for years, can enlarge and become
inflamed.
• Painful bumps or sores that continually leak fluid. These open
wounds heal very slowly, if at all, often leading to scarring and
the development of tunnels under the skin.
 Hidradenitis suppurativa often starts at puberty
with a single, painful bump that persists for weeks or months.
For some people, the disease progressively worsens and
affects multiple areas of their body. Other people experience
only mild symptoms. Excess weight, stress, hormonal
changes, heat or excessive perspiration can worsen
symptoms.
Causes
Hidradenitis suppurativa occurs deep in the skin
around oil (sebaceous) glands, apocrine sweat glands and
hair follicles. The apocrine sweat glands release fluid, dead
skin cells and other substances into the hair follicle. This
mixes with the oil from the sebaceous gland. Hidradenitis
suppurativa develops when the oil glands and hair follicle
openings become blocked with these substances. When oils
and other skin products become trapped, they push into
surrounding tissue. Bacteria can then trigger infection and
inflammation.

It's not known why this blockage occurs, but a

number of factors — including hormones, genetics, cigarette
smoking and excess weight — may all play a role.
Rocky Mountain Spotted Fever

It is the most lethal and most frequently reported

rickettsial illness in the United States. It has been diagnosed
throughout the Americas. Some synonyms for Rocky
Mountain spotted fever in other countries include “tick typhus,”
“Tobia fever” (Colombia), “São Paulo fever” or “febre
maculosa” (Brazil), and “fiebre manchada” (Mexico). It is
distinct from the viral tick-borne infection, Colorado tick fever.
Cause

• The disease is caused by Rickettsia rickettsii a species of

bacterium that is spread to humans by Dermacentor ticks.
Initial signs and symptoms of the disease include sudden
onset of fever, headache, and muscle pain, followed by
development of rash. The disease can be difficult to diagnose
in the early stages, and without prompt and appropriate
treatment it can be fatal
Signs and symptoms
Rocky Mountain spotted fever can be very
difficult to diagnose in its early stages, even among
experienced physicians who are familiar with the disease.

People infected with R. rickettsii usually notice

symptoms following an incubation period of one to two weeks
after a tick bite. The early clinical presentation of Rocky
Mountain spotted fever is nonspecific and may resemble a
variety of other infectious and non-infectious diseases.
Initial symptoms may include:

• fever
• nausea
• emesis
• severe headache
• muscle pain
• lack of appetite
Later signs and symptoms include:

• maculopapular rash
• petechial rash
• abdominal pain
• joint pain
Treatment

Appropriate antibiotic treatment is initiated

immediately when there is a suspicion of Rocky Mountain
spotted fever on the basis of clinical and epidemiological
findings. Treatment should not be delayed until laboratory
confirmation is obtained. In fact, failure to respond to a
tetracycline antibiotic argues against a diagnosis of Rocky
Mountain spotted fever. Severely ill patients may require
longer periods before their fever resolves, especially if they
have experienced damage to multiple organ systems.
Preventive therapy in non-ill patients who have had recent tick
bites is not recommended and may, in fact, only delay the
onset of disease.
 Doxycycline (For adults, 100 mg every 12 hours.
For children under 45 kg [100 lb], 4 mg/kg body weight per day
in two divided doses) is the drug of choice for patients with
Rocky Mountain spotted fever. Therapy is continued for at least
3 days after fever subsides and until there is unequivocal
evidence of clinical improvement, generally for a minimum total
course of 5 to 10 days. Severe or complicated disease may
require longer treatment courses. Doxycycline is also the
preferred drug for patients with ehrlichiosis, another tick-
transmitted infection with signs and symptoms that may
resemble Rocky Mountain spotted fever.
 Chloramphenicol is an alternative drug that can
be used to treat Rocky Mountain spotted fever; however, this
drug may be associated with a wide range of side effects and
may require careful monitoring of blood levels (as it can cause
aplastic anemia).
 Impetigo

This is a skin infection typically caused

by one of two bacteria: group A streptococcus
(the same bacteria that cause strep throat) or
staphylococcus aureus. These fairly common
bacteria are found on the skin of healthy people.
When the skin is broken — like with a cut or a
scratch — they can enter the open wound and
cause impetigo. Someone whose skin becomes
infected develops blisters that usually burst, ooze
fluid, and then harden into a honey-colored crust.
• Impetigo can affect skin anywhere on the body but often
attacks the area around the nose and mouth. It is more likely
to show up on skin that is already irritated or raw from
eczema, poison ivy, or an insect bite.
• Touching the infected skin and then touching another part of
the body can spread the infection to that spot. It also can be
spread to someone else if another person touches the
infected area. Because kids in preschool and elementary
school have lots of close contact with other kids, impetigo
occurs most commonly in them, but anyone can get it
Signs and Symptoms

Tiny blisters are usually the first symptom of

impetigo. The blisters can be caused by group A
streptococcus or staphylococcus aureus. When the blisters
burst, the skin underneath them is moist, red, and may ooze
fluid. Next, a tan or yellow-brown crust covers the wet areas,
making it look like they've been coated with honey or brown
sugar.

Staphylococcus aureus infection may also cause

larger blisters filled with fluid that starts out clear but then
becomes cloudy. These blisters usually remain whole without
bursting for a longer time. It can be difficult to tell if a case of
impetigo is caused by strep or staph bacteria. But the
treatment is similar, no matter which type of bacteria caused
the infection.
Prevention
Good hygiene practices can help prevent impetigo from spreading.
Those who are infected should use soap and water to clean their skin
and take baths or showers regularly. Non-infected members of the
household should pay special attention to areas of the skin that have
been injured, such as cuts, scrapes, bug bites, areas of eczema, and
rashes. These areas should be kept clean and covered to prevent
infection. In addition, anyone with impetigo should cover the impetigo
sores with gauze and tape. All members of the household should
wash their hands thoroughly with soap on a regular basis. It is also a
good idea for everyone to keep their fingernails cut short to make
hand washing more effective. Contact with the infected person and
his or her belongings should be avoided, and the infected person
should use separate towels for bathing and hand washing. If
necessary, paper towels can be used in place of cloth towels for hand
drying. The infected person's bed linens, towels, and clothing should
be separated from those of other family members, as well. Whilst
suffering from impetigo, it is best to stay indoors for a few days to
stop any bacteria from getting into the blisters and making the
infections worse. When a person has impetigo, it is common for
him/her to get it a second time in the space of 6–9 months. This
usually occurs in persons aged 12–16.a
Treatment
For generations, the disease was treated with
an application of the antiseptic gentian violet. Today,
topical or oral antibiotics are usually prescribed. Treatment
may involve washing with soap and water and letting the
impetigo dry in the air. Mild cases may be treated with
bactericidal ointment, such as fusidic acid, mupirocin,
chloramphenicol or neosporin, which in some countries
may be available over-the-counter. More severe cases
require oral antibiotics, such as dicloxacillin, flucloxacillin or
erythromycin. Alternatively amoxicillin combined with
clavulanate potassium, cephalosporins (1st generation)
and many others may also be used as an antibiotic
treatment
Staphylococcal Scalded Skin Syndrome

It is an illness characterized by red blistering

skin that looks like a burn or scald, hence its name
staphylococcal scalded skin syndrome. SSSS is caused by
the release of two exotoxins (epidermolytic toxins A and B)
from toxigenic strains of the bacteria Staphylococcus
aureus. Desmosomes are the part of the skin cell
responsible for adhering to the adjacent skin cell. The
toxins bind to a molecule within the desmosome called
Desmoglein 1 and break it up so the skin cells become
unstuck.
SSSS has also been called Ritter's disease or
Lyell's disease when it appears in newborns or young
infants.
Signs and Symptoms
SSSS usually starts with fever, irritability and widespread
redness of the skin. Within 24-48 hours fluid-filled blisters
form. These rupture easily, leaving an area that looks like a
burn.
Characteristics of the rash include:
• Tissue paper-like wrinkling of the skin is followed by the
appearance of large fluid-filled blisters (bullae) in the armpits,
groin and body orifices such as the nose and ears.
• Rash spreads to other parts of the body including the arms,
legs and trunk. In newborns, lesions are often found in the
diaper area or around the umbilical cord.
• Top layer of skin begins peeling off in sheets, leaving exposed
a moist, red and tender area.
• Other symptoms may include tender and painful areas around
the infection site, weakness, and dehydration.
Risk Factors
SSSS occurs mostly in children younger than 5
years, particularly neonates (newborn babies). Lifelong
protective antibodies against staphylococcal exotoxins are
usually acquired during childhood which makes SSSS much
less common in older children and adults. Lack of specific
immunity to the toxins and an immature renal clearance
system (toxins are primarily cleared from the body through the
kidneys) make neonates the most at risk.

Immunocompromised individuals and individuals

with renal failure, regardless of age, may also be at risk of
SSSS.
Treatment
Treatment usually requires hospitalization, as
intravenous antibiotics are generally necessary to eradicate
the staphylococcal infection. A penicillinase-resistant, anti-
staphylococcal antibiotic such as flucloxacillin is used.
Depending on response to treatment, oral antibiotics can be
substituted within several days. The patient may be
discharged from hospital to continue treatment at home.
Other supportive treatments include:
 Paracetamol when necessary for fever and pain.
 Maintaining fluid and electrolyte intake.
 Skin care (the skin is often very fragile)
 Although the outward signs of SSSS look bad, children
generally recover well and healing is usually complete within
5-7 days of starting treatment.
Complications

• SSSS usually follows a benign course when diagnosed and

treated appropriately. However, if left untreated or treatment is
unsuccessful, severe infections such as sepsis, cellulitis, and
pneumonia may develop. Death can follow severe infection.
 Toxic shock syndrome
It is an uncommon but severe acute illness with
fever, widespread red rash accompanied by involvement of
other body organs. Toxic shock syndrome is a medical
emergency that requires prompt treatment.

Toxic shock syndrome featured in general public

news in the early 1980s when an epidemic occurred. It was
linked to the prolonged use of highly absorbent tampons in
menstruating women. Since then manufacturers have made
changes to tampon production and the number of cases of
tampon-induced toxic shock syndrome has dropped
significantly. Other causes for toxic shock syndrome include the
use of contraceptive diaphragms and vaginal sponges (by
women), as well as wound infections.
Causes
Toxic shock syndrome is caused by the release
of exotoxins from toxigenic strains of the bacteria
Staphylococcus aureus and Streptococcus pyogenes.

Toxin-producing strains of Staphylococcus

aureus causing toxic shock syndrome was first formally
described in 1978. Prior to this time the syndrome was known
as staphylococcal scarlet fever. Both menstrual and non-
menstrual forms of toxic shock syndrome are caused by these
toxins, which release massive amounts of cytokines (cell-
mediator chemicals) that produce fever, rash, low blood
pressure, tissue injury and shock. Strains of Staphylococcus
aureus, producing toxic shock syndrome toxin-1 (TSST-1),
cause almost all of the cases of menstrual toxic shock
syndrome. Non-menstrual toxic shock syndrome are caused
by strains producing either TSST-1 or staphylococcal
enterotoxin B or C.
Signs and Symptoms

Toxic shock syndrome and STSS share similar

signs and symptoms. Fever, rash, low blood pressure, and
multiple organ involvement are seen as the hallmarks of these
diseases. Shedding of the skin in large sheets, especially of
the palms and soles, is usually seen 1-2 weeks after the onset
of illness. Individuals may experience symptoms and signs
differently.
 Narcotizing fasciitis

Necrotizing fasciitis is a very serious bacterial

infection of the soft tissue and fascia (a sheath of tissue
covering the muscle). The bacteria multiply and release toxins
and enzymes that result in thrombosis (clotting) in the blood
vessels. The result is destruction of the soft tissues and
fascia.
There are three main types of necrotising
fasciitis:
• Type I (polymicrobial i.e. more than one
bacteria involved)
• Type II (due to haemolytic group A
streptococcus)
• Type III (gas gangrene
 Bacteria causing type 1 necrotising fasciitis
include Staphylococcus aureus, Haemophilus, Vibrio and
several other aerobic and anaerobic strains. It usually follows
significant injury or surgery.

Type II necrotizing fasciitis has recently been

sensationalized in the media and is commonly referred to as
flesh-eating disease.

Type III is caused by Clostridia perfringens or

less commonly Clostridia septicum. It usually follows
significant injury or surgery and results in gas under the skin:
this makes a crackling sound called crepitus.
Signs and symptoms

• Symptoms appearing usually within 24 hours of a minor injury:

• Pain in the general area of the injury and worsening over time
• Flu-like symptoms such as nausea, fever, diarrhea, dizziness
and general malaise
• Intense thirst as body becomes dehydrated
• Within 3-4 days of the initial symptoms the following may
occur:
• Affected area starts to swell and may show a purplish rash
• Large dark marks form that turn into blisters filled with dark
fluid
• Wound starts to die and area becomes blackened (necrosis)
• Severe pain
• By about days 4-5, the patient is very ill with dangerously low
blood pressure and high temperature. The infection has
spread into the bloodstream and the body goes into toxic
shock. The patient may have altered levels of consciousness
or become totally unconscious.
 Trichomycosis axillaris

Trichomycosis axillaris is a relatively

common superficial bacterial colonization of the
axillary hair shafts. Granular concretions, which
are yellow, black, or red, adhere to the hair shaft
and clinically characterize this condition.
Cause
It is caused by the overgrowth of Corynebacterium
(mostly Corynebacterium tenuis) and basically the
concretions consist of tightly packed bacteria. They
prefer moist areas of the body thus mainly affect
underarm hair, and to a lesser extent, pubic hair
(trichomycosis pubis).

Trichomycosis axillaris occurs in males and females

of all races from both temperate and tropical climates.
It appears to be more common in men than women
but this is because many women shave their
underarm hair.
Signs and Symptoms

Usually the condition is symptomless

and all that is noticed is sweaty smelly armpits. On
closer inspection, 1-2 mm yellow, red or black
concretions can be found encircling the hair shaft,
making the hair appear beaded or thicker. Sweat
may be coloured according to the colour of the
concretions and may stain clothing. Yellow
concretions are the most common, whilst red and
black are seen most often in tropical climates.
Rarely, bacteria may invade and destroy the hair
shaft.
 Pitted Keratolysis

Pitted keratolysis is a skin infection that can be

caused by wearing tight or restricting footwear and excessive
sweating during exercise. The infection is characterized by
craterlike pits on the surface of the feet and toes, particularly
weight bearing areas. Treatment consists of the application of
topical antibiotics. After discontinuation of the antibotical
creme, be sure to change socks frequently. After exercise be
sure to thoroughly clean your feet. Dry after cleaning so they
do not remain warm and moist. Pitted Keratolysis is caused by
bacteria, which thrive in these environments.
Causes

• Cutaneous infection with Micrococcus

sedentarius.
• Dermatophilus congolensis..
• Actinomyces.
• K sedentarius.
• Staphylococcus epidermidis
Sign and Symptoms

• Sole of the forefoot .

• Small punched-out circular lesions.
• Peeling, cracking, and scaling of the feet.
• Redness, blisters, or softening and breaking
down (maceration) of the skin.
• Itching, burning, or both.
Treatment
• Pitted keratolysis can be successfully treated with topical
antibiotics such as fusidic acid cream, or with oral erythromycin .
• Wear boots for as short a period as possible
• Wash feet with soap or antiseptic cleanser twice daily
• Apply antiperspirant to the feet at least twice weekly
• Do not wear the same shoes two days in a row – dry them out
• Do not share footwear or towels with others.
• Limit the use of occlusive footwear and reduce foot friction with
properly fitting footwear.
• Absorbent cotton socks must be changed frequently to prevent
excessive foot moisture.
• Wool socks tend to whisk moisture away from the skin and may
be helpful.
 Erythrasma

It is a chronic superficial localized skin infection

caused by bacteria called Corynebacterium
minutissimum. Erythrasma is more common in
warm, humid climates, or in individuals with poor
hygiene, increased sweating, obesity, diabetes,
advanced age and poor immune function. It is more
commonly located in intertrigineous areas or skin
folds including the groin, armpit, intergluteal fold,
inframammary, and periumbilical areas.
Signs and Symptoms
The symptoms of Erythrasma are mainly visual. The patches created
by the disease are of pinkish to red color. They later become tanned in
appearance. The affected skin is visibly discolored from the normal skin.
People who have diabetes can develop the patches caused by
Erythrasma in less likely areas like arms, trunk and legs.
The areas affected by the patches assume a wrinkled texture. Generally
these discolored skin patches do not cause pain, but some patients
complain about itchiness. Particularly the patches in one’s groin areas
can cause some uneasiness.
Sometimes, this disease can be confused with similar other
dermatological disorders like the fungal contaminations and ringworm.
Therefore, Wood's lamp is employed in detecting cases of Erythrasma.
This UV light makes the lesions emit a deep red aura.
Treatment of Erythrasma

In most cases of Erythrasma, oral and

topical antibiotics are prescribed by the doctors to
combat the infections. Antibacterial soaps can also
be used to treat these cases. It prevents the
infection from reappearing in the patient’s body. If a
person suspects that he has contracted the ailment
he should wash the area with antiseptic solutions
and try to keep it dry. There are some skin creams
available in the market like miconazole and
tolnaftate. These can be applied to fight the
infection.
If self medication does not bring any positive result
to a patient, he must take medical guidance. The
doctors usually recommend topical antibiotic
solutions like clindamycin and erythromycin. Another
widely used medicine that the physicians favor is
Whitfield's ointment. This is basically an amalgam of
salicylic acid and benzoic acid. Since the infection
occurs in the moist body parts, aluminum chloride
solution is often prescribed to prevent perspiration
and moisture formation.
 Measles
It is an infection of the respiratory system caused by a virus,
specifically a paramyxovirus of the genus Morbillivirus.
Morbilliviruses, like other paramyxoviruses, are enveloped, single-
stranded, negative-sense RNA viruses. Symptoms include fever,
cough, runny nose, red eyes and a generalized, maculopapular,
erythematous rash.

Measles is spread through respiration (contact with fluids from an

infected person's nose and mouth, either directly or through aerosol
transmission), and is highly contagious—90% of people without
immunity sharing a house with an infected person will catch it. The
infection has an average incubation period of 14 days (range 6–19
days) and infectivity lasts from 2–4 days prior, until 2–5 days
following the onset of the rash (i.e. 4-9 days infectivity in total).
• An alternative name for measles in English-
speaking countries is rubeola, which is sometimes
confused with rubella (German measles); the
diseases are unrelated. In some other European
languages, rubella and rubeola are synonyms, and
rubeola is not an alternative name for measles.
Signs and Symptoms
Measles appears as distinct clinical stages.
Incubation period
• Ranges from 7-14 days (average 10-11 days).
• Patient usually have no symptoms.
• Some may experience symptoms of primary viral spread
(fever, spotty rash and respiratory symptoms due to virus in
the blood stream) within 2-3 days of exposure.
Prodrome
• Generally occurs around 10-12 days from exposure.
• Appears as fever, malaise and loss of appetite, followed by
conjunctivitis (red eyes), cough and coryza (blocked or runny
nose).
• 2-3 days into the prodrome phase, Koplik spots appear. These are
blue-white spots on the inside of the mouth and occur 24-48 hours
before the exanthem (rash) stage.
• Symptoms usually last for 2-5 days but in some cases may persist for
as long as 7-10 days.
Exanthem (rash)
• Red spots ranging from 0.1-1.0cm in diameter appear on the 4th or
5th day following the start of symptoms.
• This non-itchy rash begins on face and behind the ears. Within 24-36
hours it spreads to the entire trunk and extremities (palms and soles
rarely involved).
• The spots may all join together, especially in areas of the face.
• Rash usually coincides with the appearance of a high fever
>/=40degC.
• Rash begins to fade 3-4 days after it first appears. To begin with it
fades to a purplish hue and then to brown/coppery coloured lesions
with fine scales.
Recovery
• Cough may persist for 1-3 weeks.
• Measles-associated complications may be the
cause of persisting fever beyond the 3rd day of the
rash
Treatment

There is no specific treatment for measles which

is why immunisation is so important. Treatment for mild cases
of measles is supportive.
• Give paracetamol for fever
• Maintain fluid intake so dehydration doesn't occur
• Provide nutritional support if necessary
• Observe high-risk individuals carefully to prevent
complications
• Severe cases of measles usually require hospitalisation.
Antibiotics may be given to treat secondary bacterial
infections from complications such as otitis media, infectious
diarrhoea, pneumonia and sepsis.
Complications
Approximately 30% of reported
measles cases have one or more complications.
The most common complications that occur are:
• Diarrhoea that may be fatal if dehydration occurs
• Otitis media (almost exclusively in children) which
may lead to deafness
• Pneumonia (either primary viral or secondary
bacterial). This is the most common cause of
death.
Prevention
Measles can be prevented by vaccination with live attenuated
measles vaccine. It is available as a single antigen preparation or
combined with live attenuated mumps or rubella vaccines, or
both. Combined measles, mumps and rubella (MMR) vaccine is
currently part of routine immunisation programmes in most
industrialised countries, including New Zealand.

Measles vaccine induces long-term (probably life-long) immunity

in most individuals. Vaccination schedules recommend a two-
dose immunisation strategy, the first dose at 12-15 months,
followed by a second dose at 4-6 years. Individuals vaccinated
prior to 1968 may require revaccination as vaccines used before
this time may not have conferred life-long immunity.
 Rubella

Rubella, also known as German

measles is a viral disease characterized by rash,
swollen glands and fever. The disease is usually
mild and of little significance unless you are
pregnant. Infection of a pregnant woman
(congenital rubella syndrome) commonly results
in miscarriage, stillbirth, or birth of an infant with
major birth abnormalities.
Signs and Symptoms

• Slight fever, sore throat, runny nose and malaise (may occur
prior to appearance of rash, more so in adults than in
children).
• Rash begins on the face that spreads to the neck, trunk and
extremities.
– Appear as pink or light red spots about 2-3mm in size.
– Lasts up to 5 days (average is 3 days).
– May or may not be itchy.
– As rash passes, affected skin may shed in flakes.
– Usually not as widespread as in measles.
• Tender or swollen glands almost always accompany rubella,
most commonly behind the ears and at the back of the neck.
Treatment
Treatment for rubella focuses on caring for the
specific symptoms, such as getting plenty of rest and drinking
extra fluids so you do not get dehydrated. Acetaminophen,
such as Tylenol, can be given to children and adults for fever.
Do not give aspirin to anyone younger than 20 because of
the possible link between aspirin and Reye syndrome.

A baby (fetus) can get infected from a mother

who has rubella during her pregnancy. Babies infected in the
first trimester may also develop birth defects. Treatment
varies according to the specific problem.
 Chickenpox

Chickenpox is a common illness

among kids, particularly those under age 12. An
itchy rash of spots that look like blisters can
appear all over the body and may be
accompanied by flu-like symptoms. Symptoms
usually go away without treatment, but because
the infection is very contagious, an infected child
should stay home and rest until the symptoms are
gone.
Chickenpox is caused by the varicella-zoster virus (VZV). Kids can
be protected from VZV by getting the chickenpox (varicella) vaccine,
usually between the ages of 12 to 15 months. In 2006, the Centers for
Disease Control and Prevention (CDC) recommended a booster shot
at 4 to 6 years old for further protection. The CDC also recommends
that people 13 years of age and older who have never had
chickenpox or received chickenpox vaccine get two doses of the
vaccine at least 28 days apart.

A person usually has only one episode of chickenpox, but VZV can lie
dormant within the body and cause a different type of skin eruption
later in life called shingles (or herpes zoster). Getting the chickenpox
vaccine significantly lowers your child's chances of getting
chickenpox, but he or she may still develop shingles later.
Signs and Symptoms

In children, chickenpox usually begins as an itchy rash of red

papules (small bumps) progressing to vesicles (blisters) on the
stomach, back and face, and then spreading to other parts of
the body. The spread pattern can vary from person to person.
Also, depending on the individual case, there may be only a
scattering of vesicles or the entire body may be covered with
between 250 to 500 vesicles. The vesicles tend to be very itchy
and uncomfortable. Some children may also experience
additional symptoms such as high fever, headache, coldlike
symptoms and vomiting and diarrhea. Most adults who get
chickenpox experience prodromal symptoms for up to 48 hours
before breaking out in rash. These include fever, malaise,
headache, loss of appetite and abdominal pain. The condition is
usually more severe in adults and can be life-threatening in
complicated cases.
Treatment

• Trimming children's fingernails to minimize

scratching.
• Paracetamol to reduce fever and pain (do not use
aspirin in children as this is associated with Reye's
syndrome).
• Calamine lotion and/or oral antihistamines to
relieve itching.
• Consider oral aciclovir (antiviral agent) in people
older than 12 years who may be at increased risk of
severe varicella infections.
Complications

• Secondary bacterial infection of skin lesions

caused from scratching
• Dehydration from vomiting and diarrhea
• Exacerbation of asthma
• Viral pneumonia
Prevention
A person with chickenpox is
contagious 1-2 days before the rash appears and
until all the blisters have formed scabs. This may
take between 5-10 days. Children should stay
away from school or childcare facilities throughout
this contagious period. Adults with chickenpox
who work amongst children, should also remain
home.
Fifth Disease

Fifth disease is a mild illness caused by a virus

known as human parvovirus B19. The medical
name for fifth disease is erythema infectiosum (EI).
It is seen primarily in school-aged children between
5 and 14 years of age during the spring and winter.
Fifth disease causes a reddish rash on the child's
face so that it looks as if the child has been slapped
on both cheeks
Signs and Symptoms

• The first sign of fifth disease is firm red cheeks,

which feel burning hot. A rash follows 1 to 4 days
later with a lace or network pattern on the limbs
and then the trunk.
• The child with fifth disease is usually otherwise
quite well, but may have a slight fever and
headache.
• Although most prominent in the first few days, the
rash can persist at least intermittently for up to six
weeks.
Treatment
Fifth disease is not generally a serious
condition. There is no specific treatment. Affected
children may remain at school as the infectious
stage occurs before the rash is evident The
application of an ice-cold flannel can relieve the
discomfort of burning hot cheeks.
Complications

• Rarely fifth disease results in complications.

• Arthritis in infected adults
• Aplastic crisis in patients with blood disorders (potentially
dangerous low blood cell count)
• Intrauterine death (9%) or hydrops fetalis in 3% of the
offspring of infected pregnant women can occur if the infection
occurs in the first half of pregnancy. However, congenital
malformations do not occur. As the risk of an adverse
outcome is very low, the infection is not routinely screened for
in pregnancy.
 Roseola

Roseola is caused by human herpesvirus 6

(HHV-6) and, less commonly, HHV-7 or other viruses. You
may have also heard it called roseola infantum, exanthem
subitum, or sixth disease. The name "sixth disease" simply
comes from the fact that it was the sixth of the common
children's diseases that cause rashes to be listed in a
particular classification scheme. The other five are measles,
scarlet fever, rubella, a variant of scarlet fever that is no
longer recognized, and fifth disease
Signs and Symptoms

• High fever (often up to 40 degC) for 3-5 days

• Upper respiratory symptoms such as sore throat, cough, runny
nose or congestion
• Irritability and tiredness
• Rash appears around days 3 to 5 as fever subsides
– Typically small pink or red raised spots (2-5 mm in diameter)
that blanch (turn white) when touched
– Some spots may be surrounded by a lighter halo of pale skin
– Starts on trunk and may spread to involve the neck, face, arms
and legs
– Non-itchy, painless and does not blister
– May fade within a few hours or persist for as long as 2-3 days
Treatment

There is no specific treatment for roseola. The

disease is usually mild and self-limiting. Rest, maintaining fluid
intake and paracetamol for fever is all that is usually required.
Lukewarm baths or sponges can also be used to help reduce
fever. No treatment is necessary for the rash as it does not
itch or hurt and fades spontaneously.
Complications

• Loss of consciousness
• Jerking or twitching movements in the arms, legs or face for 2
to 3 minutes
• Wet or soiled pants in an unconscious, toilet-trained child
• Irritability
 Infectious Mononucleosis

Infectious mononucleosis is also known as

‘glandular fever’. It typically affects young adults aged 15 to 25
years. Infectious mononucleosis is caused by Human herpes
virus type 4, more often known as Epstein Barr virus (EBV).
This virus is passed from person to person by saliva such as
sharing a glass or kissing. The incubation period from contact
until symptoms is 1 to 2 months.
 Clinical Features of Infectious
Mononucleosis
Organ involved Symptoms & signs

Spleen • Splenomegaly (an

enlarged spleen)
Joints • Arthritis in one or more
joints
Kidneys • Glomerulonephritis

Nervous system • Meningoencephalitis

• Bell's palsy (facial palsy)
• Transverse myelitis
• Guillain-Barré syndrome

Gastrointestinal tract • Hepatitis

Lungs • Interstitial pneumonia

Heart • Pericarditis
Eyes • Eyelid swelling
• Keratitis
• Uveitis
• Conjunctivitis
• Retinitis
Blood system • Autoimmune
haemolytic anaemia
(breakdown of red
cells)
• Thrombocytopaenia
(reduced platelet count)
• Neutropaenia (reduced
white cell count)
• Cold agglutinins
(proteins that
precipitate in cooler
conditions)
• Immunodeficiency
Involvement of the skin

Involvement of the skin is seen in about 10% of non-

hospitalised patients. Most commonly, there is a faint,
widespread, non-itchy rash, which lasts for about a week. It is
described as maculopapular exanthem, i.e. there are flat
patches that may contain small bumpy red spots. It thought to
be directly due to the virus. This rash often appears on the
trunk and upper arms first, and a few days later extends to
involve the face and forearms. Other appearances of this rash
include:
• Morbilliform (small, flat, measles-like patches)
• Papular (small bumps)
• Scarlatiniform (tiny spots like scarlet fever)
• Vesicular (little blisters)
• Purpuric (bruise-like)
 Pityriasis Roseola

It is a rash of unknown cause which

lasts about six weeks. Pityriasis rosea most often
affects teenagers or young adults. In most cases
there are no other symptoms, but in some cases
the rash follows a few days after a upper
respiratory viral infection.
Pityriasis rosea may be set off by a viral infection but it
does not appear to be contagious. Herpes viruses 6 and
7 have sometimes been associated with pityriasis rosea,
and the rash may be a reactive response to these or
other viruses.

Pityriasis rosea clears up by itself in about six to twelve

weeks. When clear, the skin returns to its normal
appearance. It leaves no scars, although pale marks or
brown discolouration may persist for a few months in dark
skinned people.
Signs and Symptoms
Pityriasis rosea symptoms include:
 Initial phase. Pityriasis rosea typically begins with a large, slightly
raised, scaly patch — called the herald patch — on your back, chest or
abdomen.
 Progression. Smaller fine, scaly spots usually appear across your
back, chest or abdomen in a pine-tree pattern a few days to a few
weeks after the herald patch. Rarely, smaller spots may also appear
on your arms, legs or face. The rash may itch.
 Color. The rash of pityriasis rosea often is scaly and pink, but if you
have darker skin, it may be gray, dark brown or even black.
 Other signs and symptoms. About half the people who develop
pityriasis rosea have signs or symptoms of an upper respiratory
infection — such as a stuffy nose, sore throat, cough or congestion —
just before the herald patch appears
Causes

• Pityriasis rosea may be set off by a viral infection

but it does not appear to be contagious. Herpes
viruses 6 and 7 have sometimes been associated
with pityriasis rosea, and the rash may be a
reactive response to these or other viruses.
• Pityriasis rosea clears up by itself in about six to
twelve weeks. When clear, the skin returns to its
normal appearance. It leaves no scars, although
pale marks or brown discolouration may persist
for a few months in dark skinned people.
 Treatment
• General advice. The rash is irritated by soap; bathe
or shower with plain water and bath oil, aqueous
cream, or other soap substitute. Apply moisturizing
creams to dry skin.
• If the rash itches, treatment with a steroid cream or
ointment usually brings prompt relief. The steroid
probably does not speed up clearance of pityriasis
rosea but it reduces the discomfort.
• Extensive or persistent cases can be treated by
phototherapy (ultraviolet light, UVB).
• New information suggests early treatment with
aciclovir may speed up recovery of at least some
cases of pityriasis rosea.
 Hand foot and mouth disease

• Hand foot and mouth disease is a common mild and short-

lasting condition most often affecting young children during
the summer months.
• Hand-foot-and-mouth is due to an enterovirus infection,
usually Coxsackie virus A16, although it can also be due to
Enterovirus 71. It is very infectious, so several members of the
family or a school class may be affected.
• After an incubation period of 3 to 5 days, the infection results
in flat small blisters on the hands and feet, and oral ulcers.
These are sometimes painful, so the child eats little and frets.
There may be a mild fever. Sometimes in young children there
is a rash on the buttocks.
Treatment

Specific treatment is not necessary.

Antiseptic mouth washes and simple analgesics
such as paracetamol relieve the discomfort of
eating.
 Laterothoracic Exanthem

Laterothoracic exanthem is also known

as Asymmetric Periflexural Exanthem of
Childhood (APEC). It is an uncommon rash
affecting young children, which is suspected to be
due to a viral infection.
Signs and Symptoms
• Laterothoracic exanthem mainly occurs in winter and spring
and affects twice as many girls as boys. The average age
is two, most cases being between one and five years old.
• The rash is often mistaken for eczema (dermatitis) or a
fungal infection (ringworm). It usually starts in the armpit or
groin and gradually extends outwards, remaining
predominantly on one side of the body. It may spread to
the face, genitalia, hands or feet.
• The rash starts as tiny raised pink spots, which may be
surrounded by a pale halo, then slowly becomes flat and
scaly. The middle of older patches fades to a dusky grey.
Occasionally the patches are net-like or in rings. Little
blisters or blood spots may occur. The rash is usually quite
itchy.
• Sometimes other features of viral infection occur at the
onset of the rash, such as a fever, sore throat, cold,
vomiting and/or diarrhoea. The lymph glands in the armpits
and groins may be enlarged.
Treatment
• The rash will clear without treatment. The itching
can be relieved with:
• Emollients
• Topical steroids
• Oral antihistamines
 Smallpox
Smallpox is a highly contagious and sometimes deadly disease that is
caused by infection with the variola virus. It has been around for
thousands of years and has been associated with many deadly
epidemics. Widespread vaccination between 1940 and 1970 has led to
the global eradication of the virus and in 1980 the World Health
Organization (WHO) officially declared smallpox eradicated. The last
naturally occurring case of smallpox was in Somalia in 1977. The only
remaining known variola virus isolates are stored at the Centers for
Disease Control and Prevention (CDC) in the US and at the Vektor
Institute in Russia. Renewed interest in smallpox is taking place, as there
is concern that the variola virus may be used as an agent of bioterrorism.

There are 2 clinical types of smallpox, variola major and variola minor.
Variola major is the most common and severe form and has a death rate
of about 30%. Variola minor is a much less common form with an
estimated death rate of less than 1%.
 Signs and Symptoms
• Infection with the variola virus begins with an incubation period that can be from 7-17 days (on average
12-14 days). During this time most people experience no symptoms whatsoever and they are not
contagious. The first sign of smallpox disease is the prodromal phase, which lasts 2-4 days and is
characterised by:
• Fever (>40degC)
• Severe headache
• Nausea and vomiting
• Aching body
• Sore throat
• Small red spots occur on the tongue and in the mouth which turn into sores containing the virus
• Rash spreads to face, arms, legs, hands and feet and to all parts of the body within 24 hours (coincides
with subsiding fever)
• Rash becomes raised bumps that then become fluid-filled with a depression in the centre (umbilicated)
• Fever recurs and stays high until scabs form
• The bumps turn into pustules that are raised, round and firm to touch. Pustules may reach between 4
and 6mm in diameter. After about 5 days pustules begin to form a crust and then scab. By about 3
weeks after the first signs of rash appearing, scabs fall off leaving marks on the skin that eventually
become pitted scars. A person is contagious until all the scabs have fallen off.
• Smallpox could be confused with several other diseases, especially:
• Chickenpox (varicella), usually seen in children and affecting the trunk predominantly
• Widespread shingles (zoster) in immune compromised or elderly, normally starting in a single area of
the body
Treatment

• There is no cure for smallpox. The aim of keeping smallpox

under control is to prevent it from occurring. If smallpox is
suspected in an individual, state health officials must be
notified immediately and containment of the virus a major
priority. This would include strict respiratory and contact
isolation for at least 17 days and vaccination of all contacts.
• Treatment for an already ill smallpox patient should be
supportive care consisting of adequate hydration and
nutrition, eye care and antibiotics as needed for secondary
skin infections. Vaccination within the incubation period,
particularly if given within 3 days of exposure to the virus,
has been shown to prevent or significantly lessen the
severity of smallpox disease in most people.
Complications

Most patients whom survive smallpox

have extensive scarring of the skin. Other
complications may include:
• Eye problems including corneal ulceration and
blindness
• Bronchopneumonia
• Arthritis
• Osteomyelitis
 Cowpox

Cowpox is a viral skin infection caused

by the cowpox or catpox virus. This is a member
of the orthopoxvirus family, which includes the
variola virus that causes smallpox. Cowpox is
similar to but much milder than the highly
contagious and sometimes deadly smallpox
disease. Cowpox should also not be confused
with cowpock, which is an alternative name for a
condition called Milker’s nodules that is caused by
a parapox virus.
Signs and Symptoms
Most human cases of cowpox appear as one or a small
number of pus-like lesions on the hands and face, which then ulcerate
and form a black scab before healing on their own. This process can take
up to 12 weeks with the following skin findings over that period:

• Days 1-6 (after infection): the site of infection appears as an inflamed

macule (flat red lesion)
• Days 7-12: the inflamed lesion becomes raised (papular), then develops
into a blister-like sore (vesicle)
• Days 13-20: the vesicle becomes filled with blood and pus and eventually
ulcerates. Other lesions may develop close by.
• Weeks 3-6: the ulcerated wound turns into a deep-seated, hard, black
crusty sore (eschar) which is surrounded by redness and swelling.
• Weeks 6-12: the eschar begins to flake and slough and the lesion heals,
often leaving a scar behind.

Other generalised symptoms patients may report are

fever, tiredness, vomiting, and sore throat. Eye complaints such as
conjunctivitis, periorbital swelling and corneal involvement have been
reported. Enlarged painful local lymph nodes may also develop
Treatment

• There is no cure for cowpox but the disease is self-limiting.

The human immune response after being infected is
sufficient to control the infections on its own. The lesions
heal by themselves within 6-12 weeks. Often patients are
left with scars at the site of the healed pox lesions.
• Patients may feel unwell and require bed rest and
supportive therapy. Wound dressings or bandages may be
applied to lesions to prevent spread to other sites and
potentially to other people.
• Patients with underlying skin conditions such as atopic
dermatitis may be at greater risk of generalised skin
infections.
 Chikungunya fever

Chikungunya fever is a re-emerging

viral illness that is spread from human-to-human
by the bite of virus-carrying mosquitoes. The
disease is mostly confined to people living in
tropical Africa and Asia and is characterised by a
sudden and severe fever, skin rash and joint and
muscle pain.
Signs and Symptoms

• Infection with the CHIK virus begins with a short incubation

period of 2-4 days. At about 48 hours after being bitten by a
virus-carrying mosquito, patients will experience sudden
high fever with shaking chills. Some patients also get a
maculopapular rash (red flat patches that may contain
small raised spots) over the trunk, limbs and face. This
tends to last 3 or 4 days. Commonly patients will
experience severe myalgia (muscle pain) and arthralgia
(joint pain). Joint pain initially starts in the small joints of the
hands and feet, wrists and ankles, and later the larger
joints. Other non-specific symptoms may include
headache, slight photophobia and insomnia.
Treatment
There is no vaccine or specific treatment available
against CHIK V infection. Fortunately, the illness is usually self-
limiting and resolves with time. Supportive therapy with
antipyretics and nonsteroidal anti-inflammatory drugs (NSAIDs)
are used to control fever and joint pain. Fever usually disappears
after 2-3 days. Muscle and joint pain, which can be very severe
usually lasts for about 5-7 days but in some cases may linger for
much longer periods. Elderly patients in particular may suffer
muscle and joint pain for several months.

Skin discolouration and rash can be treated with

sunscreens and topical corticosteroids. Skin rash on the face
appears to resolve completely within about 3 weeks, whilst
resolution is a little longer when other parts of the body are
affected. Ulcers should be cleaned and treated with topical
antimicrobials to prevent secondary infections. These usually heal
within 7-10 days. More severe lesions may require systemic
steroid treatment.
 How to prevent chikungunya fever
The best way to prevent chikungunya fever is by preventing spread of the virus by
vector control. This means eliminating or controlling mosquito breeding sites. The CHIK
V-carrying mosquito likes to breed in artificial containers and receptacles containing
water. The following measures can be taken to reduce the breeding of mosquitoes.

• Cover tightly with a lid all water tanks, cisterns, barrels, rubbish containers, etc.
• Remove or empty water in old tyres, tin cans, bottles, trays, etc.
• Check and clean out clogged gutters and flat roofs where water may have settled.
• Change water regularly in pet water dishes, birdbaths and plant trays.
• Introduce larvivorous fish (e.g. guppy) to ornamental water features as these eat the
mosquito larvae.
• Trim weeds and tall grasses as adult mosquitoes seek these for shade on hot days.
People can do the following to prevent themselves from being bitten by mosquitoes.

• Wear long sleeves and pants.

• Install secure screens to windows and doors to keep mosquitoes out.
• Use an insect repellent such as DEET.
• Sleep under mosquito curtains or nets, this is particularly important when children are
sleeping or resting during daylight hours.
• In high-risk areas insecticide sprays may be used to kill mosquitoes.
 Kaposi sarcoma
Kaposi sarcoma is a disease of blood vessels that was
considered very rare before the start of the AIDS pandemic.
AIDS is due to infection with human immunodeficiency virus
(HIV).
There are four types of Kaposi sarcoma:
• The classic type of Kaposi sarcoma affects elderly men of
Mediterranean and Middle European descent and in men in
Sub-Saharan Africa.
• HIV-associated Kaposi sarcoma mainly affects men who have
sex with men.
• Endemic or African Kaposi sarcoma arises in some parts of
Africa in children and young adults.
• Iatrogenic Kaposi sarcoma is due to drug treatment causing
immune suppression.
Signs and Symptoms
Kaposi sarcoma presents as red to purplish spots (macules) and
raised bumps (papules and nodules) anywhere on the skin or
mucous membranes. Initially, the lesions are small and painless
but they can ulcerate and become painful. There are various forms.

• Localised nodular
• Locally aggressive
• Generalised lymphadenopathic
• Patch stage
• Localised plaques
• Exophytic lesions
• Infiltrative plaques
• Disseminated cutaneous and visceral disease
• Telangiectatic
• Keloidal
• Ecchymotic
• Lymphangioma-like / cavernous disease
Treatment
• In HIV disease, if the lesions are not widespread or
troublesome, often the best approach is simply to treat the
underlying HIV infection with highly active antiretroviral
drug combinations that suppress HIV replication (HAART).
These drugs reduce the frequency of Kaposi sarcoma and
may also prevent its progression or the development of
new lesions. It is not yet clear why this approach works;
one opinion is that the improvement in immune function
results in reduced levels of tumour growth-promoting
proteins.
• Iatrogenic Kaposi sarcoma may improve or clear if it is
possible to stop immune suppressive medication.
• The choice of more specific treatment depends largely on
the extent of the disease.
Treating localised lesions
Small, localised lesions are generally only
treated if theyare painful or they are causing cosmetic
problems. It should be noted that lesions tend to recur after
local treatments. Treatments include:

• Cryotherapy with liquid nitrogen

• Radiotherapy. This is most useful for classic Kaposi
sarcoma and is less effective for HIV-associated disease.
• Surgical excision of individual nodules.
• Laser therapy, using pulsed dye laser or pulsed carbon
dioxide laser.
• Injection with anti-cancer drugs such as vinblastine
• Topical application of alitretinoin gel (Panretin). This drug is
not yet available in New Zealand.
 Herpes simplex

Herpes simplex is a common viral infection that

presents with localised blistering. It affects most
people on one or more occasions during their lives.

There are two main types of herpes simplex virus

(HSV), although there is considerable overlap.
• Type 1, which is mainly associated with facial
infections (cold sores or fever blisters)
• Type 2, which is mainly genital (genital herpes)
 Both type 1 and type 2 herpes simplex viruses
reside in a latent state in the nerves which supply sensation to the
skin. During an attack, the virus grows down the nerves and out
into the skin or mucous membranes where it multiplies, causing
the clinical lesion. After each attack it ‘dies back’ up the nerve
fibre and enters the resting state again.

First or primary attacks of Type 1 infections occur

mainly in infants and young children, which are usually mild or
subclinical. In crowded, underdeveloped areas of the world up to
100% of children have been infected by the age of 5. In higher
socioeconomic groups the incidence is lower, for example less
than half of university entrants in Britain have been infected.

Type 2 infections occur mainly after puberty, often

transmitted sexually. The initial infection more commonly causes
symptoms.
• The infection can be passed on from someone else with an active
infection and it can also be passed on from individuals without
symptoms.
• The virus is shed in saliva and genital secretions, during a clinical
attack and for some days or weeks afterwards. The amount shed
from active lesions is 100 to 1000 times greater than when it is
inactive. Spread is by direct contact with infected secretions.
• Minor injury helps inoculate the virus into the skin. The virus can
be inoculated into any body site to cause a new infection, whether
or not there has been a previous infection of either type. The
source of the virus may be from elsewhere on the body especially
in nail biters or thumb suckers. Herpes simplex can also be
inoculated from external sources. Examples include:
• Nailfold infection in a health-care worker (‘herpetic whitlow’)
• Facial blisters in a rugby player (‘scrum pox’)
• Suckling infant with mouth sores
Treatment
Mild uncomplicated eruptions of herpes simplex require no
treatment. They may be covered if desired, e.g., with a
hydrocolloid patch.

As sun exposure often triggers facial herpes simplex,

sun protection using high protection factor sunscreens and
other measures is important.

Severe infection may require treatment with an antiviral

agent. Oral antiviral drugs include:
• aciclovir
• valaciclovir
• famciclovir.
 Complications
Eye infection
• Herpes simplex may cause swollen eyelids and conjunctivitis with opacity
and superficial ulceration of the cornea (dendritic ulcer). The lymph gland in
front of the ear is often enlarged and tender.
Throat infection
• Throat infections may be very painful.
Eczema herpeticum
• HSV in patients with atopic dermatitis or Darier disease may result in a
severe rash known as eczema herpeticum. Numerous blisters and scabs
erupt on the face or elsewhere, associated with swollen lymph glands and
fever.
Erythema multiforme
• Recurrent erythema multiforme is an uncommon reaction to herpes simplex.
Erythema multiforme mainly appears on the hands, forearms and lower legs
and is characterised by target lesions, which sometimes blister.
Nervous system
• The nerves to the face may be infected by HSV, producing temporary
paralysis of the affected muscles, sometimes with each attack. Rarely
neuralgic pain may precede each recurrence of herpes by 1 or 2 days
(Maurice's syndrome). Meningitis is rare.
Widespread infection
• This is more likely to arise in debilitated patients and may be serious
 Shingles
Shingles is a painful blistering rash caused by
reactivation of varicella, the chickenpox virus. It is correctly
known as herpes zoster.
• Chickenpox or varicella is the primary infection with the
virus, Herpes zoster, also called ‘varicella-zoster’. During
this widespread infection, which usually occurs in
childhood, virus is seeded to nerve cells in the spinal cord,
usually of nerves that supply sensation to the skin.
• The virus remains in a resting phase in these nerve cells
for years before it is reactivated and grows down the
nerves to the skin to produce shingles (zoster). This can
occur in childhood but is much more common in adults,
especially the elderly.
• Shingles patients are infectious (resulting in chickenpox),
both from virus in the lesions and in some instances the
nose and throat.
Sign and Symptoms
• The first sign of shingles is usually pain, which may be
severe, in the areas of one or more sensory nerves, often
where they emerge from the spine. The pain may be just in
one spot or it may spread out. The patient usually feels
quite unwell with fever and headache. The lymph nodes
draining the affected area are often enlarged and tender.
• Within one to three days of the onset of pain, a blistering
rash appears in the painful area of skin. Sometimes,
especially in children, shingles is painless.
• It starts as a crop of closely-grouped red bumps in a
continuous band on the area of skin supplied by one,
occasionally two, and rarely more neighbouring spinal
nerves. New lesions continue to appear for several days,
each blistering or becoming pustular then crusting over.
Shingles occasionally causes blisters inside the mouth or
ears, and can also affect the genital area.
• The pain and general symptoms subside gradually as the
eruption disappears. In uncomplicated cases recovery is
complete in 2-3 weeks in children and young adults, and 3 to 4
weeks in older patients.
• Occasionally pain is not followed by the eruption - shingles "sine
eruptione". These cases can be difficult to identify because there
is no characteristic rash.
• The chest (thoracic), neck (cervical), forehead (ophthalmic) and
lumbar/sacral sensory nerve supply regions are most commonly
affected at all ages but the frequency of ophthalmic shingles
increases with age. Rarely the eruption may affect both sides of
the body.
• In elderly and undernourished patients the blisters are deeper.
Healing may take many weeks and be followed by scarring.
Muscle weakness arises in about one in twenty patients because
the muscle nerves are affected as well as the sensory nerves.
Facial nerve palsy is the most common result. There is a 50%
chance of complete recovery and in time some improvement can
be expected in nearly all cases.
Treatment
If you think you may have shingles, see your doctor as soon as
possible. Antiviral treatment can reduce pain and the duration of
symptoms, but it is much less effective if started more than one to
three days after the onset of the shingles.
• Rest and pain relief are important - try paracetamol initially
• A bland, protective application should be applied to the rash. Try
povidone iodine or calamine lotion.
• Capsaicin cream may be helpful for pain relief for post-herpetic
neuralgia.
• Oral antiviral medication is recommended in the following
circumstances:
– Facial shingles
– Those with poor immunity
– The elderly
• Antiviral medication available for shingles on prescription include:
– Aciclovir (this is the only one available in New Zealand)
– Valaciclovir
– Famciclovir
 Molluscum contagiosum
Molluscum contagiosum is a common viral skin
infection. It most often affects infants and young children but
adults may also be infected.

Molluscum contagiosum presents as clusters of

small round bumps (papules) especially in the warm moist places
such as the armpit, groin or behind the knees. They range in size
from 1 to 6 mm and may be white, pink or brown. They often have
a waxy, pinkish look with a small central pit (umbilicated). As they
resolve, they may become inflamed, crusted or scabby. There
may be few or hundreds of spots on one individual.

Molluscum contagiosum is a harmless virus but it

may persist for months or occasionally for a couple of years. It
frequently induces a type of dermatitis in the affected areas,
which are dry, pink and itchy. Molluscum contagiosum may rarely
leave tiny pit-like scars.
How do you catch molluscum
contagiosum?

Molluscum contagiosum can be spread from

person to person (especially children) by direct skin
contact. This appears to be more likely in wet conditions,
such as when children bathe or swim together. Sexual
transmission is possible in adults.

Lesions tend to be more numerous and last

longer in children who also have atopic eczema. It can be
very extensive and troublesome in patients with
human immunodeficiency virus infection.

Molluscum contagiosum may arise in areas

that have been injured, often because they've been
scratched. The papules form a row; this is known as
Treatment
There is no single perfect treatment of
molluscum contagiosum since we are currently unable to
kill the virus. The soft white core can be squeezed out of
individual lesions. In many cases no specific treatment is
necessary.
Medical treatments include:
• Minor surgery, curettage (topical anaesthetic cream may be
applied first) or laser ablation
• Cryotherapy
• Cantharidine
• Imiquimod cream
• Wart paints containing salicylic acid or podophyllin

The dermatitis may be treated with

hydrocortisone cream, but is unlikely to fully resolve until
the infection has cleared up.
 Viral warts

Warts are tumours or growths of the

skin caused by infection with Human
Papillomavirus (HPV). More than 70 HPV
subtypes are known.

Warts are particularly common in

childhood and are spread by direct contact or
autoinocculation. This means if a wart is
scratched, the viral particles may be spread to
another area of skin. It may take as long as
twelve months for the wart to first appear.
What do they look like?
Warts have a hard ‘warty’ or ‘verrucous’ surface. You can often see a
tiny black dot in the middle of each scaly spot, due to a thrombosed
capillary blood vessel. There are various types of viral wart.
• Common warts arise most often on the backs of fingers or toes, and
on the knees.
• Plantar warts (verrucas) include one or more tender inwardly growing
‘myrmecia’ on the sole of the foot.
• Mosaic warts on the sole of the foot are in clusters over an area
sometimes several centimetres in diameter.
• Plane, or flat, warts can be very numerous and may be inoculated by
shaving.
• Periungual warts prefer to grow at the sides or under the nails and can
distort nail growth.
• Filiform warts are on a long stalk.
• Oral warts can affect the lips and even inside the cheeks. They include
squamous cell papillomas.
• Genital warts are often transmitted sexually and predispose to cervical,
penile and vulval cancer.
Treatment
Occlusion
• Just keeping the wart covered 24 hours of the day may
result in clearance. Duct tape is convenient and
inexpensive.
Chemical treatment.
• Chemical treatment includes wart paints containing
salicylic acid or similar compounds, which work by
removing the dead surface skin cells. Podophyllin is a
cytotoxic agent, and must not be used in pregnancy or in
women considering pregnancy.
• The paint is normally applied once daily. Perseverance is
essential - although 70% of warts will go with wart paints, it
may take twelve weeks to work! Even if the wart doesn't go
completely, the wart paint usually makes it smaller and less
uncomfortable.
Cryotherapy
• The wart is frozen with liquid nitrogen repeatedly, at one to three
week intervals. This is uncomfortable for a few minutes and may
result in blistering for several days. Success is in the order of
70% after 3-4 months of regular freezing. Dermatologists debate
whether a light freeze to stimulate immunity is sufficient, or
whether a harder freeze is necessary to destroy all the infected
skin. A hard freeze might cause a permanent white mark or scar.
Electrosurgery
• Electrosurgery (curettage & cautery) is used for particularly large
and annoying warts. Under local anaesthetic, the growth is pared
away and the base burned by diathermy or cautery. The wound
heals in about two weeks; even then 20% of warts can be
expected to recur within a few months.
Other treatments
• There are numerous treatments for warts and none offer a
guarantee of cure. They include bleomycin injections, laser
vaporisation, pulse dye laser, oral acitretin and immune
modulators such as imiquimod cream.
 Orf
Orf is a virus infection of the skin
contracted from sheep and goats.

Orf is caused by a virus called the

parapox virus, which infects mainly young lambs
and goats who contract the infection from one
another or possibly from persistence of the virus
in the pastures. Human lesions are caused by
direct inoculation of infected material.
Treatment

No specific treatment is necessary in

most cases, as orf usually clears up by itself in
about 6 weeks. The lesion may be covered to
prevent contaminating the environment or other
people, although person-to person spread is very
uncommon. Any secondary bacterial infection
should be treated. Large lesions can be removed
by shave excision.

Imiquimod cream has been reported to

be effective in a few cases of orf.
Complications

Patients whose immunity is reduced for

some reason may develop larger or unusual orf
lesions. Rarely widespread small blisters may
occur, suggesting blood stream spread of the orf
virus, but resolve after a few weeks.

A secondary allergy rash to the

presence of the orf virus, erythema multiforme,
occasionally develops, typically 10-14 days after
the onset of orf, to give small blistery red ring-like
lesions on the arms and legs. Less distinctive red
rashes, 'toxic erythemas' also occur and rarely
the blistering disorder pemphigoid.
 Milker's nodules
Milker's nodule is an infection of the
skin caused by a virus that infects the teats of
cows. It is sometimes called cowpock although it
is important to note this is a different condition
from cowpox (in recent reports from Europe,
cowpox has been acquired from cats and small
rodents rather than cows).
Causes

Milker's nodule is caused by a parapox

virus. It produces mild infections of the teats of
cows, i.e. ring sores, as well as ulcers in the
mouths of calves. It is similar to bovine papular
stomatitis virus, which affects the same sites in
cattle. The two viruses are variants. Both can
produce lesions on the hands of dairy farmers or
vets who examine the mouths of animals. Human
infection is from contact with infected lesions on
the animals. Human-to-human spread appears
not to have been recorded. Orf is another
parapox virus that affects sheep and goats.
Sign and Symptoms

After an incubation period of 5-14 days

small, red, raised, flat-topped spots develop.
Within a week they appear as red-blue, firm,
slightly tender blisters or nodules (lumps), usually
between 2 and 5 in number although they may be
solitary or more numerous. The nodules are
usually on the hands, particularly the fingers, but
occasionally the face. The top of the nodules
often develops a greyish skin and a small crust.
There maybe secondary bacterial infection. Many
patients develop red streaks up the lymph
channels on the arms and some enlargement of
the lymph glands.
Treatment

The nodules can just be left to resolve

spontaneously over 4-6 weeks. They should be
covered to prevent contamination of the
environment and also potential spread to other
people. Gloves should be worn if milking. Any
secondary bacterial infection should be treated.
 Erythema multiforme
Erythema Multiforme (EM) is a
hypersensitivity reaction usually triggered by
infections, most commonly herpes simplex virus
(HSV). It presents with a skin eruption
characterised by a typical target (iris) lesion.
There may be mucous membrane involvement. It
is acute and self-limiting, usually resolving without
complications.

Erythema Multiforme major and minor

forms and is now regarded as probably distinct
from Stevens Johnson Syndrome (SJS) and T
oxic Epidermal Necrolysis (TEN)
Symptoms

There are usually no prodromal

symptoms (EM minor). However, sometimes with
EM major there may be mild symptoms such as
fever or chills, weakness or painful joints.
 Treatment
For the majority of cases, no treatment is required as the rash settles by
itself over several weeks without complications.

Treatment directed to any possible cause may be required such as oral

aciclovir (not topical) for HSV or antibiotics (e.g. erythromycin) for
Mycoplasma pneumoniae. If a drug cause is suspected then the
possible offending drug should be ceased.

Supportive/symptomatic treatment may be necessary.

• Itch – oral antihistamines and/or topical corticosteroids may help.
• Oral pain – mouthwashes containing local anaesthetic and antiseptic
reduce pain and secondary infection.
• Eye involvement should be assessed and treated by an ophthalmologist.
• EM major may require hospital admission for supportive care,
particularly if severe oral involvement restricts drinking.
 The role of oral corticosteroids remains controversial as no controlled
studies have shown any benefit. However for severe disease 0.5-
1mg/kg/d prednis(ol)one is often used early in the disease process.

Recurrent EM is usually treated initially with continuous oral aciclovir for

6 months at a dose of 10mg/kg/d in divided doses (e.g., 400mg twice
daily), even if HSV has not been an obvious trigger for the patient's EM.
This has been shown to be effective in placebo-controlled double blind
studies. However EM may recur when the aciclovir is ceased. Other
antiviral drugs such as valciclovir (500-1000mg/d) and famciclovir
(250mg twice daily) should be tried if aciclovir has not helped; these
drugs are not readily available in New Zealand.

Other treatments (used continuously) that have been reported to help

suppress recurrent EM include:
• Dapsone 100-150mg/d
• Antimalarial drugs eg hydroxychloroquine
• Azathioprine 100-150 mg/d
• Others - thalidomide, ciclosporin, mycophenolate mofetil,
photochemotherapy (PUVA).
 Erythema nodosum

Erythema nodosum is a skin condition

where red lumps form on the shins, and less
commonly the thighs and forearms. It is a type of
panniculitis.
Causes
• Throat infections; these may be due to streptococccus, or
viral in origin.
• Sarcoidosis; EN is often associated with enlargement of
the lymph nodes (bihilar lymphadenopathy) in the lungs in
sarcoidosis. This is known as Lofgren's syndrome. It may
result in a dry cough or some shortness of breath.
• Tuberculosis (TB); EN occurs with the primary infection
with TB. TB in New Zealand is currently uncommon.
• Pregnancy or the oral contraceptive pill; EN may occur
after the first 2 or 3 cycles on the pill. EN may occur in
pregnancy, clear after delivery, then recur in subsequent
pregnancies.
• Other drugs; other drugs which can cause EN include:
sulphonamides, saliclyates, bromides, iodides and gold
salts.
• Other causes; there are many other causes of EN but
these are uncommon in New Zealand.
Treatment

• Bed rest is advised for severe EN.

• Firm supportive bandages or stockings should be
worn.
• Aspirin or other anti-inflammatory medication.
• A course of potassium iodide is often effective in
clearing it.
Mild cases subside in 3 weeks, more
severe ones in about 6 weeks. Cropping of new
lesions may occur within this time, especially if
the patient is not resting
Gloriani, Kevin Patrick
Gonzales, Diane Joyce
Gozales, Karla Jane
Levita, Ailyn
Martinez, Jussel
Merlan, Mariel

Mrs. Michelle T. Bono