PYODERMA

Definisi
 Infeksi kulit yang disebabkan oleh
Staphylococcus aureus &
Streptococcus  hemolyticus.
 Kolonisasi the nares, perineum,
axillae  20%.
Normal skin :

• Colonized by bacterial flora.

• The most common are various non

pathogenic Gram-negative bacteria.

 Faktor predisposisi

- Higiene buruk,

- Daya tahan tubuh menurun.

- Ada penyakit kulit lain.

 klasifikasi

1. Pioderma primer  kulit normal.

2. Pioderma sekunder  pada kelainan

kulit lain.
 terapi

1. Topical treatment :

• Mupirocin ointment  highly

effective apply 3 times daily for 7

– 10 days.
2. Systemic antimicrobiol treatment

1. Organism: Group A Streptococcus

• Drug of choice / dose :

 Penicillin 250 mg qid for 10 days.

 Benzathine penicillin
• 600,000 units IM in children 6 years
or younger
• 1.2 million units if 7 years or older. if
compliance is a problem,,,
• Alternative drugs :

 Erythromycin 250 – 500 mg

(adults) qid for 10 days.

 Cephalexin 250 – 500 mg

(adults) qid for 10 days.
2. Organism : Staphylococcus aureus

• Drug of choice / dose :

 Dicloxacillin 250 – 500 mg

(adults) qid for 10 days.
• Alternative drugs :
 Cephalexin 250 – 500 mg (adults)
qid for 10 days; 40 – 50 mg/kg/d
(children) for 10 days.
 Amoxicillin plus clavulanic acid (-
lactamase inhibitor) : 20 mg/kg/d
tid for 10 days.
3. Organism : GAS & Staphylococcus

aureus in pencillin-allergic patients

if organism is sensitive.
• Drug of choice / dose :

 Erythromycin ethylsuccinate : 1

– 2 g/d (adults) in four divided

doses for 10 days; 40 mg/kg/d

(children) qid for 10 days.

• Alternative drugs :
 Clatrithromycin 250 – 500 mg bid
for 10 days.
 Azithromycin 250 mg qd for 5 – 7
days.
 Clindamycin 150 – 300 mg
(adults) qid for 10 days; 15
mg/kg/d (children) qid for 10
days.
4. Organism : Methicillin-resistant

Staphylococcus aureus.

• Drug of choice / dose :

 Minocycline 100 mg bid for

10 days.
• Alternative drugs :
 Trimetoprim-sulfamethoxa-zole
160 mg trimethoprim + 800 mg
sulfamethoxazole bid.
 Ciprofloxacin 500 mg bid for 7
days.
 Impetigo & Ecthyma

Staphylococcus aureus &

Streptococcus pyogenes :

• Superficial infections of the

epidermis (impetigo).
• Extending into the dermis (ecthyma).

• Characterized by crusted erosions or

ulcers.
 epidemiologi

• Primary infections  more children.

• Secondary infections  any age.
• Bullous impetigo  children, young
adults.
 etiologi
• Staphylococcus aureus & GAS or
mixed.

• Bullous impetigo  80% caused by

Staphylococci which produce exotoxin
& cause SSSS.
 portals of entry of infection
• Primary impetigo  arises at minor
breaks in the skin.
• Secondary impetigo
(impetiginization)  underlying
dermatoses & traumatic breaks in
the integrity of the epidermis.
 Underlying dermatosis
• Inflammatory dermatoses
 Atopic dermatitis
 Contact dermatitis
 Stasis dermatitis
 Psoriasis vulgaris
 Chronic cutaneous lupus erythematosus
 Pyoderma gangrenosum
• Ulcers :
 Pressure.
 Stasis.
• Dermatophytosis :
 Tinea pedis.
 Tinea capitis.
 Riwayat anamnesis

• Duration of lesions :

 Impetigo  days to weeks.

 Ecthyma  weeks to
months.
 Gambaran klinis

• Impetigo  variable pruritus,

especially associated with atopic
dermatitis.
• Ecthyma  pain, tenderness.
 Pemeriksaan fisik
LESI KULIT
• Non bullous impetigo :
 Vesicles or pustules rupture,
erosions, crust.
 Golden-yellow crusts  often
seen but are not
pathognomonic.
• Bullous impetigo :
 Vesicles & bullae containing clear
yellow or slightly turbid fluid
without surrounding erythema,
erosion form.
 Distribution : > intertriginous
sites.
• Ecthyma :

 Ulceration with a thick adherent

crust.

 Lesions may be tender, indurated.

 Distribution : > distal extremities.

 DIAGNOSIS BANDING

• Perioral dermatitis.
• Allergic contact dermatitis.
• Herpes simplex.
• Epidermal dermatophytosis.
• Scabies.
• Herpes zoster.
• Excoriated insect bite.
PEMERIKSAAN LABORATORIUM

• Gram’s stain  Gram (+) cocci

• Culture  Staphylococcus aureus

 DIAGNOSIS

Clinical finding confirmed by

Gram’s stain or culture.

 PROGNOSIS
• Untreated impetigo : forming
ecthyma  invasive infection with
lymphangitis, suppurative
lymphadenitis, cellulitis or
erysipelas, bacteremia, septicemia.
• Ecthyma : often heals with scar.

• Recurrence : failure to eradicate

organism or reinfection from a

family member.
 Folliculitis

Is a pyoderma beginning

within the hair follicle.

Classified :

• Superficial folliculitis.

• Deep folliculitis.
Superficial folliculitis :

• Termed follicular or Bockhart’

impetigo.

• Pustules at the infundibulum

hair follicle.
Local treatment :

• Local antibiotics (mupirocin).

• Warm saline compresses.

More extensive case :

• Systemic antibiotic  a first-

generation cephalosporin, or a
penicillinase - resistant penicillin
such as oxacillin, cloxacillin or
dicloxacillin.
Furuncles & Carbuncles

Furuncle
• Deep seated inflammatory
nodule  hair follicle.

• Usually from a preceding

superficial folliculitis 
elvolving into an abscess.
• The neck, face, axillae &

buttock.

• Complicate preexisting

lesions.
• Start as a hard, tender, red folliculo
centric nodule in hair-bearing skin 
enlarges  painful & fluctuant 
rupture occurs  pus & necrotic
material  pain surrounding the lesion
subsides  redness & edema diminish
several days to weeks.
 Carbuncle
• Larger, more serious

inflammatory with a deeper base.

• Fever, malaise  patient appear

quite ill.
• Involved area is red & indurated,

multiple pustules on the surface

 yellow-gray irregular crater at

the center  heal slowly by

granulating.
Furuncle & carbuncle 

bacteremic spread of infection &

recurrence  individuals perspire

excessively or poor skin hygiene.

Treatment of furuncles & carbuncles :

• Drainage.

• Systemic antibiotic if surrounding

cellulitis or associated fever :

 Dicloxacillin 250 – 750 mg
PO qid 4 – 6 h in adult.

 Clindamycin 150 – 300 mg

PO qid.

 Erythromycin 250 – 500 mg

PO qid.
• Severe infection in

dangerous area  maximal

antibiotic by parenteral &

immobilized  vancomycin

1 – 2 g i.v. daily.
• Antibiotic at least 1 week.

• Topical treatment :

mupirocin 2% ointment.
 Abscess

Caused by Staphylococcus

aureus commonly occur in

folliculo centric infections 

folliculitis, furuncles &

carbuncles.
• Can also occur at sites trauma,
burns or site of insertion of
intravenous catheters.

• Initial lesion  erythematous

nodule  enlarges with the
formation of a pus-filled cavity.
Treatment :

• Incision & drainage.

• Similar management of folliculitis,

furuncle & carbuncle.

 Soft Tissue Infections

Characterized by an acute,

diffuse, spreading, edematous,

suppurativa inflammation of the

dermis & subcutaneous tissues.

Systemic symptoms :

• Malaise.

• Fever.

• Chills.
 Erysipelas
Superficial cutaneous cellulitis
with marked dermal lymphatic
vessel involvement  painful,
bright-red, raised, edematous,
sharply marginated from the
surrounding normal skin.
• Predilection : face, lower
legs, areas of preexisting
lymphedema, umbilical
stumps.

• Age of onset : any age.

• Incubation period : few days.

 Cellulitis
• Has many of the features of
erysipelas but extends into the
subcutaneous tissue.
• Not raised the lesion &
demarcation from ininvolved skin
is indistinct.
• Tissue feels hard on palpation &

painful.

• Age of onset : any age.

Caused :

• Staphylococcus aureus.

• Streptococcus B hemolytic.

Incubation period : few days.

Laboratory

• Direct microscopy smears :

Gram stain.

• Biopsy (Dermato-pathology).
Diagnosis
• Clinical feature.
• Confirme by culture in only
25% of cases in
immunocompetent patient.
• Biopsy & frozen-section
histopathology.
Management

• Rest, immobilization.

• Drain abscess, debride necrotic

tissue.

• Antimicrobiol therapy : 
 Antimicrobial agent (dosing (PO

unless indicate), usually for 7-14 days

1. Natural penicillins :

• Penicillin V : 250 - 500 mg

tid/qid for 10 days.

• Penicillin G : 600,000 - 1.2
million U IM qd for 7 days.
• Benzathine penicillin G :
600,000 U IM in children  6
years, 1.2 million units if  7
years, if compliance is a
problem
2. Penicillinase-resistant

penicillins :

• Cloxacillin : 250 – 500 mg

(adults) qid for 10 days.

• Dicloxacillin : 250 – 500 mg

(adults) qid for 10 days.

• Nafcillin : 1.0 – 2.0 g IV q4h.

• Oxacillin : 1.0 – 2.0 g IV q4h.

3. Aminopenicillins :
• Amoxicillin : 500 mg tid or 875 mg
q12h.
• Amoxicillin plus clavulanic acid (-
hemolytic inhibitor) : 875 / 125 mg
bid; 20 mg/kgd tid for 10 days.
• Ampicillin : 250 – 500 mg qid for 7 –
10 days.
4. Cephalosporins :

• Cephalexin : 250 – 500 mg

(adults) qid for 10 days; 40 –

50 mg/kg/d (children) for 10

days.
• Cephradine : 250 – 500 mg

(adults) qid for 10 days; 40 –

50 mg/kg/d (children) for 10

days.

• Cefaclor : 250 – 500 mg q8h.

• Cefprozil : 250 – 500 mg q21h.

• Cefuroxime axetil : 125 – 500

mg q21h.

• Cefixime : 200 – 400 mg q12 –

24h.
5. Erythromycin group :

• Erythromycin

ethylsuccinate : 250 – 500

mg (adults) qid for 10 days;

40 mg/kg/d (children) qid

for 10 days.
• Clatrithromycin : 50 mg

bid for 10 days.

• Azithromycin : 500 mg on

day 1, then 250 mg qd

days 2 – 5.
6. Clindamycin : 150 – 300

mg (adults) qid for 10

days; 15 mg/kg/d

(children) qid for 10 days.

7. Tetracycline :

• Minocycline : 100 mg bid

for 10 days.

• Doxycycline : 10 mg bid.

• Tetracycline : 250 – 500

mg qid.
8. Miscellaneous agents :

• Trimethoprim-sulfamethoxazole :
160 mg TMP + 800 mg SMZ bid.

• Metronidazole : 500 mg qid.

• Ciprofloxacin : 500 mg bid for 7

days.