Bacterial skin infections or pyodermae are a group of diseases, caused by

microorganisms inducing purulent inflammation of skin.

TRAINING AND EDUCATIONAL PURPOSES

• To determine the ways and possible conditions of infection by

pyogenic flora
• To generalize classification and general characteristics of pyogenic
lesions of skin and mucous membranes
• To explain the role of different factors promoting its development
• To determine the general course and clinic of pyoderma
• To distinguish peculiarities of pyogenic lesions of mucous
membranes
• To distinguish characteristic clinical peculiarities of staphyloderma
• To classify typical manifestations of streptoderma
• To define the principles of therapy and prophylaxis of pyogenic
lesions

TO KNOW:
 modem views on etiology and pathogenesis of different clinical types of
pyoderma;

 factors promoting developments and progression of pyoderma;

 principle of classification of impetiginous lesions of skin and its

appendages;

 symptomatology of the main clinical types of pyoderma;

 the main approaches to the general and local treatment of pyoderma;

 the peculiarities of preventive measures of impetiginous lesions of the skin and

its appendages.

TO BE ABLE TO:

 correctly collect anamnesis and carry out examination of the patient with
pyoderma;
  run diagnostic tests and use additional examination methods, which
confirm the diagnosis;

 make a differential diagnostics with the diseases with the similar

clinical presentation picture;

 make a plan of recommendations for treatment and prophylaxis of

pyoderma patients.

Content topics

Epidemiology. In economically developed countries the patients with pyoderma

compose 1/3 of patients, suffering from infectious diseases. The morbidity rate in
children is higher than in adults, it composes 25-60% of the total number of cases of
dermatoses. Pyoderma is the most common among the worker of such industries as
metalworking, metal mining, coal mining, timber manufacturing, transportation, and
various branches of agriculture as well.
Etiology. Most frequently the agents of pyoderma are staphylococcus and
streptococcus. Different types of pustular skin diseases can occur initially as separate
nosologic entities or as a complication of other dermatoses (scabies, eczema, atopic
dermatitis etc.). Staphylococci under the microscope have got rather correct round shape
(their accumulations are often similar to a bunch of grapes) with a diameter of about 0.8-
0.9 microns. The most virulent is Staphylococcus aureus. Staphylococci are also
presented in form of spherical formations, joining in long chains. The diameter of one
coccus varies from 0.5 to 1 micron. Pycocci occur on the skin in the form of avirulent
microorganisms in 90-92% of healthy people, and it is possible to detect their
pathogenic forms only in 8-10% of population. Saprophytes can acquire
pathogenicity under certain conditions and their virulence can increase under the
action of alkaline reaction of the skin or in case of joining of other agents, such as
fungi. In case of Gram-stained pus smear, both staphylococci and streptococci are well
stained in blue that means they are Gram-positive. The toxins, released by pyococcy,
are highly toxic and are capable to lyse erythrocytes, leukocytes.
 Pathonesis. Virulence of pyococci plays an important role in the occurrence of
pyoderma. A number of factors, such as the acid reaction of the horny layer of
epidermis, sebaceous glands, enzymatic activity of the skin etc., counteract the
increased virulence of staphylococci and streptococci. A number of exogenous and
endogenous factors contribute to the development of pustular lesions of skin. The
most frequent exogenous factors include the excessive skin contamination with
gasoline, oil, dust particles (coal, cement and other), micro injuries (insect bites,
excoriations, needlesticks and other), maceration of homy layer (long dish-washing,
doing laundry), hypothermia and hyperthermia.
The endogenous factors, contributing to the development of pyoderma, are low-
calorie food, hypovitaminosis, chronic debilitating diseases, intoxications (alcoholism,
narcomania), physical and nervous strains, diabetes, immunodeficiency etc.
There is no innate immunity against the pyococcus infections, but unstable infectious
immunity can appear in the course of pyoderma, the intensity of which varies in wide
range. The frequent for pustular diseases are the allergic reactions appearing in the result
of sensitization to metabolic products of their agents, whereof the positive
intracutaneous tests with the corresponding allergens (vaccines) indirectly testify.
The character of pyoderma development in clinical respect depends on the place
of influence of agent. Staphylococci more often affect hair follicles, whereas
streptococci mainly parasitize on the smooth skin. Favorite localization of panaritium,
for example, is periungual walls, of ectymas is shins, furuncles and carbuncles are
more common on the buttocks, lower back etc.
Besides pyococci, the pustular skin lesions can be caused also by collibacillus,
proteus vulgaris, fungi, pseudomonas aeruginosa, pneumococci etc.
Depending on the agent, pyodermae are divided into staphylococcus,
streptococcus and mixed; depending on the deepness of lesion they can be superficial
and deep, on the character of the course they are acute and chronic, on the origin they
are primary and secondary.

Staphylococcal skin infections

 Staphylodermae are characterized by the development of inflammatory
process, mainly in the area of appendages location, such as cutaneous and hair
follicles, sebaceous and sweat glands. As a rule, a hair or opening of sebaceous gland
is in the center of pustules. Much less frequently, staphylococci cause the lesions of
the surface layers the smooth skin that is mainly observed in children. Newborns and
infants have got the connection of epidermis with derma insufficiently developed due
to the weakness of the basal membrane and dermal papillae smoothness that is why
during the staphylococci penetration, the morphological elements such as bubbles and
phlyctenas develop.

The following forms of staphylodermae are distinguished; these are surface -

ostiofolliculitis and deep - folliculitis, furuncle, carbuncle, hydradenitis, sycosis,
vesicle-pustulosis in children, neonatal impetigo, multiple abscesses of children
(pseudofurunculosis), exfoliative dermatitis, and neonatal bullous impetigo.
Ostiofolliculitis is characterized by the appearance of small pustule with the size
of grain of millet or pinhead, of greenish-yellow or milky-white colour, of spherical
shape, surrounded by acute inflammatory hyperemic circle. A pustule is localized in
hair follicle and pierced with unaltered hair in the center. The accumulation of pustules
is observed in a small area of skin; they do not increase due to peripheral enlargement
and do not merge. The process is most often localized on the skin of face, neck,
forearms, lower legs, hips. The patients feel little itching. The pustules shrivel forming
greyish-yellow crusts in 4-8 days. After crusts falling, insignificant pigmentation
remains on the skin, which soon disappears. Ostiofolliculitis appear under the
influence of minor skin irritations such as shaving, friction, maceration due to
excessive sweating.
In some cases, certain ostiofolliculitis can grow at periphery or deathward,
becoming deep folliculitis, furuncles and carbuncles. Growing at periphery
ostiofolliculitis eventually reaches the size of a pea, especially in children and
scabies patients with wrists lesion. These ostiofolliculitis are called BockharVs
impetigo.
 The diagnosis of ostiofolliculitis is set in presence of small tight conical pustules, in
their center pierced with a hair and surrounded by hyperemic circle.
Hystologically, a small cavity, bounded above by the horny layer, and bounded
below by the callous cells of epidermis, is located in the ostium of the hair follicle. The
cavity is filled by the conglomerate mass of polymorphonuclear leukocytes, some
lymphocytes, and staphylococci as well. An edema appears around the hair follicle in
the derma and capillaries broaden, around which perivascular infiltrate from lymphoid
and polymorphonuclear cells is observed.
For the treatment of ostiofolliculitis, the pustule is pierced with a sterile needle, the
tectum and pus is removed, the affected areas are anointed by the 1-2% alcohol
solutions of aniline dyes (methylene blue, brilliant green, Castellani liquid). After that
the skin is wiped with 2% salicylic or boric spirits and sprinkled with 5-10% of boric
powder. With large crusts the affected surface is salved with antibiotic ointments
(Fusiderm, Bactroban, Altargo, neomycin, tetracycline, and erythromycin). The
topical application of Zineryt lotion (erythromycin zinc complex), OXI, Ugrinum
lotions, and Diacneal cream is also effective.
Profound folliculitis (folliculitis profunda) is a purulent inflammation of the
entire hair follicle and the adjacent adipose tissue, arising in the result of pathogenic
staphylococci penetration in the depth of follicle. Initially a painful red papule (nud)
of size from a pea to a cherry appears on the skin around the ostium of hair follicle.
A hair is located in the center of a papule. In a few days, the papules tauten,
becoming a follicular pustule of conic form with base induration. A pustule dries out
after some time forming the crust, in some cases connective tissue necrosis and
intense suppuration can occur. A pustule in the center ulcerates gathering to matter
of greenish-yellow or white colour. Profound folliculitis remains pigmented scar.
The reasons for the appearance of profound folliculitis are the same as for
ostiofolliculitis.
 Hystologically, in profound folliculitis there is infiltrate consisting of neutrophils and
lymphocytes around the hair follicle. A hair follicle melts itself, and a cavity filled with matter,
forms in its place.
The treatment of folliculitis is the same as of ostiofolliculitis.
Furuncle (furunculus) is acute purulonecrotic inflammation of hair follicle and
its surrounding connective tissue, caused by pathogenic staphylococci. A furuncle develops
in the presence of low immunological reactivity of organism. The contributing factors in furuncle
appearing are the cutaneous injuries, scratching of allegrodermatosis, catarrhal and
infectious diseases, vitamin deficiencies, hypothermia and other. A typical localization of
furuncle is the areas of friction between skin and clothes, such as neck, lower back and
buttocks.
The symptoms of furuncle develop gradually. In the majority cases, the process
develops in the setting of ostiofolliculitis, which spreading depthward, leads to the
formation of the node of acute inflammatory character. During the period of 5 to 7
days the furuncle becomes soft in the center, the fluctuation appears. The infiltrate
ulcerates discharging matter prolifically. In the center of the burst there appears
necrotic tissue of green colour (necrotic core). After its separation there is a deep
crater-like ulcer. The ulcer bottom is covered with granulations, gradually discharging
from the matter, thus the ulcer cicatrizes.
The development of the furuncle is accompanied by the pains and burning
sensation, and sometimes high temperature.
In the case of relapses of furuncle several times in different places they say about
the chronic furunculosis. The development of furunculosis is promoted by the
dysfunction of internal organs and nerve system, depletion of immunological reactivity,
anemia, diabetes, infectious diseases, hypo and avitaminosis, the presence of chronic
foci of infection, the use of corticosteroids and other. In children the furunculosis
develops with gastro-intestinal disorders, hypotrophy, and rickets.
 The typical clinical picture is a massive infiltration, conical shape, redness, pain,
the presence of a hair and necrotic core in the center enables quite easy to set a
diagnosis of furuncle.
Hystologically, a massive infiltration, consisting of polymorphonuclear leukocytes,
lymphocytes, fibroblasts and a small number of plasma cells, forms in derma and
subcutaneous fat. Collagen and elastic fibers break down completely with hair follicle.
In the focus of lesion, a massive argentophil grid appears which forms the membrane,
impeding penetration of infection from the focus into the patient organism.
In the treatment the skin around the furuncle is disinfected with alcohol or ether,
after that a hair is pulled out gently from the center of infiltrate with a sterile forceps, pure
ichthyol is put on the furuncle, covering it with a thin layer of cotton wool. The
procedure is repeated twice a day, until in the center of the follicle the opening
forms, on which the gauze folded in several times and moistened with hypertonic solution
of sodium chloride is put. After discharge of the core, the ointment with antimicrobial
effect and stimulating tissue regeneration is
applied, such as (Fusiderm, Bactroban), and skin around the furuncle is
wiped with 2% boric and salicylic spirits.
In the case of multiple furuncles, furuncles in the area of face, hairy part of the
head, as well as chronic relapsing furunculosis, antibiotic therapy should be applied in
order to prevent the occurrence of septicophlebitis of cerebral vessels and general
sepsis. Currently, it is recommended to use the broad spectrum antibiotics from the
group of cephalosporins, tetracyclines, macrolides etc. in adequate doses during 7 to
10 days with an obligatory determination of pyococcus sensitivity to antibiotics. In
severe cases the antibiotics are administrated parenterally. Concurrently
antihistamines, such as suprastin, cetrine, claritine, aerius etc. are prescribed.
Carbuncle (carbunculus) represents a severe inflammatory process, covering
several hair follicles, sebaceous glands and subcutaneous fat. As a rule, a carbuncle
develops in the result of dissemination of purulent process with numerous profound
folliculitis or in conjugating of close furuncles that leads to extensive skin necrosis.
Carbuncle is caused by the pathogenic stains of staphylococci.
Endogenous factors first of all play an important role in the development of
carbuncles.
The general condition of the carbuncle patient is usually compromised, there is
high temperature, headache etc.
Carbuncles are most often localized on the skin of hindhead, back, lumbus, i.e. in
the places of friction and irritation of the skin and its frequent pollution.
At the beginning of the process there are several openings on the skin surface
above infiltrate, and infiltrate is surrounded by edema. After the cores separation and
intense discharging of matter, mixed with blood, necrotic mass of green colour can be
seen on the infiltration site. After purification of the openings from the necrotic masses,
there appear deep ulcers, sometimes reaching up to fasciae or muscles. In the result of
filling the ulcers with granulations, their cicatrization occurs, and the process ends with
formation of retracted stellar scars.
In advanced age, as well as with exhaustion, neuropsychic defatigation and
diabetes, the course of the disease acquires malignancy, neuralgic pains and
deliration appear and sepsis and erysipelatous inflammation can occur.
Hystologically, in carbuncle there is deep necrosis of all layers of derma and subcutaneous fat.
Around the necrotic area there is a massive infiltrate, consisting of neutrophils and a small
number of lymphocytes.
Carbuncle treatment requires an obligatory use of antibiotics and other systemic
drugs, so as in treatment of severe forms of furuncle and chronic furunculosis. A
topical treatment is the same as in furuncle.
Hydratenitis is a purulent inflammation of apocrine sweat glands, located in
axillary cavities, on labia majora, mammillae, anal area. It is caused predominantly by
staphylococcus aureus. The contributing factor of development of hydratenitis is
excessive sweating in axillary folds and perineum, consumption as a result of
hypotrophy, infectious, nervous and endocrine diseases. From the external factors,
the significant are excessive contamination of skin, microtraumas and cuts resulting
from shaving hair in the axillary cavities.
Hydratenitis in children is observed only in senior age, when apocrine sweat
glands attain full growth and begin to function (period of puberty).
Hydratenitis develops gradually. At the beginning the feeling of discomfort and
insignificant soreness appear at the sites of localization of apocrine glands. The skin is
not changed, and in palpation it is possible to detect small indurated formations. Later
the skin at the affected sites becomes red, painful pea-sized nodes begin to extrude,
which rapidly increasing reach the size of pigeon egg. Sometimes separate nodes can
merge. In one to two days the nodes acquire soft consistency and are perforated with
formation of openings, from which a large amount of matter is discharged. Gradually,
the abscess cavity is filled with granulations, and the process ends with formation of
retracted scar.
Maturation of hydratenitis is accompanied by high temperature, severe pains and
general weakness. Disease can become chronic, when new nodes are developing one
by one. The relapses are especially frequent in people with heavily pronounced
sweating, insufficiently observing hygiene. The relapses occur mainly in summer in hot
period.
Hystologically, the pathological process in hydratenitis develops in the deep layers
of the skin around the body and excretory ducts of apocrine gland, where there is an
infiltrate from neutrophilic leukocytes and purulent fusion of sweat gland. The profound
destructive changes of vessels occur in the center of necrosis.
The disease is so typical by localization and clinical picture, that the diagnosis is
set without much difficulty.
The treatment does not differ numerous furuncle, furunculosis and carbuncle; it
includes timely application of antibiotics, immunomodulatory, local and symptomatic agents.
 Sycosis (sycosis vulgaris, sycosis simplex, sycosis staphylogenes) is a chronic
staphylococcal skin lesion of face in the area of beard and mustache. Sycosis is
observed almost exclusively in men. It can rather rare affect also internal surface of
nose, eyebrows and pubic area. It is characterized by chronic course, relapsing
eruptions of ostiofollicular pustules on the indicated areas of the skin. Contributing
factors in the development of sycosis are integrity violation of epidermis, chronic
rhinitis, nervous and endocrine diseases, in the first place, hypofunction of testes.
The development of sycosis begins with the appearance on the skin in the area of
beard and mustache of small pustules the size of a millet grain, placed in the follicle
ostium. In a few days, the purulent process affects the entire hair follicle (profound
folliculitis). Gradually the skin of the affected site infiltrates, gets bluish discoloration, is
covered with mixed crusts, swells. The site of the lesion focus enlarges peripherally
due to the formation of new folliculitis. When pressing on the infiltrate, droplets of
yellow green pus are discharged from the extended hair follicles. After dropout of crusts, at the
sites of lesions small erosions and ulcers appear, from which seropurulent liquid is
released. The general state of health of sycosis patients is not altered, sometimes the
patients can complain about light itching, burning sensation and insignificant sickliness.
Prolong course of the disease and its localization on the open skin area sometimes
leads to oppression of mental state of patients.
Sycosis is rather easy to diagnose on basis of typical localization of lesion areas,
chronic course, and presence of infiltrate with follicular pustules. Parasitic sycosis
(profound barber's rash) differs by more severe course; the pathogenic fungi are
detected during laboratory testing. Hystologically, in the area of hair follicle, the abscesses
appear, filled with matter, the infiltrate consists of polymorphonuclear leukocytes and
fibroblasts, a small number of lymphocytes and plasma cells. The edema, degeneration of hair
follicle and surrounding connective tissue is observed in epidermis and derma.
 In the acute period of sycosis development the broad spectrum antibiotics are
administrated, including tetracyclines or macrolides (azithromycin, doxycyclinum,
tetracyclinum etc.).
The topical therapy of sycosis should be started with removal of all crusts from the
surface under purulent process, by softening them with plant oil, then the lotions of 1 %
solution of resorcinol, 0.1 % solution of rivanol or furacilin are put on. The affected
hairs are tweezed, and the surrounding tissues are wiped daily with 70% ethyl alcohol.
Later, the antibiotic and corticosteroid ointments are applied (Fusiderm, Oxycortum,
Betaderm, Bactroban).
Vesiculopustulosis in children is a widespread purulent disease, which
appears in the first years of life. In the ostium of the sweat glands numerous pustules
appear, filled with white yellow matter, the size of a pin head to a small pea, they do
not merge with each other and are surrounded by bright edematous circle.
Vesiculopustulosis is localized at the sites of the greatest sweating and skin
maceration. Premature infants of asthenic constitution mainly suffer from disease.
Diagnosis is set on grounds of typical clinical presentation and process
localization. The disease should be differentiated from scabies, in which the
papulovesicles are paired.
Epidemic neonatal pemphigus (pemphigus neonatorum epidemicus) is a cute
infectious disease, differentiating from other pyodermae by very high contagiousness.
Often the infection is transmitted to children from the adults (especially from medical
personnel), suffering from pyodermae or quinsy, or through household articles. Sometimes, there
are epidemic outbreaks of neonatal pemphius in maternity hospitals or day nursery.
The disease appears in 7-10 days after the birth. In the setting of erythematous
patches, the blisters the size of pea are forming, filled with serous contents, they are rapidly
increasing in the periphery, reaching the size of nut and becoming less stressed. The content
changes from serous into purulent.
 The blisters can be placed over the entire the skin cover, especially often on the
abdomen near the umbilicus, on the buttocks, hips, back, chest and extremities. They rather
quickly go into wet erosions, on the periphery of which the remains of blisters i.e. scraps of
epidermis overhang. Drying up, the erosions do not leave crusts and regress with the
formation of pink-brown pigment spots without scars.
The general condition of the patients is not altered; the disease mostly lasts 4 to 5 weeks.
The process in weakened children can rapidly spread, covering new skin areas by
autoinoculation (infection transmission from affected skin areas to the health). Children
condition significantly worsens, the temperature rises up to 38- 39°C, dyspeptic
phenomena join. As concerns blood there are leucocytosis, eosinophilia, increased
ESR. In some cases the disease can be complicated by conjunctivitis, otitis and even
sepsis that sometimes lead to the death of a child.
Exfoliative dermatitis (dermatitis exfoliativa) presents especially severe form of
epidemic neonatal pemphigus. The disease begins with prodromes, such as nausea
and temperature rise. Bright erythema appears in the folds of skin, around the mouth,
umbilicus, anus and genitalia. In the setting of erythema there appear rather big tense
blisters, which rapidly erode. In exfoliative dermatitis the positive Nikolsky's sign is
observed, i.e. in case of friction of skin at the visible-healthy sites, it flakes off, forming
the erosions; when pulling the scraps of blister with the tweezers, the epidermis
exfoliates on the surrounding skin areas (the presence of acantholysis). The disease is
accompanied by high temperature, dyspeptic phenomena. For several days, the
process affects the entire skin cover, and sepsis develops, often with fatal outcome.
The diagnosis of epidemic neonatal pemphigus is set on the basis of appearance in
children on erythematous acute inflammatory background of stressed blisters, which
rapidly erode. The disease is necessary to differentiate mainly from syphilitic neonatal
pemphigus and congenital epidermolysis bullosa. Both of these diseases are already
observed at childbirth, when epidemic neonatal pemphigus develops only on the 7 th to
10th day after the birth. In case of syphilitic pemphigus, the blisters affect the skin of
palms and feet, which is not observed in case of epidemic pemphigus. In case of
congenital syphilis in children it is possible to observe at one time syphilitic rhinitis,
diffuse popular infiltration of Hochsinger, osteochondritis, and in the process of
microscopy of blisters content in the dark field of view there are a large number of
causative agents of syphilis such as pale treponems, classic serological reactions of
blood, treponemal immobilization test and fluorescent antibody test are strong
positive. Congenital epidermolysis bullosa is characterized by intrauterine appearance
of blisters, which occur most frequently at the sites of birth injuries, such as hairy part
of the head, buttocks, upper and lower extremities.
The treatment of epidemic neonatal pemphigus involves high-priority
administration of antibiotic therapy in order to prevent complications and
development of sepsis.
Multiple abscesses in children (abscessus multiplex infantum), or
pseudofurunculosis, is observed in neonates and infants. The disease begins with
the appearance of superficial pustules in the ostium of sweat glands (periporihis). The agent is
staphylococcus aureus, which penetrates in the depth of the sweat gland and
causes the forming of deep indurated painful nodules. The skin over the nodules is not altered at the
beginning, but soon it acquires reddish-brown color. The nodules the size of a pea to a nut
soon suppurate and dense yellowish-green matter is discharged onto the surface of the skin. The
nodules are very similar to furuncles, but they have not got core in the center (hence the name
pseudofiirunculosis) and are not connected with pilosebaceous apparatus. Multiple nodules are
located on the trunk, hairy part of the head, buttocks, lower and upper extremities. After
discharge of a matter, the process ends with cicatrization.
The course of the disease is rather soft, often relapses, is accompanied by high
temperature, leukocytosis, increased ESR, and can be complicated with phlegmon,
septicemia.
 In the pathogenesis of multiple abscesses appearance a significant role is played by
unhygienic maintenance of children, increased sweating, malnutrition, the presence of dyspepsia
and enteritis, rickets, tuberculosis and other infectious diseases.
The diagnosis is set on grounds of appearance in children of persistent recurrent
abscesses not connected with hair follicles and sebaceous glands.
Hystologically, the appearance of purulent abscesses, connected with sweat glands
and their ducts, are observed in derma and subcutaneous fat.
The treatment includes the administration of antibiotic injections. Topically,
unmixed ichthyol is applied at the affected sites or the abscess is pierced with a sterile needle after
skin disinfection with the following anointment by alcoholic solutions of aniline dyes. After
ulceration the antibiotic ointments are applied at these sites.
Bullous impetigo (impetigo bullosa) is referred by one authors to streptoderma, and the
others to the pyoderma, caused by staphylococci (benign form of staphyloderma).
Clinically, the disease is characterized by the appearance of blisters or phlyctenas the size of a pea to a
pigeon's egg, filled with serous nebulous liquid or matter. The elements are not stressed; they are
surrounded with hyperemic circle, and quickly erode. The erosions with wet surfaces can enlarge
at periphery; they are surrounded with the scraps of epidermis. Bullous impetigo is localized on
the trunk, back of the hands, less often on the feet and lower legs. The course of the disease is
benign; the general state of the children is satisfactory. The treatment consists of anointment
of erosions with the alcoholic solutions of aniline dyes and antibiotic ointments.
Streptococcal infections of skin – streptoderma
Streptoderma are caused by streptococci, which unlike staphylococci, do not affect
pilosebaceous apparatus and sweat glands and do not infect derma and subcutaneous
fat with the following development of necrosis. Streptococci mainly cover the smooth skin,
and the diseases caused by them are of superficial character and in majority of cases manifest
as elements in the form of blisters or phlyctenas, filled with clear or slightly nebulous
contents. Most frequently, streptodermae are observed in women and children due to the fact
that their skin is more delicate.
 The following forms of streptodermae are distinguished, these are streptococcal
impetigo, streptococcal intertrigo, syphiloid papular impetigo, superficial panaritium, perleche,
lichen simplex, ecthyma vulgaris, and superficial chronic diffuse streptoderma.
Streptococcal impetigo (impetigo streptogenes) is caused by streptococcus and
localized mainly on the face, extremities, sometimes on the trunk. In the pathogenesis of
streptococcal impetigo the skin injuries are of certain importance, as well as its unhygienic
conditions, metabolic disorder, reduced immunological reactivity. Impetigo is
especially common in children.
The blisters or phlyctenas with the size of a pea to a nut, not stressed and filled with
serous or slightly nebulous liquid appear on the hyperemic, lightly swollen skin, and rapidly
increase in size. There is a hyperemic circle on the periphery of phlyctenas.
Phlyctenas quickly erode (during the period of several hours) and are covered with
thin straw-yellow crust. After the falling of crust away, the pink spot remains and after
some time it disappears without any trace. A patient suffers from itching, which sometimes
can become intense. In some cases regional lymphadenitis can develop. Phlyctenas are located
independently, but sometimes they can merge due to peripheral growth, forming arcs, rings,
garlands (ring-shaped impetigo). Streptococcal impetigo has benign course and it ends in full
recovery after 7-8 days.
Intertriginous streptoderma, or streptococcal inertrigo (intertrigo
streptogenes) is mostly observed in children, especially overfed children, with excessive
sweating and gastrointestinal disorders. In the pathogenesis of the disease the dermatoses,
accompanied by itching, and diabetes are also important. Intertriginous streptoderma is
localized in the skin folds, such as inguinal-scrotal, gluteal, in axillary cavities, behind the
ears, under the breasts in women, and in the folds of the abdomen in obese people. This
disease is characterized by the appearance of erosive wet surface of bright pink colour,
strictly bounded from the adjacent skin and surrounded by epidermal collarette. In the depth
of the folds the bleeding folds appear. Subjectively, the patients notice itching and burning
sensation. It is possible to notice at the close skin sites the pustules at different stages of
development. The disease has long-term course.
Syphiloid papulose impetigo (impetigo papulata syphiloides) develops
predominantly in infants and is localized on the buttocks, posterior surface of femora and lower
legs. On the hyperemic surface the phlyctenas appear, at the base of which there is papulous
infiltrate. Phlyctenas erode very quickly, leaving erosive papules. Clinically the disease is
analogous to papulo-erosive syphilide. For differential diagnostics it is necessary to
carry out the analysis of erosion discharge for the presence of treponema pallidum, and
serological study of the patient as well.
Hystologically, in all forms of streptococcal impetigo there is formation of cavity under the
homy layer of epidermis. The cavity is filled with serous exudate with some amount of
neutrophilic leukocytes and separate epithelial cells. Spongiosis occurs in the spinous layer of
epidermis. Vascular distention with perivascular infiltrate, consisting of neutrophils
and lymphocytes, occurs in derma.
Superficial panaritium, is predominantly observed in adults. The phlyctenas
appears on the hands around the nail plates, which contain at the beginning serous,
and then nebulous purulent discharge. The disease is associated with injuries of the fingers,
burrs, which create favorable conditions for the penetration of streptococci. The affected
phalanx of a finger swells and hurts.
After breaking of phlyctena there appears erosion, covering the nail wall like
horseshoe. The process can lead to the rejection of nail plate. Sometimes there are
lymphangitis, general uneasiness and fever.
Angular impetigo (angulus infectiosus) is characterized by the appearance of linear
phlyctenas at the corners of the mouth, which quickly erode, and the cracks appear on their
place, which are especially painful when the mouth is opened. The disease can be localized
in the corners of the eyes, in the places of adhesion of ear conches. On the skin around the
crack of the angle of mouth there appear melichrous crusts, and maceration of epidermis on
the edges of the cracks. The contributing factors to the perleches development are
frequent lips licking, dental prostheses wearing, i.e. maceration of the corners of the mouth
sites with saliva. The patients complain about itch, pain while eating.
Angular impetigo should be differentiated with yeast affection of the corners of mouth,
in case of which the process is not so vivid and there are no crusts. It must be taken into
account the possibility of affection of the corners of mouth with erosive syphilitic
papules, which certainly are based on tight elastic infiltrate; eruptions of syphilides
are observed on the other parts of the body, as well as positive serological
reactions.
The treatment of different forms of impetigo, and angular impetigo is generally
external. In the case of presence of crusts the ointments with disinfectants or
antibiotics are applied.
On the erosive wet surfaces the lotions with disinfectants (0,25% solution of silver nitrate,
2% solution of resorcinol etc.) are applied. The healthy skin around the lesion foci is regularly
wiped with the 2% salicyl alcohol in order to prevent autoinoculation of infection. At the same
time, it is necessary to treat the diseases, which cause the appearance of streptoderma, and
eliminate the promoting factors.

Ecthyma vulgaris (ecthyma vulgare) refers to profound pyodermae, caused by

streptococcus, though there are a number of publications, which indicate that ecthyma
can be of staphylococcal etiology as well. Micro injuries and excoriations contribute to the
penetration of the agents from the external environment. Nervous and mental stresses,
diseases of liver and blood (anemia, leucosis), diabetes, thrombophlebitis, vasculitis,
vitamin deficiency etc. are of certain importance in the pathogenesis of the disease is
played.
The disease develops gradually, beginning from the appearance on the skin of usual
phlyctena the size of pea to a nut, filled with serous contents, which later acquire mattery
hemorrhagic character. Phlyctena is located in the setting of erythematous infiltrate, its contents
dry up very quickly in the crust of yellowish-brown colour, which has got multi-layer
characteristic. Under the skin, there is deep tissue necrosis, covering not only derma, but
subcutaneous fat as well. The crust drops off in several days, and the ulcer with soft uneven
congested hyperemic edges and bleeding bottom, covered with dingy pultaceous detritus.
After two-three weeks the ulcer is slowly cicatrizing. The scar is surrounded by the zone of
hyperpigmentation.
There are, as a rule, several ecthymae, and they are most frequently localized on the skin of the
lower legs, buttocks, femoris, lumbus, less often they are on the upper extremities.
Ecthymae can recur, causing lymphangites and lymphadenites, phlebitis, deep
necroses. In the severe course of the disease so-called ecthyma terebrans can appear.
Most frequently it occurs in undernourished children, suffering from anemia or rackets.
Some authors consider blue pus bacillus to be the agent of ecthyma terebrans. In this case
infiltrate and ulcerative defect spread depthward. The disease begins with the appearance
on the skin of the buttocks, lower extremities, hairy part of the head of blisters, rapidly
evolving into pustules and deeply ulcering. Such ecthymae cause severe pains. Ecthymae
terebrans have got malignant course, are complicated by sepsis, and can be fatal.
Ecthyma vulgaris most frequently should be differentiated with syphilitic ecthyma, which has
not got acute inflammatory nature. There are no impetiginous multiple small elements near
ecthyma, and the syphilides (especially papulous) can be detected at the other sites of the
body. The final diagnosis is defined by the positive serological reactions. In case of scabies,
complicated by ecthyma, military-papular rash appears on the other typical areas of skin, the
borrows are typical; the patient complains about strong itching, especially at night.
Hystologically, in derma and subcutaneous fat there is necrosis of tissue. The focus
is surrounded with indurated infiltrate, consisting of neutrophilous leukocytes and
lymphocytes. Edema and vasodilatation appear around the infiltrate.
On the initial stages of the development of ecthyma vulgaris, the phlyctenae are pierced
with a needle for removing their contents, the crusts are softened with application of 2%
salicyl ointment. In case of formed ecthyma or ecthyma terebrans, antibiotic therapy in
accordance with the results of antibiogram, A vitamins and B group vitamins, and
disinfecting ointments for topical treatment are put on. The skin around erythema is wiped
with 2% salicyl alcohol.
Superficial chronic diffuse streptoderma (streptodermia chronica diffusa
superficialis) is a chronic streptococcal disease, which is characterized by diffuse lesion of
significant sites of skin covering. Most frequently it affects the lower extremities, the
process can be also localized on the opistheners. The affected areas have got largely
scalloped lines, sharply bordered from the surrounding healthy skin by the rim of
exfoliative epidermis. The skin of the affected areas is sharply hyperemic, of congestive
bluish colour, slightly infiltrative, the surface is eroded in the form of wet disk-like sites. The
erosions are covered with many thin lamellate crusty scales of yellowish or greenish colour.
After removal of the crusts the surface wets with the release of dense serous or serous
yellow exudate. The process spreads over the periphery. With time, staphylococcal
infection joins to streptococcal, though there is no lesion of hair follicle and sebaceous
gland. The skin of the entire lower leg can be affected on the lower extremities. In the
process of development, the lesion area is epithelialized and covered with large lamellate
scales. Superficial chronic diffuse streptoderma is often complicated with
eczematization, especially on separate skin areas, where against the background of bright
red erythema there appear military papules, microvesicles, small erosions with release
of the drops of serous fluid.
In the pathogenesis of the disease development a significant role belongs to
congested phenomena in the lower extremities, varicose symptom complex, i.e.
prolonged disturbed circulation, development of tissue hypoxia and derangement of
metabolic processes in skin.
The disease has got a chronic course, with often relapses, especially around non- healing
wounds and trophic ulcers.
Superficial chronic diffuse streptoderma should be differentiated with eczema,
when the erythema is bright red, the foci are without distinct borders, oozing lesion is punctate,
there are no crusty scales, and the process has got symmetric character.
 Hystologically, in the erosion places there are no horny and granular layers. At the
sites of epidermis continuity there are parakeratosis, spongiosis, intensively pronounced
acanthosis. Vascular distention with perivascular infiltrate, predominantly
lymphocytic occurs in derma.
In case of acute course of superficial chronic diffuse streptoderma antibiotic
therapy in accordance with the results of antibiogram is put on. For topical treatment the
lotions of disinfecting and astringent solutions (5% tannic or 2% boric acid, 1 % solution of
resorcinol, 0,25% solution of silver nitrate) are applied. At the same time, it is necessary to
carry out curative interventions, aiming at the elimination of factors contributing to disease
development.

Strepto-staphylococcal skin infections - mixed pyoderma

Mixed pyoderma combine a number of chronic skin diseases of pyogenic nature,

mainly polymicrobial one. Their main etiological cause is combined
streptococcal and staphylococcal flora. Possible is the participation in the genesis of these
diseases other microorganisms as well, such as colibacillus or blue pus bacillus, Proteus vulgaris
etc.

In the pathogenesis of mixed pyoderma the essential role belongs first of all to sharp
decrease of immunological reactivity of organism and the appearance of sensitization
to byproducts of pyoderma agents, especially in children with allergic dermatitis,
malnutrition, vitamin deficiency, metabolic disorders, endocrine dysfunctions etc.
Mixed pyoderma include impetigo vulgaris, chronic ulcerative vegetating
pyoderma, chancriform pyoderma and botryomycoma.
Impetigo vulgaris (impetigo vulgaris) is preceded by the prodromes, such as high
temperature and itching at the sites of the following rash appearance.
 The disease appears at the beginning as streptococcal impetigo with the
appearance at erythematous and slightly infiltrated background of phlyctenas, the contents
of which due to overlay of staphylococcal infection get muddy quickly, become mattery
and acquire yellowish-grey or greenish colouring. The matter dries up into the form of
melichrous crust. After the crust drops out, the erosion appears, surrounded with delaminated
horny masses of epidermis. Subjectively, the process is accompanied by light itching.

Impetigo vulgaris is mainly localized on the skin of face at the sites of natural
orifices, such as nostrils, mouth, palpebral fissures, in women it can sometimes be localized
on the hairy part of the head as well. The process seldom causes inflammation of
regional lymph nodes. The evolution of disease lasts 10 to 14 days, after that a
temporary hyper pigmentation remains on the skin at the lesion sites. The possible are the
lesions of mucous membranes of nostrils.
The treatment is predominantly topical and includes the application of 1-2%
boric-tar ointment or naphthalani unguentum. The healthy skin areas are regularly wiped
around the foci with 1% salicylic alcohol. Ointments with antibiotics are applied
(mupirocin).
Chronic ulcerative pyoderma (pyodermia chronica ulcerosa) gradually
transforms into ulcerative vegetating form. It is caused by the mixed strepto-
staphylococcal infection. For the development of chronic ulcerative pyoderma the essential
is, on the one hand, the reducing of pathogenicity of the disease agents and immunological
response of the organism, and on the other hand, the weakening of the resistance of the
microorganism, that leads to prolonged soft course of the disease. Its manifestations are localized
exceptionally on the lower legs, and very seldom on the lower part of femora. In the setting of
slightly edematous areas of hyperemia the phlyctenas appear, rapidly covered with thick
crusts, beneath which the ulcers with callous undermined edges occur. After the dropping of
the crusts off, the bottom of the ulcers becomes naked, it is covered with necrotic masses
and soft grey granulations with significant amount of purulent and serous-purulent
discharge. The process spreads over periphery, covering large sites of the skin. Around
the ulcers there are pustular multiple small erosions. There is painfiilness at palpation.
Chronic ulcerative vegetating pyoderma (pyodermia chronica ulcero-vegetans)
is characterized by the appearance over the ulcer periphery of vegetations, which are
verrucous growths, which can appear over the entire surface of the lesion. The bottom
of the ulcers is bleeding. Vegetations can enlarge along the periphery as well; in this case the
process acquires serpiginous character. When pressing at the sites of lesion, the drops of dense
matter are released from small fistular openings. The disease lasts for months or years and
ends with formation of uneven hyperpigmented scars with small islets of unaltered skin.
It is necessary to distinguish chronic ulcerative vegetating pyoderma from
serpiginous nodular syphilide and verrucous form of skin tuberculosis that requires
additional examination of the patient.
When there are ulcerative purulent processes, the antibiotic therapy is appointed. In case of
intense mattery discharges, the lotions with 2% solution of rivanol, solution of microcide (at a
dilution 1:1) are appointed, and in the period of remission 2% gentian violet ointment.
Pyoderma, of the type of ecthyma vulgaris, sometimes is located independently on the genital
organs, resembling syphilitic chancre, hence the name of the disease of chancriform
pyoderma (pyodermia shancriformis). It is very seldom, that chancriform pyoderma is
localized on the face, lips and eyelids. The disease is caused by staphylococcus aureus. The disease
is typical for untidy persons, who do not look after hygiene of the body, as well as the subjects with
the presence of narrow preputial ring, when smegma accumulation causes maceration of the
skin of the penis with further suppuration.
Clinically, chancriform pyoderma manifests as the appearance of clearly limited
superficial ulcer of round to oval form with overlapped edges, located on the
inflammatory infiltrate the size up to 2 cm. The bottom of the ulcer is fleshy red,
sometimes covered with necrotic masses or purulent releases. It is painful at palpation.
As a rule, with chancriform pyoderma there is regional lymphadenitis the size from kernel of a
cherry to a nut, painful on palpation. The disease lasts from one to three months and ends
with the cicatrization.
In all cases chancriform pyoderma should be differentiated with syphilitic solid chancre.
In solid chancre the subjective sensations (pain, burning, itching) are absent, the infiltrate is of
dense-elastic, but not soft consistency, does not overlap ulcer, the acute inflammatory
phenomena are absent. As a rule, there are no purulent discharges. Regional
lymphadenitis is also painless on palpation, of dense- elastic consistency. In some
cases the clinical picture of chancriform pyoderma reminds syphilitic solid
chancre so much, that the diagnosis is possible to be set only on grounds of the
results of multiple tests for Treponema pallidum and data of serological reactions.
For the treatment of chancriform pyoderma the bathes with a weak solution of
potassium permanganate, lotions with a physiological solution of sodium chloride or 2% solution
of boric acid are applied to the full cicatrization. At the stage of differentiation with syphilitic
solid chancre no antibiotics should be applied both topical, and for general therapy.
The group of chronic mixed pyoderma includes also pyogenic granuloma or
botryomycoma (botriomycoma), which is benign fungiform tumor-like growth, caused
by Staphylococcus aureus. Botrycoms is most frequently localized on the skin of vermilion border,
nose, ears, on the fingers and toes. Its appearance is preceded by the injuries, cuts, pricks, by
means of which pyococci penetrate into the skin. Clinically, botryomycoma manifests as
small-lobular tumor on the peduncle the size of a pea to a hazelnut, of round form and soft
consistency. Botryomycoma has got intense red colouring and a large number of vessels,
which are easily injured and bleed. Botryomycoma with time can be partially necrotized or
form an ulcer with discharge of insignificant amount of seropurulent liquid.
Botryomycoma can exist without treatment for a long time, not disappearing by itself.
The treatment consists in surgical (or with electrocoagulation) removal of the tumor.
Sometimes botryomycoma can recur, so it is recommended to remove not only tumor itself,
but its base as well, at the same time applying antibiotic therapy up to the absolute regress of the
disease.
 Pyoallergids are secondary allergic diseases, which are caused by the
sensitization of patient organism to pyococci and their byproducts in the presence of purulent
skin diseases with chronic course. Pyoallergids are most frequently observed in case of
streptococcal infections (superficial chronic diffuse streptoderma, intertriginous
streptoderma and other).
Pyoallergids appear mainly at the sites remote from the focus of pyoderma and are
symmetrically located. Clinically, they most frequently remind eczematous reaction, as
the small miliary papules and microvesicles appear on the bright red background which
has not got clear boundaries, and is covered with fine scales. In the result of itch the scratches
(excoriations), covered with small hemorrhagic crusts, appear on the surface of
pyoallergids. And dense blisters can appear in palpation on the palms and plantae.
The treatment of pyoallergids is analogous to that conducted in case of allergic skin
diseases.

Prophylaxis of pyodermae. Preventive measures are essential in treatment of

purulent diseases. Physically healthy and weather-beaten people even in adverse
conditions seldom suffer from pyodermae, which attack in general people, who are
colds-prone, suffering from gastrointestinal disorders, increased sweating, alcohol abuse.
Patients with furunculosis, hidradenitis, ecthyma, multiple abscesses, strepto-
staphylodermae should exclude from their diet food rich in carbohydrates (honey,
chocolate, sweets, white bread etc.)
Personal hygiene of the skin is important for the prophylaxis of pyoderma. The
preventive measures, aimed at the preventing of pyodermae spread, include the timely detection
and medicamental sanation of people suffering from chronic nasal staphylococcal carriage.
This type of nasal infection is directly connected with the risk of appearance of pyodermae and
pyoseptic complications in dermatological and surgical practice. Both patients and medical staff can
be the carriers of Staphylococcus aureus, as well as the personnel of child care centers and
other categories of persons. To eliminate staphylococcal carriage (eradication of
staphylococci), the nasal ointments with antibiotics are applied, the ointment of mupirocin, in particular,
by smearing of each nasal opening twice a day during 5 to 7 days.
Children with pustular skin diseases in children's groups must be immediately isolated
and treated up to moment of disappearance of all clinical manifestations of disease. The staff
of nurseries and kindergartens, suffering from anginas, herpetic eruptions, acute respiratory
diseases of the upper airway, as well as pyodermae, must not be allowed to work.

SCABIES

Scabies is a parasitic contagious skin infestation caused by the itch mite

Sarcoptes scabies.
Etiology. Human scabies is caused by the itch mite Sarcoptes scabiei of
Sarcoptidae family. The size of the male mite is 0.2 mm in length, 0.14-0.19 mm in
width. Female is somewhat larger, it is 0.4-0.45 mm in length and 0.25-0.35 mm in
width. Under the microscope itch mite is like turtle. After fertilization the male dies,
and female burrows into the epilayer of the epidermis, where makes tunnels in
parallel with the surface of the skin, in which it lays eggs. A mite can be removed
from the itch tunnel with an injection needle or by means of thin sections of stratum
corneum in the places of itch tunnels made by the female. For the period from one
and a half to two months of its life, the female lays up to 50 eggs, of which three or
four days later the mite larvae hatch. After two weeks, the mites become mature.

Epidemiology. Annually up to 300 million cases of scabies morbidity are

registered in the world. Fluctuation of scabies morbidity is of sinuous character with rise and fall
rates periods in 15-30 years. Mainly, morbidity rate increase is caused by the worsening of
sanitary conditions, poverty, migrations, economic crisis, natural disasters, population
crowding, especially during the wars. It is observed the parallelism of increase of scabies
cases and diseases transmitted predominantly through sexual contact. The source of
infection is ill person. The main way of disease transmission is family and domestic.
The infection occurs through the direct contact with the sick person, through bed sheets,
clothing, gloves, socks and other items that he used. The children often become infected
through shared toys in the kindergarten.

Clinical picture. The clinic of scabies is based on the peculiarities of agent

parasitizing, skin reaction and topical distribution of itch mites on the host. The
incubatory period at the introduction of infection by the female is virtually
absent, as it immediately borrows into the epilayer of the epidermis and starts to gnaw
through tunnel and lay eggs, that is, there is the main clinical symptom of the disease. At the
introduction of infection by larvae one can talk about the incubation period, which corresponds to
the period of larva transformation into the mature female (approximately two weeks). The
clinical symptoms of the scabies are itching, which increases in the evening time, the
presence of borrows, polymorphism of skin (papulovesicles, papules, scratches, bloody
crust), characteristic localization of the rash.

The first subjective sign of the disease is intense itching in the places of borrows
made by the female. The itching becomes worse in the evening and at night, that is
due to the biological female characteristics, (period of agent activity, salivation
and substances present in the excrements, irritation of the nerve endings at
movement of the itch), tunneling mainly at night, and the development of organism
sensitization to parasites and their waste products. Itch can be localized and
generalized. Its intensity varies with different people and depends upon the number
of rashes and distribution process.

On the place of the female penetration into the skin a small papulovesicle (rarely
papule) appears, which has infiltrative basis. At the distance of 2-7 mm from this
element another papulovesicle appears (that is the exit site of the female onto the
skin surface), these are so called conjugated freckles. Between the papulovesicles
one can see itch tunnels, which have the form of thin strips of grey color, either
straight or curved in the form of S letter. By means of light palpation one can find
the tunnel relief, this is symptom Cezary. In the result of scratching there appear
excoriations or small erosions with bloody crusts.
 Typical places of scabies localization are areas of the hands between the
fingers, flexor surface of the brachium and elbow joints, the front and rear edges of
axillary cavities, lateral surface of the chest and abdomen, nipples areola breast of
women, navel area, buttocks and inter-gluteal folds, internal surface of the femora
and external genitalia, these are areas with thin stratum corneum. The symptom of
Hardy-Gorchakov helps in the diagnostics; this is the presence of pustules
(impetigo, rarely ecthyma) and purulent crusts on elbows. The eruptions in view of
impetigenous elements, papulovesicles, crusts in the area of inter-gluteal fold skin
with the transition to the lumbus, were called the triangle symptom or the rhomb of
Michaelis. Scabies, as a rule, is not localized on the skin of the head, neck, back,
axillary cavities, palms and plantae (except for children and persons with mental
disabilities), that is an important feature for the differential diagnostics with some
other dermatoses. Clinical presentations of scabies on hand skin can be absent or slightly
observable as to neat people and persons working with mineral oils, fuel oil (drivers, fitters,
turners and others), turf and asphalt.

The peculiarities of clinical presentation of scabies nowadays are light itching

and inconsiderable in number eruptions during continuous course. There can be
urticarial elements, the absence of rash on the hands due to frequent contact with
detergent agents, pastes, chemicals and others.

Scabies is often complicated by the secondary pyococcus infection in the results

of the scratching (impetigo, ecthyma, folliculitis, boils), and by microbial eczema,
especially in the area of breasts as for women. At eczematization there appears
rash, which is typical to eczema; on the erythematous ground there appear small
vesicles, oozing lesion, excoriations, and crusts. Eczematization, as a rule, develops
as a result of irrational therapy or intolerance to some local agents (of brilliant green,
benzyl benzoate, furacilin and others), less frequently as a result of sensitization of
mite waste products.

Morbid anatomy. Histologically borrows look like tunnels in the homy layer of
epidermis. Cephalic reminds a funnel and slightly opens outwards and the cavity is
visualized in the caudal section of the borrow, where the female is situated. Small
vasodilatations with a little cellular infiltration around them take place in papillary
dermis. Sometimes acanthosis and spongiosis are observed in the epidermis.

Diagnostics. The diagnosis is based on the characteristic clinical picture of the

disease and the identification of scabies mite in the laboratory research. With the
traditional method the material for the study is obtained by means of the needle
from the papulovesicles, located in the end of the borrow, or by means of
superficial slice of the epidermis with a razor in the location of borrow. After putting the obtained
material on a glass slide in a drop of 10-20% of alkali solution, the
specimen is examined at law magnification under a light microscope.

Differential diagnostics. Most frequently it is necessary to differentiate

scabies from skin prurigo, wherein intense itching and papular elements are
observed as well. In contrast to scabies, in indicated disease itching worries patient
both in the daytime and at night, and more often it takes priority of rash. The
popular elements are not conjugated, are located randomly and can appear on face
skin, the itch borrows are absent. Indirect evidence in favor of scabies can be
itching and similar rash of family members of the patient.

Scabies affection of the penis skin, especially in the form of ecthyma, can be
crucial for the suspected syphilitic solid chancre or popular rash, specific to the
secondary period of syphilis. The presence of specific carnification at the heart of
syphilitic solid chancre, the revealing of pale treponemes in serum of chancre or in
lymph node aspirates, as well as the absence of scabies signs on other parts of the
body and positive serological reactions allow diagnosing syphilis.

One type of neglected stage of scabies is so-called Norwegian scabies, which is

observed in persons with mental illness and in patients suffering from syringomyelia,
multiple sclerosis, leprosy. The skin at this time is covered with thick, as bark,
crusts of dark green colour, resembling shell. Under the crusts after their removal on
erythematous background a lot of white dots can be seen these are scabies mites.
 Treatment. In order to kill off the scabies mites, local antiparasitic agents,
disintegrating the cornel layer of epidermis and killing parasites, are applied. Appropriate
antiparasitic agents as ointments, solutions and sprays are necessary to rub in all skin
integuments, except for face and scalp, for adults. As infants and young children can
have scabies manifestations on the face, scalp plantae and palms, accordingly, the
indicated parts of the body subject to treatment with antiparasitic agents as well.

For scabies treatment benzyl benzoate is used. This method differs from the
others in such a way that along with high efficiency, there is no unpleasant smell that
allows the patient to be at work, in public transport etc. Benzyl benzoate (benzyl-
benzene carboxylate in form of 20% suspension in soap solution: 20 g of benzyl
benzoate, 2 g of green soap and 78 ml of water) is rubbed in with a cotton swab
after that the patient puts on clean clothes and change linen. Inflictions are repeated
during the period of two days more without washing. In three days after end of
treatment the patient takes a shower and changes clothing. Nowadays, 25% benzyl
benzoate cream is used more often than suspension.

The application of the above methods of therapy of scabies, taking into account
the toxicity of antiparasitic medicines, is often accompanied by skin irritation
(contact dermatitis). In this case, the patients are recommended desensitizing agents
and antihistamines, zinc oxide powders, indifferent water magmas, steroid creams
and ointments. In case of bacillosis overlay, antibiotics both oraly and topically are
used temporarily, and lesion focuses are salved with aniline dyes and 2% salicyl
alcohol, as well. If scabies is accompanied by eczema, then 24 hours before the
antiscabious therapy, the affected area must be salved with one of the topic
corticosteroids. The patients with constant itching after the treatment for a long time
are recommended mitigatory and local anti-itching therapy.

Prophylaxis and antiepidemic measures for scabies patients are carried out
accounting the epidemiology of disease. Early diagnostics and active case
detections are of great importance here. Control of curability is executed in three
days after the ending of therapy, and then in every ten days during a month and a
half. The effectiveness of therapy mostly depends on thoroughness of sanitary and
preventive measures.

PEDICULOSIS

Pediculosis (pediculus) is an infestation of the skin and hair, caused by the

parasites of three kinds, these are head lice (Pediculus capitis), body lice
(Pediculus corporis) and pubic or crab lice (Pediculus pubis).

Head lice (Pediculus capitis) are spread through direct head-to-head contact
or due to sharing hair combs, hats and others. The size of the male is 2-3 mm, the
female is 2.4-4 mm, and both are of grey color with black dots on the belly edges.
Inhabiting the scalp, the female lays eggs (nits) of grayish-white color with 0.75-0.8
mm in length, which are attached to the hair with help of chitinous membranes. In
neglected cases the lice can infest the eyebrows, mustache and beard. The nits are
attached to the hair and can be seen as white spot formations.

Clinical picture. Due to bites of the lice, there occurs intense pruritus (itching),
which causes the appearance of excoriations, covered with hemorrhagic crusts.
Often due to pyococcus infection in lesions there appear sycoses, follicles, and
impetigo vulgaris. Abscesses and eczematous foci may develop. In complication of
the pediculosis with pyoderma, the hair in the affected areas is glued in form of thick
bundles, so called mats, at the same time, the regional lymph nodes can increase
and become painful. In the back of the head, especially of the girls and women with
long hair, there appears grainy pyodermia (impetigo granulata).

Diagnostics. To diagnose infestation, the scalp should be examined for the presence of
the living parasites and nits.

Treatment. For the treatment of scalp pediculosis, 10% water-soap emulsions of

benzyl benzoate and such shampoos as Pedilin, Nittiform are used, for treating the skin and
hair of the head for 10-15 minutes, thereafter they are washed with hot water and soap.
The use of Para-Plus spray is effective. The preparation is sprayed onto the scalp skin
and the entire length of the hair; herewith the tip of the spray should be at a distance of 3 cm
from the hair. After spraying the preparation it is necessary to wait for 10 minutes. During
the exposure one should not cover a head with a towel or scarf. After use of preparation
"Para-Plus" it is necessary to thoroughly wash a head with a shampoo. The dead nits,
remained on
the hair, should be combed out. All textile products, which the patient contacted
with, such as towels, pillows, hats and others, must be treated with the preparation
"Para-Plus" to prevent the secondary infestation. In case of dermatitis or
eczematization inflammations are eliminated with neutral lotions, which contain
corticosteroids.

Body lice (Pediculus corporis, seu vestimenti) are rare nowadays on the
territory of Ukraine; mainly people without a permanent residence have them. They
are somewhat larger than head ones, with size 3-5 mm in length, of white color,
without black spots on the abdomen. Lifetime of the parasites is 30-45 days; they
well tolerate cold and can starve for several days, die immediately in boiling. Body
lice carry saprotyphus and relapsing fever. Lice live and lay eggs in the folds of the
clothes, especially in areas adjacent to the neck, shoulders and lower back.

Clinical picture. The lice bites cause intense itching; sometimes the eruption in
form of urticarial elements can appear. In result of itching in the areas of lice
parasitizing the scratches covered with bloody crusts appear, which are often
complicated by the secondary pyococcus infections (impetigo, follicles, boils,
abscesses), eczema. During long-term parasitic process the skin thickens and
become dry (lichenification).

Diagnostics. To diagnose pediculosis, the dressing should be examined for the

presence of the lice and the clinical picture should be appropriate.

Treatment. Treatment involves clothing disinfection (such as ironing, boiling,

use of the spray "A-PAR", "Para-Plus" etc.) and the following shower of the
patient.
 Pubic or crab lice (Pediculus pubis), differ from the head and body lice by a
smaller size (male is 1 mm, female is 1.5 mm) and round form (look like crabs). The
places of parasitizing are mainly area of pubis, perineum, scrotum and anus. In case
of people with excessive pilosis, the pubic lice can migrate to the chest, in the
axillary cavities, on the beard and eyebrows. There, they are attached to the skin by
means of craw-like formations. With their curved legs the parasites cling to the
lower parts of the neighboring hairs. The pubic lice do not affect scalp. Small nits
are found on the hair. Pubic lice are visible to the naked eye as greyish-brown spots
with size of a pin's head near the base of the hair.

Pubic lice infestation occurs, mainly, through sexual contacts, but as an

exception, it can occur during visiting public bathes or through the bedding. From
time to time in pubic lice, the phenomena of eczematization appear on the skin
(especially on the thighs) in the result of scratching and use of irritating solutions and
ointments.

Clinical picture. Pubic lice cause intense itching with their bites, which is the
reason of excoriation and bloody crusts appearance. Blue spots (maculae cocruleae)
with a diameter up to 1 cm of round or oval form appear in view of the
line in the places of lice bites on skin of the abdomen, inner thighs and sides of the
chest. The appearance of the spots is the result of the mixing of the patient's blood
and lice saliva when biting. The blue spots do not disappear during diascopy, which
is a significant sign in differential diagnostics from roseolous syphilides and
saprotyphus.

Diagnostics. Pediculosis is determined on the basis of the presence of the

parasites and nits, as well as blue spots, in the places of the bites on the skin of the
abdomen, inner thighs and sides of the chest.

Treatment. Treatment of pubic pediculosis is in the removing of the hair from

the affected areas and rubbing of the 33% sulfuric ointment, or 25% emulsion
(cream) of benzyl benzoate during the following 3-4 days, after that the patient
should take a shower with a soap and change clothes. Last time the sprays
containing permethrin are successfully used for the treatment of the pubic
pediculosis.