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Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022
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Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
Many species of bacteria, such as Staphylococcus, Acinetobacter, Brevibacterium, and Corynebacterium, are normal skin flora, and they are generally nonpathogenic. However, some bacteria can invade damaged or even healthy skin, resulting in skin and wound infections. The clinical picture can vary according to the tissue involved. Superficial skin and soft-tissue infection results in cellulitis, deeper infection results in abscess formation, and involvement of the follicular unit results in folliculitis. Although skin infections are common, even experienced clinicians may have difficulty recognizing their many presentations.
Erysipelas
Erysipelas (shown) and cellulitis are usually caused by group A streptococci. Erysipelas involves the superficial dermis and lymphatic vessels, leading to edema and a characteristic sharp, distinct outline, whereas cellulitis involves deeper tissue and fades gradually into the surrounding skin. Erysipelas can result in lymphatic scarring and chronic lymphedema. The lower extremities are involved in 70-80% of erysipelas cases; the face is affected in 5-20% of patients.[1] Complications of the infection usually are not life-threatening, and most cases resolve after antibiotic therapy.
Shown is an intensely painful erysipelas eruption on the leg of a 65-year-old man.
Image from Smuszkiewicz P, Trojanowska I, Tomczak H. Cases J. 2008;1(1):125. PMID: 18721475; PMCID: PMC2547098. [Creative Commons Attribution License 2.0 Generic (CC by 2.0).]
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
Shown is the left leg of a 43-year-old man who presented to the intensive care unit (ICU) with a delayed diagnosis of necrotizing fasciitis.
Necrotizing Fasciitis
Group A beta-hemolytic streptococci are responsible for most necrotizing fasciitis cases, but other bacteria may also cause the condition. Early diagnosis and treatment are crucial, as mortality varies between approximately 8.3% and 23.7%.[2-4]
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
A scalp lesion on a 60-year-old man is shown; note the thick, oyster shell–like scale crust.
Ecthyma
Ecthyma is an ulcerative pyoderma of the skin caused by streptococci or staphylococci. The infection begins with a pustule that later erodes and forms a punched-out ulcer with a hemorrhagic crust. Ecthyma usually affects the lower extremities of children, persons with diabetes, and neglected elderly patients.
The lesion can be diagnosed clinically as staphylococcal ecthyma on the basis of the golden color of the purulent exudate. The presence of large clusters of gram-positive cocci confirms the diagnosis of staphylococcal ecthyma. Treatment of ecthyma includes administration of oral antibiotics and maintenance of good hygiene.[5,6]
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
Shown is the elbow of a 48-year-old man who presented with draining sinus tracts (arrows).
Botryomycosis
Botryomycosis is a deep staphylococcal infection with formation of sinus tracts. Histopathologic examination revealed very large colonies of cocci, referred to as grains. Huge staphylococcal colonies are extruded from the sinus tracts and resemble grains of sand.
Image courtesy of Jessica Connett, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
The 18-month-old child above presented with desquamation of the skin at the granular layer, leaving a wet-appearing surface beneath.
Staphylococcal Scalded-Skin Syndrome (SSSS)
SSSS is a toxin-mediated exfoliative dermatitis caused by systemic spread of the same exfoliative toxin that causes bullous impetigo. The major sites of involvement include the face, the retroauricular area, and the neck. The infection site is usually distant from the site of skin damage.
The diffuse erythematous rash often begins on the face and intertriginous areas and then generalizes, and it may be associated with systemic symptoms. Young children and neonates are slow to clear the toxin and are more prone to the syndrome because of their lack of immunity and their immature renal clearance capability. Adults with renal insufficiency and immunosuppression are also particularly at risk; their mortality risk is 60%, compared with 5% for children. Treatment of SSSS includes administration of intravenous antibiotics and fluid rehydration.[6,7]
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
A 54-year-old man presented with a fever and the above acutely tender eruption on his foot.
Lymphangitis
Lymphangitis results from inflammation of the lymphatic channels caused by a distal infection. The most common cause of lymphangitis is Streptococcus pyogenes. Patients with streptococcal lymphangitis can be quite toxic and febrile, and the infection can rapidly progress, leading to serious complications.
Patients often present with a red streak traveling up the involved extremity, a raised border around the affected area, and lymphadenitis. A history of a recent cut or abrasion to an area of skin distal to the site of infection is common. Children with lymphangitis may have fever, chills, and malaise, and some children may report headache, loss of appetite, and muscle aches.[8]
Image of Mycobacterium marinum granulomas on the hand. Image courtesy of Brett Sloan, MD, FAAD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
Mycobacterium Marinum Infection
M marinum infection, also called fish tank granuloma or swimming pool granuloma, is often an occupational dermatosis acquired via skin trauma. Aquarium owners, anglers, and fish processing workers are among those that most frequently contract this zoonotic infection. There have also been reported cases of M marinum infections among "fish pedicure" clients.[9]
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
Shown is the eye of a 60-year-old woman who presented with a purulent endophthalmitis after using an 18-year-old bottle of eye drops from her medicine cabinet.
Pseudomonas Aeruginosa Infection
P aeruginosa is a gram-negative rod that grows well in aqueous environments. In healthy individuals, it can cause folliculitis after exposure to poorly chlorinated pools or hot tubs. P aeruginosa has low virulence; consequently, infections most commonly occur in those with weakened immune systems and patients hospitalized longer than 1 week.[10]
Pseudomonal infections can involve any part of the body, but when the bacteria are introduced into the eye, a rapidly progressive and destructive infection may ensue. In adults, P aeruginosa is a common cause of bacterial keratitis, scleral abscess, and endophthalmitis; in children, of ophthalmia neonatorum. When it causes endophthalmitis, progression to pseudomonal sepsis can occur.
Histologic examination in disseminated cases characteristically shows vascular necrosis with a distinct absence of inflammatory cells. The organisms are visible as a blue haze surrounding the blood vessel.[11]
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
An 18-year-old man presented with 1 week of presumed psoriasis lesions. However, testing revealed syphilis.
Syphilis
Syphilis infections in the United States has been steadily increasing since 2000, with the highest incidence in men who have sex with men.[12] Skin lesions associated with syphilis are notoriously polymorphous, but they most commonly present as papulosquamous lesions on the trunk and coppery papules on the palms and soles with peripheral adherent scale. Histopathologic examination typically reveals elongation of rete ridges, interface dermatitis, endothelial swelling, and a lymphoplasmacytic infiltrate.
Immunostaining may reveal treponemal organisms within the lower third of the epidermis. Clinicians must always have a degree of suspicion regarding a possible diagnosis of syphilis, as it manifests as many other diseases do and can mimic many other infections.
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
A 65-year-old man presented with a new cardiac murmur and a Janeway lesion on the sole of his foot.
Bacterial Endocarditis-Associated Skin Lesions
Janeway lesions present in the setting of acute bacterial endocarditis as hemorrhagic, stellate, nontender infarctions of skin on the palms or soles. Biopsy findings demonstrate staphylococcal embolization of arterioles.
Osler nodes are associated with subacute bacterial endocarditis, and they are related to immune complex formation. Although similar to Janeway lesions, Osler nodes present as tender, blanchable, pink papules on the digits.
Image courtesy of Medscape.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
Shown is a 50-year-old woman who presented with a rash on her face. Examination revealed pustules and honey-colored crusts on an erythematous base.
Impetigo
Impetigo (shown), an acute and highly contagious gram-positive bacterial infection of the superficial epidermis, is the most common bacterial infection in children. Most cases begin as a streptococcal infection, although staphylococci may overgrow the streptococci in later phases of the infection.[10] Risk factors include warm ambient temperatures and humidity, atopy, poor hygiene, trauma to the skin, and contact sports. In many countries, widespread impetigo suggests an underlying scabies infestation.[13,14]
Diagnosis of impetigo is often based solely on the patient's history and clinical appearance. Bacterial culture and sensitivity can be used to confirm the diagnosis and are recommended when methicillin-resistant Staphylococcus aureus (MRSA) is suspected or in the presence of an impetigo outbreak or poststreptococcal glomerulonephritis.[15-17] Nasal decolonization and management of fomites can be helpful to prevent reinfection and spread to other individuals.
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
The image shows a fluctuant nodule on the thigh of an infant from a daycare center.
Abscesses
The initial treatment for an uncomplicated abscess (shown), including those caused by MRSA, is drainage. Smaller abscesses up to 5 cm in diameter, when adequately drained, demonstrate similar outcomes with or without antibiotics, but, overall, MRSA abscesses benefit from the addition of an antibiotic.
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
The skin of a patient with the above lesions was refractory to treatment with a cephalosporin. Bacterial culture studies showed MRSA.
Bacterial furuncles represent small follicular abscesses (shown). Appropriate treatment requires drainage. Antibiotics have little effect until appropriate drainage has been completed. Surface carriage may result in spreading of the infection to adjacent follicles and can be addressed by topical agents such as chlorhexidine.
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
Gonococcemia
Gonococcemia is defined as the presence of Neisseria gonorrhoeae in the bloodstream, which can lead to the development of disseminated gonococcal infection. Women commonly present with gonococcemia immediately following a menstrual period.
A characteristic skin lesion, an acral hemorrhagic pustule (arrow), is shown above. Patients with gonococcemia commonly have septic arthritis or arthralgia.[18]
Image courtesy of Dirk M Elston, MD.
Bacterial Skin Infections: Beneath the Surface
Carly A Elston, MD; Dirk M Elston, MD | July 11, 2022 | Contributor Information
The image shows a retiform purpura rash on the foot of a pediatrics resident who developed headache, fever, malaise, and hypotension after completing an ICU rotation.
Meningococcemia
Meningococcemia, an acute infection of the bloodstream, presents with retiform purpura (shown). The individual stellate lesions have an erythematous rim and a gun-metal gray hemorrhagic center. Bilateral adrenal necrosis with ensuing acute addisonian crisis is a potentially fatal complication, and patients should be treated with appropriate antibiotics as well as corticosteroids in the setting of acute hypotension.
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Contributor Information
Authors
Carly A Elston, MD
Assistant Professor
University of Alabama at Birmingham
Birmingham, AL
Disclosure: Carly A Elston, MD, has disclosed no relevant financial relationships.
Dirk M Elston, MD
Professor and Chairman
Department of Dermatology and Dermatologic Surgery
Medical University of South Carolina
Charleston, SC
Disclosure: Dirk M Elston, MD, has disclosed no relevant financial relationships.
Reviewer
Brett Sloan, MD, FAAD
Professor of Dermatology
University of Connecticut School of Medicine
Farmington, CT;
Residency Site Director
Connecticut Veterans Affairs Healthcare System;
Assistant Clinical Professor
Yale University School of Medicine
New Haven, CT;
Editor-in-Chief, Journal of the American Academy of Dermatology Case Reports
Disclosure: Brett Sloan, MD, FAAD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Journal of the American Academy of Dermatology; UpToDate; Medical Review Institute of America.
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References
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Oud L, Watkins P. Contemporary trends of the epidemiology, clinical characteristics, and resource utilization of necrotizing fasciitis in Texas: a population-based cohort study. Crit Care Res Pract. 2015;2015:618067. PMID: 25893115.
Audureau E, Hua C, de Prost N, et al. Mortality of necrotising fasciitis: relative influence of individual and hospital-level factors, a nationwide multi-level study, France, 2007-12. Br J Dermatol. 2017 Dec;177(6):1575-82. PMID: 28452064.
Bucca K, Spencer R, Orford N, Cattigan C, Athan E, McDonald A. Early diagnosis and treatment of necrotizing fasciitis can improve survival: an observational intensive care unit cohort study. ANZ J Surg. 2013 May; 83(5):365-70. PMID: 22989238.
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Bernigaud C, Zakrzewski M, Taylor S, et al. First description of the composition and the functional capabilities of the skin microbial community accompanying severe scabies infestation in humans. Microorganisms. 2021 Apr 23;9(5):907. PMID: 33922793.
McAdam AJ, Milner DA, Sharpe AH. Infectious diseases. In: Kumar V, Abbas AK, Aster JC, eds. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2015:341-402.
Usatine RP, Krejci-Manwaring J. Dermatology. In: Rakel RE, Rakel DP, eds. Textbook of Family Medicine. 9th ed. Philadelphia, Pa: Elsevier Saunders; 2016: 740-81.
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