Many microorganisms normally reside on the skin. The bacterial flora function beneficially by inhibiting the growth of many strains of pathogenic bacteria. Infections develop when the normal surface of the skin is broken by injury or when some disease disrupts the protective “acid mantle” that, in health, protects the skin from colonization by infective germs. These organisms fall into the usual spectrum of infectious agents discussed in Chapter Three.
Impetigo
Impetigo is a common infection of the skin caused by the bacterial germs
Streptococci (Group A beta hemolytic) and Staphylococci (coagulase
positive). These organisms are introduced into the skin after disruption of the normal barrier, such as following insect bites or trauma. If there is itching, the subsequent scratching allows the organisms to embed themselves into areas of normal skin and form pustules. This infection becomes contagious and is usually disseminated by direct physical contact. General symptoms, such as fever and swollen glands, are uncommon. The pustules, resembling acne, usually have surrounding areas of redness and crust formation, may multiply and spread.
Most commonly involved are the exposed parts, your extremities and face. Cultures are helpful in determining the exact organisms involved. Prompt treatment with hot moist compresses, disinfectant soaps and
meticulous cleansing of the surrounding skin can bring rapid resolution of all but the most stubborn skin infection. Your hands should be washed frequently and fingernails kept clean. Conscientious avoidance of scratching or rubbing
the offending lesions is important to prevent the lesions spreading to other areas.
The diet that encourages resistance of infection is simple, with fruits, fresh vegetables, and whole grains predominating. Strictly avoid sugar and greasy foods.
Several types of complications can be seen, usually classified as a type of
pyoderma. Folliculitis occurs when the bacteria invade tissues surrounding
the hairs. This is more common in the armpits and bearded area. Cellulitis develops from the dispersion of the infection along deeper planes of skin.
Lymphangitis, often confused with blood poisoning, presents itself as a streak
of redness, indicating the advancement of infection along the lymphatic channels. Each of these problems responds well to alternating hot and cold compresses, or hot and cold contrast baths described in Chapter I 7 on hydrotherapy. Use them in combination with strict antisepsis of the skin. Boils
Any collection of pus in a localized are is usually of bacterial origin. Small pustules, especially those occurring in the beard area, are called furuncles. A yellow discharge (exudate) will usually drain spontaneously when the lesions open, while pain and pressure are immediately reduced. Occasionally, mild fever and lethargy may occur, but signs of a severe infection are usually absent.
The mature lesion, brought to a head by repeated applications of hot compresses is ready for incision and drainage. After careful cleansing with alcohol or other antiseptic, a sterile needle or sharp blade can be used to open the top of the lesion and allow the pus to drain. The application of a charcoal poultice will also aid in its resolution. Lesions in the central portion of the face are more dangerous, because of the veins that drain in toward the cavernous sinus of the brain. A physician should evaluate these.
A second class of localized abscess is the carbuncle. These are usually deeper and more painful. Conditions, which predispose to developing these infections are high fat diets increasing oil production of the skin, occlusive dressings and cosmetics that block the drainage of oil and sweat glands. Unusual friction rubs or excessive exposure to oil may also be harmful. Reduced resistance to infection transpire in the malnourished, alcoholics, diabetics, newborns, and those with blood diseases. Inasmuch as these germs are contagious in character, hand washing, antiseptic skin cleaning, and other hygienic measure are mandatory.
Enzymes released by the offending bacteria produce marked swelling of the skin with inflammation. It is occasionally difficult to distinguish between erysipelas and severe cellulitis. The former condition, however, develops into “blood poisoning,” with bacteria traveling to create abscesses elsewhere in the body. They may even infect the inner lining or valves of the heart. Rest with elevation of an infected extremity is beneficial. Cool, wet dressings or alternating hot and cold compresses are crucial, while in advanced cases specific antibacterial therapy is recommended.
Scarlet Fever
Scarlet fever results from the production of a toxin by the betahemolytic
streptococcus. The rash involves the mouth and throat, and the skin over the
body. Usually the patient manifests sore throat, headache, loss of appetite, and fever for two to five days before the skin rash appears. The latter begins as a patch on the posterior neck, chest, or axillae. It then extends to involve the abdomen, extremities, and face with a pin point type of redness. The involved skin feels and looks like sandpaper, and the rash blanches with pressure. Pallor is present around the eyes and on the end of the nose. The tongue is often coated white with the edges appearing red, as a strawberry. Peeling skin over the hands and feet frequently evolves.
Untreated, the condition may last from four to six weeks. Severe complications, such as mastoiditis, sinusitis, arthritis, and even carditis may occur. Specific antistreptococcal therapy is usually indicated in the prevention of these complications. General hydrotherapy treatments and a spare diet during the acute phase are valuable to hasten rapid convalescence. Acne Vulgaris
A very distressing condition that occurs primarily among adolescents is acne vulgaris. Although the exact cause of this troubling affliction is not completely known, acne is definitely associated with hormone changes. These include those that cause sexual maturation and growth during the teenage years. Skin variations take several possible courses. Frequently, around the face, neck, and back ones hair follicles will become plugged with a waxy secretion that appears as the typical blackhead (comedone). These plugs can
be removed with a “comedone extractor.” The device can be purchased at any pharmacy. Using this instrument is much preferable to pinching the pimple. Traumatizing the skin can spread infection.
Obstruction to drainage of this material can develop a bacterial infection, producing the typical whitehead or pustule. These may be large and
extensive, In more serious forms, called cystic acne, infection may produce permanent scarring. A high fat diet, rich in fried or greasy foods, or meat and cheese, frequently changes the oil secretions on the skin and thus aggravates this tendency. Average teenage diets are often low in natural seed oils, nuts, fruits, and grains. This further enhances the development of acne. Poor diets may perpetuate it for several years.
Combined with high—fat dietary patterns is the increasing use of fashionable cosmetics. Most of them block the pores and prevent the skin from breathing. There are dozens of skin remedies available in pharmacies today. However, I find the following remedial agencies important, both in prevention and treatment of acne.
The skin must be cleansed once or twice daily with an antiseptic soap. This reduces the germ count and prevents the bacterial colonization in deeper pores that may be plugged. Blackheads and other lesions should never be squeezed or picked at, particularly with dirty hands or fingernails.
Whiteheads can be treated, as mentioned above for furuncles, with incision and drainage after appropriate antiseptic preparation. Sunlight exposure is important, not only to curtail bacterial colonization, but for general toning of the skin to resist disease.
Teenager’s diets should be simple but varied, with adequate vitamin and mineral composition, and a strong emphasis on fruits, whole grains, nuts, and vegetables. Butter fats, cocoa, coconut, meat, and fried greasy foods should be strictly avoided. Most saturated fats tend to clog the pores. Soymilk is valuable to further reduce any dietary source of cholesterol or saturated fat. Sugar intake should be restricted to aid general resistance to infection. Habits of adequate rest, daily exercise, and frequent bathing are most advantageous. Cold Sores
Painful ulcerating lesions around the mouth, on the face, and in the genital region are usually caused by a virus, called Herpes simplex. These lesions, frequently called cold sores or fever blisters, may follow an infection. Respiratory illness, influenza, or serious bacterial diseases are some of the common triggers. Nearly everyone is exposed to the Herpes simplex virus during childhood or young adult life. In most individuals a gradual immunity develops, In the unfortunate others, the Herpes virus invades a regional nerve. From this protected position it periodically spawns the skin reaction. A
may be present, associated with the skin lesions. Involvement of the brain
(meninges), the cornea, or Herpes infections superimposed on eczema are
more serious diseases. They should be evaluated by a skilled physician. Specific antiviral agents are somewhat experimental, all with potential side effects. The treatment of keratitis (infection of the cornea) is urgent, to prevent ulceration and blindness.
Several simple treatments are most helpful for cold sores about the mouth or other skin locations. They act as drying agents to the skin, including
camphor, alcohol, and similar proprietary medications. Topical
hydrocortisone containing creams (corticosteroids) can be applied for temporary symptomatic relief.
Varicella
Chicken pox or varicella is caused by a virus in the same family as
Herpes simplex. The virus produces in adults a disease called Herpes zoster
or shingles. The childhood variety is quite typical with a reddened rash, becoming raised and developing small blisters. These evolve in various stages and eventually form crusts. This disease is contagious and is probably
transmitted from one person to another through the skin or respiratory tract. Severe itching, however, can lead to secondary bacterial infection. Sometimes deep scabs produce permanent scarring. Topical drying lotions can give relief of itching, while specific treatment of secondary bacterial infections is
essential.
Zoster or shingles is a second disease caused by the same Herpes virus. The first manifestation of this condition is usually severe pain, localized to one side and following a nerve distribution in the face, neck, or trunk. At this early stage of the disease the condition may be misdiagnosed as a heart attack, hiatus hernia, migraine, or other pain syndrome. Several days later, however, the eruption appears as grouped reddened papules that rapidly evolve into tiny blisters distributed on the skin over the nerve (called the dermatome). Diagnosis is usually simple at this stage, while therapy is more difficult.
Although complications are rare and contagion is uncommon, in elderly people severe pain may persist. This is called “postherpetic neuralgia.” It is rare in patients younger than 50 years, but may be quite disabling to the
elderly. The shingles infection itself is self-limited. Topical drying lotions are helpful. A relatively new cream is now available for pain control. Called
Zostrix, it is actually based on cayenne pepper, containing the ingredient
capsicum.
In our institution I have seen relief from a series of steam baths, producing a mild fever. Just as the fever helps fight the childhood viral disease, I find fever effective in reducing the sequelae of this disease and hastening the clearing of the rash. Moist compresses, such as the use of a charcoal poultice, can also reduce the pain and local inflammation over the involved nerve. Sprays, such as Dermaplast, may produce temporary relief for the pain and irritation. Experimental treatment using the smallpox vaccine for shingles patients was studied and found ineffective.
Molluscum Contagiosum
This viral disease affects the mucous membranes as well as the skin. It produces multiple raised reddened lesions, each having a small central crater. The size is less than ¼ inch (2 to 4mm). Clusters of lesions tend to erupt in groups or lines. These papules emit a thick white material with pressure. They spread by contact. In order to remove them, a method must be chosen that minimizes scar formation and pain. Freezing with liquid nitrogen, the use of a comedone extractor (see page 136), or disruption of the central core with a scalpel or sterilized needle can produce rapid relief with insignificant scarring. Warts
The common wart is caused by a virus, which invades the skin, producing the characteristic elevation of the skin or mucous membrane. Several forms occur. The common rough thickened plaques (verruca
vulgaris) occur frequently in childhood. They are most familiar on the hands,
fingers, and around the nails. Satellite lesions may occur, or they may appear in areas of trauma. Small capillaries, when thrombosed, may exhibit black dots, resembling seeds.
Flat warts are multiple skin-colored papules on the face, neck, or the back of the hand. Around the eye or mouth small pointed (filiform) warts may appear like soft pliable tags. A most difficult wart to eradicate is the one found on the sole or plantar wart, occurring in the thick calloused skin of the feet. It is important to differentiate these from corns or callouses. A final type of wart is seen in the genital area, called condyloma accuminata. These cauliflower— shaped, warty clusters may extend into the vaginal or rectal mucosa. Usually related to sexual contact, they may become quite painful.
There are several acceptable methods of treating warts. Electric needles can be used to dry up the warts, but this usually requires local anesthesia.
(duofilm), trichloracetic acid, ammoniated mercury ointment, or cantharidine
(Cantharone). These treatments will not usually leave a scar.
Electrosurgery is also effective, and for most lesions the remaining scar will not be too visible. Approximately 20% of the warts resolve
spontaneously within one year. Plantar warts should be treated carefully with a nonscarring procedure. Permanent scars may be painful. Gentle excavation of the wart with a scraping instrument (curette). Also, the use of chemical irritants or freezing measures are usually quite effective. The venereal wart
(condyloma accuminata) can be a real therapeutic challenge. One treatment
involves an application of a special solution, 25% podophyllin in tincture of benzoin. Caution is required, because of skin irritation risk. This treatment should NEVER be used during pregnancy!
The study of warts can be challenging, because of the antigen-antibody relationships of this ubiquitous virus. It has provided a model for
understanding the production of tumors. This some day may help us develop safer and more physiologic ways of fighting other viruses, such as those that cause various types of cancer.
Yeast Infections
A number of distinct species of yeasts or fungi can infect the skin and its appendages. Although some are always disease producing (called patho-
genic), many are opportunists and live normally on the skin, causing infection
and symptoms only when conditions prevail that allow excessive growth or an imbalance in normal body flora.
Ringworm is a common and very distressing fungal infection. It is classified sometimes by location and also biologically to describe different organisms which can be cultured. Small red, itching, scaling spots develop on the skin surface, then grow outward. The margin gradually increases in size, while the central portion of the eruption begins to heal spontaneously. Occasionally, after shaving their legs, women can develop deeper fungus infection of the hair follicles, characterized by redness, itching, and granuloma formation.
Another location for infection with the ringworm (Tinea) organism is the nails. Called onychomycosis, this infection usually involves single nails, more
commonly on the toes. As fungal organisms grow in the nail plate, the nail becomes opaque, brittle, cracked, and partially separated from its bed. Occa- sionally an associated fungus infection occurs in the surrounding skin.
The third type of ringworm, Tinea cruris, occurs in the groin. This may itch and exude some fluid. It slowly spreads until treatment is instituted. The hands, feet, and scalp can also be involved with the Tinea family of
organisms. Formerly occurring as an epidemic in children, Tinea capitis is now less common. These round or oval, sharply defined lesions cause breaking of the hair, patchy baldness, and occasionally drain a pus-like material. A special fluorescent (Wood’s) light may illuminate the lesions, producing a bright yellowish-green fluorescence.
The most superficial infection, Tinea versicolor, occurs in hot humid climates. Slight scaling patches usually involve the trunk, neck, and upper arms. Gentle scraping may make the scaling more evident. Confirmation of the diagnosis in these fungus infections involves scraping the scaling lesions into a glass slide. After applying a 10% solution of potassium hydroxide and heating the slide gently, the characteristic fungus organism can be seen under the microscope. They usually appear, like most yeasts and fungi, as branching strands, called hyphae.
Treatment of superficial fungus infections is quite effective, using a number of common antifungal preparations. The application of sulfur ointment, painting with tincture of iodine, or half strength of Whitfield’s s ointment is usually helpful. Topical salicylic acid, or the use of newer creams, such as Tinactin can prove beneficial. Most are over—the—counter items available at any pharmacy. Toenail involvement is often resistant to therapy. It may require the surgical removal of the nail, or periodic trimming and
tolerance of a slow, ever present infection.
Many yeast-type organisms can infect the skin, The most common infection, however, is produced by the yeast Candida albicans. Formerly called monilia, this infection still is described occasionally as Moniliasis. When seen in the mouth, the disease is called thrush. Cottage cheese-like growths are seen along the surface of the cheeks, in the tonsillar area, and coating the tongue surface. Frequent in infancy, this lesion responds well to specific antifungal therapies, such as nystatin, or the painting with Gentian violet.
Vaginal involvement with yeast is also a common occurrence. Often producing inflammation, pain, or a cheesy discharge these Vaginitis
infections are easily treated, but seldom completely eradicated. Aggravating factors include the use of hormone agents, birth control pills, and elevated blood sugar, as in uncontrolled diabetes. It is a troublesome affliction of pregnancy, also seen commonly in times of stress, and immune deficiencies.
moist diaper area. Appearing as pinpoint red papules, then coalescing to a red diaper rash, the yeast grows and spreads. Plastic “disposable” diapers contribute to this predicament. Careful drying, cleansing, and the topical use of mild ointments, such as A & D ointment, Desitin, or a powdered
cornstarch can allow improvement of most cases. Ultraviolet light from the sun is helpful, not only in drying involved skin, but killing the offending organism.
ECZEMA
The terms dermatitis and eczema are used for a variety of inflammatory allergens, and other factors. Characteristically, the skin changes consist of reddening’s swelling, moist “weeping,” and mild to severe itching. Later stages exhibit scaling with crust formation and eventual scarring. Several types are described below.
Contact Dermatitis
Skin changes in this category of inflammation start in areas of contact with the irritating or allergy-producing agent. The reaction is usually localized, and limited to the area of exposure. There are two main types. Primary or toxic dermatitis may occur in any individual without prior