Philippine Dermatological Society
Rm. 1015 South Tower, Cathedral Heights Building St. Lukes Medical Center, E. Rodriguez Sr. Ave., Quezon City Email: pds_org@pldtdsl.net Website: http://www.pds.org.ph Telephone No: 727-7309; 723-0101 loc. 2015
Officers & Board of Trustees
President		Arnelfa C. Paliza, MD
Vice President		Georgina C. Pastorfide, MD
Secretary		Donna Marie L. Sarrosa, MD
Treasurer		Maria Luz G. Aquino, MD
Board Members		Marcellano S. Cruz, MD Ma. Victoria C. Dizon, MD Lonabel A. Encarnacion, MD Ma. Teresita G. Gabriel, MD Daisy K. Ismael, MD Rosalina E. Nadela, MD Socouer M. Oblepias, MD Eugenio B. Reyes, MD
Immediate Past President		Ma. Lorna F. Frez, MD

Cutaneouos Bacterial Infections

Treatment Guidelines on Common Primary Cutaneous Bacterial Infections

Impetigo

Impetigo contagiosa is a common superficial bacterial infection caused by Streptococcus and Staphylococcus sp. or a combination of both bacteria.

While it is more common in children, it may occur at any age.

Bullous and non-bullous impetigo represent two clinical forms.

It presents clinically as thin-roofed bullae or more commonly ruptured vesicles/bullae which expose a red, moist base covered by honey-colored crusts with a “stuck-on appearance”, usually on the face and other exposed areas.

Prevention
• Antibacterial cleansers
• Screen and treat family members with impetigo

Treatment
For limited local infections:
• Mupirocin 2% or fusidic acid ointment or cream is to be applied 2- 3x a day for 7-10 days.

Updated!
• May soak the lesions TID in warm water or saline solution to remove the crusts

Organism	Drug of Choice	Alternative
Group A Strep	Penicillin Benzathine PCN ≤6 years old 600,000 units, IM >7 years old 1.2M units	Erythromycin Cefalexin
Staphylococcus aureusq (children)	Cloxacillin/Dicloxacillin 250 mg QID	Cefalexin 40-50 mg/kg
Grp A Strep & S. aureus	Erythromycin 40 mg/kg/day (children)	Clarithromycin Azithromycin Clindamycin 15 mg/kg/day (children)
MRSA (Methicillin Resistant Staphylococcus Aureus)	Minocycline Sodium fusidate 250-500 mg/tab, BID or TID	Cotrimoxazole Ciprofloxacin

For widespread infections:

Updated!
• Recurrent disease maybe secondary to the colonization of Staphylococcus aureus in the nares. Mupirocin cream or ointment maybe applied BID to the anterior nares

• A penicillinase resistant systemic antibiotic such as cloxacillin 250 mg, cefalexin 250 mg 4x a day or sodium fusidate 250-500 mg BID may be prescribed. See table for other drugs.

Ecthyma

Ecthyma is a deeper bacterial infection characterized by an ulcerative staphylococcal or streptococcal pyo­derma, nearly always of the shins or dorsal feet.

Ecthyma is characterized by a saucer-shaped ulcer with a raw base and elevated edges. Lesions usually heal with scarring.

Treatment
• Cleansing with soap and water, followed by app­li­cation of mupirocin, bacitracin, or fusidic acid cream or ointment, 2-3x a day.
• Cloxacillin or a first-generation cephalosporin must be given systemically

Folliculitis

The common folliculitis is a staphylococcal infection involving the superficial portion of the follicular duct and presents with perifollicular red papules or pustules eventually with crust formation. Tenderness may be present.

Distribution is variable; often the scalp, arms, legs, axillae and trunk are involved.

Treatment
• Heat, friction and occlusion should be avoided or minimized.
• Antibacterial soap and topical antibiotics like mupi­rocin or fusidic acid are effective in limited areas of involvement.
• Oral antistaphylococcal antibiotics (oxacillin, clo­xa­cillin, cefuroxime, sodium fusidate are indi­cated for extensive cases.)

Furuncles & Carbuncles

A furuncle (boil) is a walled-off, deep, painful, fluctuant mass enclosing a collection of pus, often evolving from staphylococcal folliculitis.

A carbuncle is an extremely painful, deep, interconnec­ted aggregate of infected follicles (coalescing furuncles).

Treatment
• Warm, moist compresses are applied 15 to 30 mi­nutes several times a day.
• Oral anti-staphylococcal antibiotics for at least 7 days should be given
• Drainage is the primary management for fluc­tuant lesions.
• Nasal carriage of Staphylococcus aureus is era­dicated by mupirocin 2% cream or fusidic acid cream applied to the anterior nares BID for 5 days. For persistent colo­nization, rifampicin 600 mg once a day and cloxa­cillin 500 mg four times a day, for 7 to 10 days is prescribed.

Cellulitis

Cellulitis is an infection of the dermis and subcutaneous tissue characterized by red, hot, tender and painful plaque with an ill defined border.

In adults and children this is most often caused by Group A ß-hemolytic Streptococcus and Staphylococcus aureus.

Facial, periorbital, head and neck involvement in chil­dren less than 2 years old is most commonly caused by H. influenza.

Treatment
• Warm compresses and analgesics to relieve pain.
• Elevation of an involved extremity hastens reco­very.
• Empiric treatment with antibiotics aimed at Staphy­lococcal and Streptococcal organisms is appropriate.
• Ampicillin for children because it has coverage for H. influenza.
• Hib immunization in children has dramatically reduced the incidence of cellulitis in children less than 2 years old.
• Hib serves as chemoprophylaxis of household mem­bers in patients less than 4 years old who are un­immunized.

Erysipelas

Erysipelas is an acute inflammatory form of cellulitis with prominent lymphatic involvement

More superficial involvement with margins that are more clearly demarcated from normal skin.

Prodromal symptoms consist of malaise, chills, fever and occasionally, anorexia and vomiting.

Treatment
• Penicillin V orally (20 to 50 mg 4x a day) is the drug of choice. Erythromycin can also be used.
• Azithromycin 500 mg on day 1 and 250 mg on days 2 to 5, or clarithromycin 250 to 500 mg every 12 hours for 7 to 14 days are alternatives for patients who cannot take penicillin.

Paronychia

Paronychia is an inflammatory reaction involving the folds of the skin surrounding the nail.

Paronychia is characterized by acute or chronic purulent, tender, and painful swellings of the tissues around the nail usually of the fingers.

Causative bacteria are usually Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas, Proteus sp or anaerobes.

Treatment
• Protection against trauma. Cover with a bandage or dressing.
• Incision and drainage should be done on acutely inflamed abscesses.
• For acute suppurative paronychia due to S. aureus, a semisynthetic penicillin or a first-generation cephalos­porin maybe given orally. Sodium fusidate tablet 250-500 mg BID or TID is also effective.

Erythrasma

Erythrasma is a chronic, bacterial infection caused by Corynebacterium minutissimum. It affects the inter­triginous areas like the groin, axillae and occasionally the toes.

Present as sharply marginated, brownish-red, scaling patches on affected areas.

Predisposing factors include diabetes, warm, humid climate and prolonged occlusion of the skin.

Treatment
• Antibacterial cleanser
• Benzoyl peroxide (2.5%) gel daily for 7 days or topical erythromycin solution BID for 7 days. Topical azoles are also effective.
• Systemic antibiotic therapy using erythromycin or tetracycline 250 mg QID for 7 days is prescribed in resistant cases.

Characteristics of an ideal antibacterial agent for common skin infections:

1. Should have activity against Staph. aureus (inclu­ding methicillin-resistant strains) and Strepto­coccus.
2. Low resistance rates
3. Low sensitizing potential
3. No cross sensitivity with other antibiotics
4. Excellent pharmacokinetics

Protective device for wound healing

Protect the wound from further damage, such as contact with dirt, soil or insects, by applying protective gauze or dressing. Dressings may also help reduce odor and help absorption of moisture especially in highly exu­dative lesions. Wound dressings are also beneficial in improving the appearance of wound site and may even help promote the functional use of the affected part.

As a further precaution, dressings must be changed frequently and disposed immediately.