PEDIATRIC CUTANEOUS BACTERIAL INFECTIONS

DR. PEARL C. KWONG MD PHD

BOARD CERTIFIED PEDIATRIC DERMATOLOGIST

JACKSONVILLE, FLORIDA

DISCLOSURE

• No relevant relationships

PRETEST QUESTIONS

• In Staph scalded skin syndrome:

• A. The staph bacteria can be isolated from the nares , conjunctiva or the perianal area

• B. The patients always have associated multiple system involvement including GI hepatic MSK renal and CNS

• C. common in adults and adolescents

• D. can also be caused by Pseudomonas aeruginosa

• E. None of the above

PRETEST QUESTIONS

• Scarlet fever

• A. should be treated with penicillins

• B. should be treated with sulfa drugs

• C. can lead to toxic shock syndrome

• D. can be associated with pharyngitis or circumoral pallor

• E. Both A and D are correct

PRETEST QUESTIONS

• Strep can be treated with the following antibiotics

• A. Penicillin

• B. First generation cephalosporin

• C. clindamycin

• D. Septra

• E. A B or C

• F. A and D only

PRETEST QUESTIONS

• MRSA

• A. is only acquired via hospital

• B. can be acquired in the community

• C. is more aggressive than OSSA

• D. needs treatment with first generation cephalosporin

• E. A and C

• F. B and C

CUTANEOUS BACTERIAL PATHOGENS

• Staphylococcus aureus: OSSA and MRSA

• Gp A Streptococcus GABHS

• Pseudomonas aeruginosa

CUTANEOUS BACTERIAL INFECTIONS

• Folliculitis

• Non bullous Impetigo/Bullous Impetigo

• Furuncle/Carbuncle/Abscess

• Cellulitis

• Acute Paronychia

• Dactylitis

• Erysipelas

• Impetiginization of dermatoses

BACTERIAL INFECTION

• Important to diagnose early

• Almost always curable

• Serious complications if delayed Rx or if Rx is inadequate

• Septicemia, nephritis, carditis, arthritis

PTS PRONE TO BACTERIAL INFECTIONS

• Immunocompromised pts

• Babies /Children

• Pts with chronic skin conditions

BACTERIAL INFECTION

• Localized

• Spreading

• Superficial

• Deep

• Rash is secondary to the infection

SKIN REACTION TO BACTERIAL INFECTION

• Guttate psoriasis

• SSSS

• TSS

• Scarlet fever/scarlatina

• Beaus lines and onychomadesis

FOLLICULITIS

• Infection of the hair follicles

• Superficial or deep

• Staph most common pathogen but Strep Gram negative and even dermatophytes

• Folliculitis barbae (sycosis barbae)

• Pseudomonas Folliculitis (hot tub folliculitis)

FOLLICULITIS

FOLLICULITIS

IMPETIGO

• Superficial infection

• Bullous or nonbullous

• Erythematous papules with honey yellow colored crusting; peripheral collarettes

• Multiple lesions due to autoinoculation

• S Aureus , GABHS or both

• Topical antibiotics if localized , oral if spreading

IMPETIGO

IMPETIGO

IMPETIGO

IMPETIGO

BULLOUS IMPETIGO

FURUNCLE CARBUNCLE

• Boils

• Painful deep perifollicular abscesses with central necrosis suppuration; fluctuant

• S aureus

• Carbuncles larger deeper seated abscess aggregates

• I and D and oral antibiotics.

FURUNCLE/CARBUNCLE

FURUNCLE/CARBUNCLE

CELLULITIS

• Acute infection of the skin sub q

• Erythema swelling tenderness

• Borders not elevated or sharply defined

• Follows skin trauma

• Can have constitutional sx

• S aureus and GABHS and under 2 H influenza type b,streppneumoniae

PERIORBITAL CELLULITIS

• Erythema and periorbital swelling

• Can spread thru orbital septum

• Orbital cellulitis: proptosis ophthalmoplegia decreased visual acuity

• Need CT and consult to ophthalmology. Need to rule out meningitis

• Complication: abscess formation and cavernous sinus thrombosis

• Used to be due to Hib now more Staph and strep

CELLULITIS

ERYSIPELAS

• Superficial cellulitis with marked lymphatic involvement

• GABHS

• Direct inoculation thru break in skin

• Warm shiny bright red infiltrated plaque distinct border

ERYSIPELAS

PERIANAL STREPTOCOCCAL DERMATITIS PSD

• Frequently overlooked

• Sharply circumscribed perianal erythema

• Fissuring and purulent discharge and or functional disturbances

• Strep /staph.

PERIANAL STREP INFECTION

BLISTERING DACTYLITIS

• Bullous manifestation of strep or staph infection

• Painful tense one finger or several

• DDx herpetic whitlow

DACTYLITIS/ACUTE PARONYCHIA

SKIN REACTIONS TO BACTERIAL INFECTION

• SSSS

• TSS

• Scarlet fever/scarlatina

• Guttate psoriasis

• Beaus lines and onychomadesis

STAPH SCALDED SKIN SYNDROME

• Blistering skin disease caused by epidermolytic toxin producing S aureus

• Exfoliative toxin ETA ETB

• Generally starts with infection of the conjunctiva or the nares perioral region perineum or umbilicus/

• Initial nidus can be from pneumonia septic arthritis endocarditis or pyomyositis

• Fever malaise lethargy irritability poor feeding

• Erythema crusting denudation and tender skin.

• Nikolsky sign is positive

SSSS

SSSS

SSSS

STAPH SCALDED SKIN SYNDROME

SSSS

SSSS

SSSS NEWBORN

SSSS NEWBORN

TOXIC SHOCK SYNDROME

• Acute febrile illness

• Fever rash hypotension multisystem organ involvement

• Classic history : use of superabsorbent tampons.

• Non menstrual cases : nasal packing postpartum state and a variety of staph infections

TSS

Temp >38.9

Diffuse macular erythroderma

Desquamation and 1-2 weeks after onset , esp palms and soles

Hypotension

Multisystem involvement of 3 or more:GI , MSK, renal , hepatic , hematologic, CNS

Negative tests on blood throat or CSF cultures, or serologic tests for RMSF leptospirosis or measles.

TSS

DESQUAMATION TSS

DESQUAMATION

SCARLET FEVER/SCARLATINA

• Caused by GABHS

• Fever chills sore throat headaches

• Tonsillopharyngeal erythema exudate or petechial macules of the palate

• Tongue with white strawberry appearance then red strawberry tongue

• Circumoral pallor

• Asstd cervical lymphadenopathy

• Sandpapery

• Pastia’s lines: petechial component in the flexural areas

• Desquamation

SCARLET FEVER /SCARLATINA

SCARLET FEVER

SCARLET FEVER

DESQUAMATION POST SCARLET FEVER

ONYCHOMADESIS SECONDARY TO STREP INFECTION

GUTTATE PSORIASIS

IMPETIGINIZATION OF DERMATOSES

• Atopic dermatitis

• Tinea capitis

• Psoriasis

IMPETIGINIZED ECZEMA

IMPETIGINIZED ECZEMA

IMPETIGINIZED ECZEMA

IMPETIGINIZED ATOPIC DERMATITIS

IMPETIGINIZED TINEA CAPITIS

APPROACH TO TREATMENT

• Empirical treatment

• Cultures to determine sensitivity

• Topical antibiotics

• Systemic antibiotics

• Pediatric considerations

• I and D

• Prevention

TOPICAL ANTIBIOTICS

OTC options: neosporic polysporin bacitracin

Mupirocin

Fusidic acid

Silvadene

Clindamycin

Gentamicin

SYSTEMIC ORAL ANTIBIOTICS

• Cloxacillin

• Augmentin

• Cephalexin. First generation , second generation

• Clindamycin

• Sulfa

• Ciprofloxacin

• Doxycycline

SPECIAL PEDIATRIC CONSIDERATIONS

• Allergies

• Safety in children: Doxy, cipro

• Palatability

• Dosing

• Cost

• Drug Interactions

SURGICAL TREATMENT

• I and D abscess

TREATMENT OF SKIN BACTERIAL INFECTIONS• Cultures important.

• Important to know WHERE to culture.

• Good complete physical exam

• Recognize yellow crusting, wet lesions.

• Don’t forget to look in the groin perianal area eyelids external ear canals, folds

• Don’t forget to treat contacts. Contacts may include FIDO the family dog

PREVENTION

• Disinfectants: Bleach baths, hibiclens wash, mupirocin to nostrils and to body folds

• Disinfect surfaces.

• No toys in bathtubs, no loofahs etc

• Change blades from shavers

• WARN PTS INFECTION CAN BE RECURRENT!

• Treat family pets too!

CA-MRSA

• Usually presents as deeper furuncle/carbuncle

• More aggressive

• Common in community not just hospital setting

CA MRSA ERADICATION SUGGESTIONS:

• Treat affected areas with topical antibiotics Mupirocin

• Prone areas : nares folds

• Bleach baths

• Hibiclens

• Treat contacts including Fido

• Mouthwash to treat pharynx and soak toothbrushes combs in mouthwash

• Clorox wipes vs Saniwipes

• Change linens daily

• Change razors

PRETEST QUESTIONS

• In Staph scalded skin syndrome:

• A. The staph bacteria can be isolated from the nares , conjunctiva or the perianal area

• B. The patients always have associated multiple system involvement including GI hepatic MSK renal and CNS

• C. common in adults and adolescents

• D. can also be caused by Pseudomonas aeruginosa

• E. None of the above

PRETEST QUESTIONS

• Scarlet fever

• A. should be treated with penicillins

• B. should be treated with sulfa drugs

• C. can lead to toxic shock syndrome

• D. can be associated with pharyngitis or circumoral pallor

• E. Both A and D are correct

PRETEST QUESTIONS

• Strep can be treated with the following antibiotics

• A. Penicillin

• B. First generation cephalosporin

• C. clindamycin

• D. Septra

• E. A B or C

• F. A and D only

PRETEST QUESTIONS

• MRSA

• A. is only acquired via hospital

• B. can be acquired in the community

• C. is more aggressive than OSSA

• D. needs treatment with first generation cephalosporin

• E. A and C

• F. B and C