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ecthyma
Infection of the skin involving the dermis characterized by crusted erosions or ulcerations. A lesion of neglect. Develops in excoriations, insect bites, minor trauma in diabetics, elderly patients, soldiers & alcoholics.
Etiology:
1) contagious ecthyma is caused by orf virus [2]
- primary infection of superficial break in skin
- animal bite [2]
2) according to ref [1]
a) Staphylococcus aureus
- most commonly phage group 2, type 71 same etiologic agent as Staphylococcal scalded skin syndrome
b) Streptococcus pyogenes
c) primary infection of superficial break in skin
d) secondary infection of pre-exsiting dermatosis
e) predisposing factors
- colonization of skin by S aureus & S pyogenes
- warm ambient temperature
- high humidity
- neglect
Epidemiology:
- persons with diabetes mellitus
- neglected elderly [3]
Clinical manifestations:
1) durations of lesions: weeks to months
2) painful rash with purulent-appearing papules [2]
3) ulceration with thick, adherent hemorrhagic crust
4) lesions round or oval, may be > 3 cm in size (saucer-shaped)
5) distribution: ankles, dorsal aspect of feet, thighs, buttocks
- case report shows lesions on hands [2]
6) regional lymphadenopathy may be present
7) often leaves a scar after healing
* images [2,3]
Differential diagnosis:
1) Herpetic ulcers
2) excoriated insect bite
3) neurotic excoriations
4) cutaneous diptheria
5) porphyria cutanea tarda
6) venous stasis
7) atherosclerotic ulcers
Complications:
1) lymphangitis
2) suppurative lymphadenitis
3) cellulitis or erysipelas
4) septicemia
Management:
1) contagious ecthyma [2]
- routine wound care
- antibiotic agents for possible bacterial superinfection
2) topical agents
- mupirocin (Bactroban) TID to affected skin & to nares for 7-10 days
- benzoyl peroxide (prevention)
3) systemic antibiotics
a) group A streptococcus (S pyogenes)
- penicillin VK 250 mg PO TID
- benzathine penicillin
- 600,000 units IM (< 6 years of age)
- 1,200,000 units IM (> 6 years of age)
- erythromycin 250-500 mg PO QID for 10 days
- cephalexin 250-500 mg QID for 10 days
b) Staphylococcus aureus
- dicloxacillin 250-500 mg PO QID
- cephalexin
- 250-500 mg PO QID for 10 days (adults)
- 40-50 mg/kg/day for 10 days (children)
- amoxicillin clavulanate (Augmentin)
- 20 mg/kg/day divided TID for 10 days
- macrolides for penicillin-sensitive individuals
- erythromycin
- 1-2 g/day divided QID for 10 days (adults)
- 40 mg/kg/day divided QID for 10 days (children)
- clarithromycin 250-500 mg PO BID for 10 days
- azithromycin 250 mg QD for 5-7 days
- clindamycin
- 150-300 mg QID for 10 days (adults)
- 15 mg/kg/day divided QID for 10 days (children)
c) methicillin-resistant Staphylococcus aureus (MRSA)
- mupirocin ointment
- minocycline 100 mg PO BID for 10 days
- Bactrim DS 1-2 tabs QD
- ciprofloxacin 500 mg PO BID
Specific
ecthyma gangrenosum
General
skin disease (dermatologic disorder, dermatopathy, dermatosis)
References
- Color Atlas & Synopsis of Clinical Dermatology, Common
& Serious Diseases, 3rd ed, Fitzpatrick et al, McGraw Hill, NY,
1997, pg 604-609
- Thurman RJ, Fitch RW
Images in clinical medicine. Contagious ecthyma.
N Engl J Med. 2015 Feb 19;372(8):e12
PMID: 25693031
http://www.nejm.org/doi/full/10.1056/NEJMicm1304779
(case report, images)
- Elkston CA, Elkston DM
Bacterial Skin Infections: More Than Skin Deep.
Medscape. July 19, 2021
https://reference.medscape.com/slideshow/infect-skin-6003449