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ACMS DERMATOLOGY LECTURE SERIES 3 SeboEczema herpeticum, Cellulitis, Necrotising fasciitis & SEBORRHEIC DERMA TITIS This is caused by the commensal organism Malassezia Furfur It forms flaky skin with a shiny scale that may coalesce, oily and erythematous. Typically the pain is minimal, in the form of an itch Problematic areas on adults: face – hairline, nasolabial fold & eyebrows Problematic areas on infants: cradle cap: this is asymptomaticCRADLE CAP ■ Cradle cap is a form of infantile seborrhoeicdermatitis thatpresentsat 8- 12 months ■ It appears as a diffuse, yellow,greasy scale ■ The scale coalescesinto plaques that are locatedon the scalp mostcommonly ■ Other areastypically affectedinclude the groin and armpitInvestigating Seborrhoeic dermatitis ■ Diagnoses are madevia clinical diagnosis – assessing the appearanceofthe skin ■ Ordinarily the testsare morecentred around starting systemictreatmentse.g with traditionalDMARDs or biologics ■ Howeverothertestsincluding blood tests& a skin biopsycan be taken if there is a possibility of a differential diagnosis or in the discoveryof an underlying cause (such as HIV)Management ■ Infantile seborrhoeic dermatitis is usually self-limiting ■ Management of seborrhoeic dermatitis in infants involves: – Use of a topical emollient and infant brush to loosen the scales on thescalp – Bathing the infant daily with an emollient as a soap substitute – A topical imidazole cream or a short course of a low-potency topical corticosteroid if appropriate. ■ In adults, SD is a chroniccondition ■ Management of seborrhoeic dermatitis of the face and body involves: – topical imidazole and an anti-fungal shampoo – To settle inflammation: a short course of a low to medium potencytopical corticosteroid cream such as hydrocortisonefor flaresNecrotising fasciitis ■ This is a life-threateninginfection characterisedby quicklyprogressing inflammation as well as necrosisof thefascia and subcutaneoustissue ■ It is caused by virulent bacteria suchas group A streptococcusorstaphylococcusaureus or gas-forming organisms such as clostridium perfringensSigns and symptoms of necrotising fasciitis 1. Pain disproportionatetoclinical signs 2. Skin changes: dark discolouration, blistering 3. Pain subsides as nervesbecomedestroyed 4. Oedemaextendingbeyondthe area of erythema 5. SystemicillnessInvestigating necrotising fasciitis ■ Blood tests:show signs ofinfection & sepsis e.g raised WCC, CRP + may also show evidence oforgan dysfunction ■ Bacterialcultures: to identify causativeorganism to guide antibiotic therapy ■ CT/MRI scans: visualise the gas in tissuesManagement of necrotising fasciitis ■ Broad spectrumantibiotics: such as IV clindamycin, meropenem,vancomycin ■ Surgical debridement= this is urgent and necessarytoremovenecrotic tissue & control infection. Use wide margin to ensure no residue infection is left behind ■ Haemodynamicsupport: tomanageseveresystemicillness – IV fluids, vasopressors & supportivecare in an ICU setting ■ Amputationif severeMCQ! A 77 yearold female presentto hospital with left leg rednessand pain. She is diagnosed with cellulitis and given intravenousfluids.She has a backgroundofasthma and heart management plan?itionally has a knownpenicillin allergy. What is the most appropriate A. Flucoaxcillin B. Clindamycin C. Benzylmethylpenicillin D. Co-amoxicolavMCQ! A 77 yearold female presentto hospital with left leg rednessand pain. She is diagnosed with cellulitis and given intravenousfluids.She has a backgroundofasthma and heart management plan?itionally has a knownpenicillin allergy. What is the most appropriate A. Flucoaxcillin B. Clindamycin C. Benzylmethylpenicillin D. Co-amoxicolavEczema herpeticum ■ Thisis an infection usuallycausedbythe infection of herpes simple1virus intolargeareasof the skin ■ Thisaffects peoplewithatopic dermatitisandother inflammatoryskindiseases. ■ Presentationof eczemaherpeticumistypically: 1. Clustersof smallitchy,painfulblistersthatooze pus when broken open 2. Blistersappearingred,purpleor black ■ Systemicsymptomsinclude:highfever,chills,swollenlymph glands,malaiseInvestigating and treating eczema herpeticum ■ The diagnosis is usually clinical ■ Clinical appearance may not always be used such as if there is an additional bacterial infection or concurrent severe eczema flare-up ■ A viral and bacterial swab from one of the blisters may be taken to confirm the infection ■ Treatment is usually with antiviral medications: such as aciclovir in a liquid or tablet form. In those severelyunwell: can be IV ■ Damage to the skin may lead to infection by bacteria which is normally harmless on the skin (secondary bacterial infection): thus an antibiotic may be needed ■ Someone with EH should avoid contact with: those with atopic eczema, the immunosuppressed and newborn babiesCellulitis ■ Cellulitis is an infection of the dermis layerof the skin and subcutaneous tissue ■ Cellulitis can occuranywhere but is morecommon in the limb ■ It is most commonly caused by staphylococcusaureus ■ Featuresinclude: 1. Warm, erythematous, painful affected skinarea 2. Blisters 3. Local lymphadenopathyInvestigating cellulitis ■ Blood tests:check for raised inflammatorymarkers ■ Cultures from thesites of original entry ofinfection; including skin breaks ■ Culturing fluids from bullae, frank pus or abscesses ■ Imaging if underlying bone thoughttobe involved:X-ray, MRI or CTManaging cellulitis ■ Limb elevation,analgesia and antipyretics are oftenused ■ Flucoxacillinis used to treat the infection ■ Flucoxacillin& benzylpenicillinin the case of severe cellulitis ■ Penicillinallergies = substitutewith clarithromycinor clindamycin ■ Hospital admissions if there are comorbidities and systemicupset