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The term “cellulitis” is commonly used to indicate a nonnecrotizing inflammation of the dermis and hypodermis related to acute infection that does not involve the fascia or muscles, and that is characterized by localized pain, swelling, tenderness, erythema, and warmth.

Pathophysiology

Cellulitis usually follows a break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound. Facial cellulitis of odontogenic origin may also occur. Patients with toe web intertrigo and/or tinea pedis and those with lymphatic obstruction, venous insufficiency, pressure ulcers, and obesity are particularly vulnerable to recurrent episodes of cellulitis. Organisms on the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis.

The vast majority of cases are caused by Streptococcus pyogenes or Staphylococcus aureus. Occasionally, cellulitis may be caused by the emergence of subjacent osteomyelitis. Cellulitis may rarely result from the metastatic seeding of an organism from a distant focus of infection, especially in immunocompromised individuals. This is particularly common in cellulitis due to Streptococcus pneumoniae and. Neisseria meningitidis, Pseudomonas aeruginosa, Brucella species, and Legionella species have also been reported as rare causes of cellulitis resulting from hematogenous spread.

Frequency

United States

Because cellulitis is not a reportable disease, the exact prevalence is uncertain; however, it is a relatively common infection. A 2006 study found an incidence rate of 24.6 cases per 1000 person-years. In a large epidemiological hospital-based study on skin, soft tissue, bone, and joint infections, 37.3% patients were identified as having cellulitis.

International

Cellulitis has been found to account for approximately 3% of emergency medical consultations at one United Kingdom district general hospital.

Mortality/Morbidity

Cellulitis generally is a localized infection. Most patients treated appropriately recover completely. Mortality is rare (5%) but may occur in neglected cases or when cellulitis is due to highly virulent organisms (eg, P aeruginosa). Factors associated with an increased risk of death are the presence of concurrent illness (eg, congestive heart failure, morbid obesity, hypoalbuminemia, renal insufficiency) or complications (eg, shock).

Race

No racial predilection has been noted.

Sex

No predilection for either sex is usually reported, although a higher incidence among males has been reported in some studies.

Age

No age predilection is usually described; however, studies found a higher incidence of cellulitis in general among individuals older than 45 years. Moreover, cellulitis at certain anatomic sites may show a predilection for persons in certain age groups.

• Facial cellulitis is more common in children younger than 3 years.
• Perianal cellulitis is predominantly a disease of children.

Clinical

History

The incubation period is somewhat organism dependent. Postoperative cellulitis at the surgical site due to group A beta-hemolytic streptococci may develop rather rapidly. On the other hand, cellulitis due to staphylococci usually is delayed in onset.

• Patients report local pain and swelling at the site of cellulitis.
• The patient may report a history of trauma to the site. Severe bacterial cellulitis may occur as a postsurgical complication, such as following hip replacement or liposuction, or secondary to lymphatic occlusion following either radical mastectomy or conservative breast surgery; impaired lymphatic drainage and edema are also considered predisposing factors to leg cellulitis following saphenous vein resection for coronary artery bypass. However, cellulitis may follow a trivial injury to the skin (eg, scratch, abrasion, animal bite, intravenous or subcutaneous drug injection, body piercing). Cellulitis has also rarely been reported as a possible postprocedural complication of radiation therapy.
• Fever is common, and chills may be noted, particularly if suppuration has occurred.
• Malaise may be present.

Physical

• Involved sites are red, hot, swollen, and tender.
• Unlike erysipelas, the borders are not elevated or sharply demarcated.
• Lymphangitis, regional lymphadenopathy, or both may be present.
• Malaise, chills, fever, and toxicity may occur.
• In severe cases, patients may develop hypotension.
• Local suppuration may follow if therapy is delayed.
• Overlying skin may develop areas of necrosis.
• The most commonly involved site is the leg.
• Perianal cellulitis due to group A streptococci is usually observed among children with perianal fissures. It is characterized by perianal erythema and pruritus, purulent secretions, painful defecation, and bleeding in the stools.
• Pneumococcal facial cellulitis occurs primarily in young children who are at risk for pneumococcal bacteremia. It may manifest as 2 distinctive clinical syndromes, as follow:
• Extremity involvement in individuals with diabetes mellitus or substance abuse
• Head, neck, and upper torso involvement in individuals with systemic lupus erythematosus, nephrotic syndrome, or hematologic disorders

Causes

• In immunocompetent adults, cellulitis is usually due to S pyogenes and, occasionally, S aureus. Isolation of methicillin-resistant S aureus (MRSA) is steadily increasing, especially among intravenous drug users, HIV infected patients, prisoners, athletes, military trainees, and male homosexuals. Bacterial strains may also show multiple resistance to other standard antibiotic treatments, including erythromycin.
• In children, the most common cause of cellulitis is S aureus. Other causes include S pyogenes (perianal cellulitis), Haemophilus influenzae, and S pneumoniae.
• Recurrent staphylococcal cellulitis may occur in patients with nasal carriage of staphylococci and those with Job Syndrome. S aureus is also the leading cause of soft tissue infections in persons who abuse injection drugs.
• Recurrent cellulitis due to streptococci may be observed in patients with chronic lymphedema (eg, from lymph node dissection, irradiation, Milroy disease, elephantiasis). Streptococcal infections are also common in injection drug users.
• Non–group A streptococci (ie, groups B, C, and G) are commonly implicated in cellulitis in patients with lymphatic obstruction or venectomy for coronary artery bypass graft.
• S pneumoniae is an uncommon cause of cellulitis in adults. Pneumococcal cellulitis may occur from bacteremia. In a review of pneumococcal skin infection in adults, all such patients had an underlying chronic illness or were immunocompromised by drug or alcohol abuse. Pneumococcal facial cellulitis occurs primarily in young children at risk for pneumococcal bacteremia.
• Patients who are immunocompromised with granulocytopenia, such as renal transplant recipients, may develop cellulitis due to infection with other organisms, including gram-negative bacilli (eg, Pseudomonas, Proteus, Serratia, Enterobacter, Citrobacter), anaerobes, other opportunistic pathogens (eg, Helicobacter cinaedi, Fusarium species), mycobacteria, and fungi (eg, Cryptococcus). Preseptal cellulitis caused by dermatophytes is rarely observed, mostly in the pediatric age group. Persistent cellulitis due to Cryptococcus neoformans infection has also been reported in a patient receiving renal dialysis.
• Escherichia coli may be responsible for cellulitis in patients with nephrotic syndrome.
• Cellulitis from unusual bacterial species, including Enterococcus faecalis, Enterobacteriaceae, and Bacteroides and Clostridium species, may be observed following subcutaneous injections of illegal drugs. If Clostridium species or other anaerobes (Bacteroides, Peptostreptococcus, Peptococcus, Prevotella) cause the infection, crepitant cellulitis is often observed clinically.
• Other uncommon causes of cellulitis include Neisseria meningitidis; Mycobacterium avium-intracellulare; Pasteurella multocida, following animal bites; Aeromonas hydrophilia, following contact with fresh water; Streptococcus iniae, a fish pathogen causing infections in aquaculture farms; and Chromobacterium violaceum and Vibrio vulnificus, following contact with seawater. Cellulitis from marine vibrios in hepatopathic patients may also follow ingestion of contaminated raw oysters. Acinetobacter baumannii is an emerging multidrug-resistant pathogen that causes hospital-acquired soft tissue infections, including cellulitis, following gunshot wounds or use of invasive devices. H influenzae has become a rare cause of buccal cellulitis in children after the introduction of the H influenzae type B vaccine.

Xeroderma pigmentosum (XP) is an inherited disease that causes extreme sensitivity to ultraviolet (UV) light. UV light damages the genetic material (DNA) in cells and disrupts normal cell function. Normally, damaged DNA is repaired by the body, but the DNA repair systems of people with XP do not function properly. In XP, the damaged DNA builds up and becomes harmful to the body’s cells, particularly in the skin and eyes. Xeroderma pigmentosum is inherited in an autosomal recessive pattern. It affects both men and women of all ethnic backgrounds. XP is estimated to occur in 1 in 1,000,000 individuals in the United States. In some areas of the world, such as North Africa (Tunisia, Algeria, Morocco, Libya, Egypt), the Middle East (Turkey, Israel, Syria), and Japan, XP occurs more often.

Skin Symptoms

People with xeroderma pigmentosum experience skin symptoms and changes from being in the sun. These may include:

• unusually severe sunburn that may include blistering after only being in the sun a short time
• sunburn lasts much longer than expected, sometimes for several weeks
• development of lots of freckles at an early age
• excessively dry skin (xerosis)
• rough-surfaced skin growths (solar keratoses)
• irregular dark spots
• development of any of the three common types of skin cancer: basal cell carcinoma, squamous cell carcinoma, or melanoma

The name “xeroderma pigmentosum” means “dry pigmented skin.” Exposure to the sun over time causes the skin to become darker, dry, and parchment-like. Even in children the skin looks like the skin of farmers and sailors who have been in the sun for many years. People with xeroderma pigmentosum who are younger than 20 years old have more than 1,000 times the risk of developing skin cancer than people without the disease. The first skin cancer may develop before a child with XP is 10 years old, and many more skin cancers may develop in the future. In XP, skin cancer develops most often on the face, the lips, on the eyes, and on the tip of the tongue.

Eye Symptoms

People with xeroderma pigmentosum also experience eye symptoms and changes from being in the sun. These may include:

• eyes are painfully sensitive to the sun
• eyes are easily irritated and become bloodshot
• ectropion, a turning out of the edge of the eyelid
• inflammation (keratitis) of the cornea, the clear part of the front of the eye that lets light through
• cloudiness of the cornea
• darkening of the skin of the eyelids; sometimes the eyelashes fall out

Nervous System Symptoms

About 20-30% of people with xeroderma pigmentosum also have nervous system symptoms such as:

• hearing loss that gets worse over time
• poor coordination
• spastic muscles
• a smaller-than-normal head (called microcephaly)
• intellectual impairment that gets worse over time
• seizures

Nervous system symptoms may be present in infancy, or they may not appear until late childhood or adolescence. Some people with XP will only develop mild nervous system symptoms at first, but the symptoms tend to become worse over time.

Diagnosis

The diagnosis of xeroderma pigmentosum is based on the skin, eye, and nervous system symptoms (if present). A special test performed on blood or a skin sample can look for the DNA repair defect present in XP. Tests may be done to rule out other disorders that can cause similar symptoms, such as Cockayne syndrome, trichothiodystrophy, Rothmund-Thomson syndrome, or Hartnup disease.

Treatment

There is no cure for xeroderma pigmentosum, so treatment focuses on any problems that are present and preventing future problems from developing. Any cancers or suspicious lesions should be treated or removed by a skin specialist (dermatologist). An eye specialist (ophthalmologist) can treat any eye problems that occur. Since it is the UV light that causes damage, a big part of prevention of problems is protecting the skin and eyes from sunlight. If someone with XP has to go outside during the day, he or she should wear long sleeves, long pants, gloves, a hat, sunglasses with side shields, and sunscreen. When indoors or in a car, the windows should be closed to block the UV rays from sunlight (although UVA light can still penetrate, so a person must be fully clothed). Children with XP should not play outdoors during the daytime. Some types of indoor light (such as halogen lamps) can also give off UV light. Indoor sources of UV light in the home, school, or work environment should be identified and eliminated, if possible. People with XP can also wear sunscreen indoors to protect against unrecognized sources of UV light. Other important parts of preventing problems are frequent skin examinations, eye examinations, and early testing and treatment for nervous system problems such as hearing loss.

Scleredema is a skin disorder in which the skin thickens and hardens, sometimes with redness. What causes scleredema is not known. It is often associated with diabetes, and among people with diabetes, men are affected much more often than women (10:1). Scleredema may occur after a viral illness, or streptococcal throat infection, and in these cases females are affected twice as often as males. Despite being sometimes called scleredema adultorum, the disorder occurs in individuals of all ages and all ethnic backgrounds.

Symptoms
When scleredema occurs, the affected area of skin becomes thickened and hardened. It may become red or darkened in color, and may look rough like the skin of an orange (called peau d’orange). In most cases scleredema begins on the face, neck, or upper back. It may spread to the arms or chest, but the hands and feet are not usually affected. Other symptoms may occur depending on the area affected:

• face – difficulty in opening the eyes or mouth
• skin over joints – limited motion
• tongue – difficulty speaking or chewing

In some individuals, scleredema affects not just skin but other body parts such as the heart, liver, spleen, muscles, or throat.

Diagnosis
Scleredema is usually suspected based on the appearance of the skin and the medical history of the individual (such as having diabetes or a recent infection). A skin sample (biopsy) is taken and examined under the microscope to confirm the diagnosis. A throat culture for streptococcal throat infection is obtained and blood glucose is tested for diabetes. A special blood test is done to check for blood disease such as multiple myeloma, which may appear after scleredema begins.

Treatment
Many different types of medications have been tried as treatments for scleredema, but no one medication has been proven to be best. Individuals may benefit from corticosteroids, cyclosporine, methotrexate, UVA1 phototherapy, or psoralen with ultraviolet light A. If infection is present, antibiotics may be required. If diabetes is present, it should be controlled with diet, exercise, and medication. Physical therapy may help if movement of body parts is restricted.

Individuals who develop scleredema after infection tend to have a shorter course of disease, with symptoms resolving within 6 months to 2 years. Individuals with diabetes who develop scleredema have symptoms for a longer period of time, often many years.

A wart is generally a small, rough growth, typically on hands or feet, that resembles a cauliflower.

Warts are common, and are caused by a viral infection, specifically by the human papillomavirus (HPV).

Warts typically disappear after a few months but can last for years and can recur. A few papillomaviruses are known to cause cancer.

Types of wart

A range of different types of wart have been identified, which differ in shape and site affected, as well as the type of human papillomavirus involved. These include:

* common wart (verruca vulgaris): a raised wart with roughened surface, most common on hands and knees
* flat wart (verruca plana): a small, smooth flattened wart, tan or flesh coloured, which can occur in large numbers; most common on the face, neck, hands, wrists and knees
* filiform or digitate wart: a thread- or finger-like wart, most common on the face, especially near the eyelids and lips
* plantar wart (verruca, verruca pedis): a hard sometimes painful lump, often with multiple black specks in the center; usually only found on pressure points on the soles of the feet
* mosaic wart: a group of tightly clustered plantar-type warts, commonly on the hands or soles of the feet
* genital wart (venereal wart, condyloma acuminatum, verruca acuminata): wart affecting the genital areas

Treatment

Without Prescription

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Prescription

Treatments that may be prescribed by a medical professional include:

* Keratolysis, removal of dead surface skin cells usually using salicylic acid, blistering agents, immune system modifiers, or formaldehyde.
* Cryosurgery, which involves freezing the wart (generally with liquid nitrogen), after which the wart and surrounding dead skin falls off by itself. Surgical removal of the wart is sometimes also performed.
* Laser treatment.
* Imiquimod, a topical cream that helps the body’s immune system fight the wart virus by encouraging interferon production.
* Candida injections at the site of the wart, which also stimulate the body’s immune system.
* Cantharidin, a chemical found naturally in many members of the beetle family Meloidae which causes dermal blistering.

None of these treatments are very effective on single uses except Cryosurgery; the wart often returns after the skin has healed from the treatment, but repeated treatment should get rid of the wart permanently. As they disappear after a few months and maximally a few years, treatment is necessary only if the lesions are painful or are a cosmetic problem.

One review of 52 clinical trials of various cutaneous wart treatments concluded that topical treatments containing salicylic acid were the best supported, with an average cure rate of 75% observed with salicylic acid compared with 48% for placebo in six placebo-controlled trials including a total of 376 participants. The reviewers also concluded that there was little evidence of a significant benefit of cryotherapy over placebo or no treatment.

Over-the-counter

There are also several over-the-counter options. The most common ones involve salicylic acid. These products are readily available at most drugstores and supermarkets. There are typically two types of products: adhesive pads treated with salicylic acid, or a bottle of concentrated salicylic acid. Removing a wart with this method requires a strict regimen of cleaning the area, applying the salicylic acid, and removing the dead skin with a pumice stone or emery board. It may take up to 12 weeks to remove a stubborn wart.

Another over-the-counter product that can aid in wart removal is silver nitrate in the form of a caustic pencil, which is also available at drug stores. This method generally takes three to six daily treatments to be effective. The instructions must be followed to minimize staining of skin and clothing.

Over-the-counter cryosurgery kits are also available, however they can often cost 3 times as much as the previously named products.

Like prescription treatments, over-the-counter treatments usually require multiple applications, and are only necessary if the warts are problematic. Additionally, these treatments are capable of destroying healthy skin as well as warts, so caution must be exercised by those attempting them without medical supervision.

Cold sores (oral herpes) are caused by infection with the herpes simplex virus (HSV). There are two types of Herpes Simplex Virus: HSV Type 1 and HSV Type 2. The ways in which herpes infections manifest themselves vary tremendously among individuals.

Most cases of oral herpes (cold sores) are caused by HSV-1.

There is no cure for HSV infection.

HSV is generally transmitted by direct contact of lips or genitals when the sores are present, or just before they appear (known as shedding).

Symptoms

1. Prodromal symptoms
2. Skin appears irritated
3. Sore or cluster of fluid-filled blisters appear
4. Lesion begins to heal, usually without scarring

It is estimated that 50% of adults in the UK are carriers of the Herpes Simplex Virus, many of which will never exibit any symptoms of infection. It is also possible for the virus to be transmitted across the skin in the absence of a coldsore. Oral herpes lesions typically occur on the lips, but can occur almost anywhere on the face. They can also occur on the fixed mucosa inside the mouth, including the hard palate (roof of the mouth), and gingiva (gums). Oral herpes and cold sores can sometimes be confused with canker sores. Only a medical physician can provide adequate diagnosis.

Outbreak Triggers

Physical or psychological stress can trigger an outbreak. Local injury to the face, lips, eyes or mouth, as through trauma, surgery, or sunburns are well established triggers of recurrent orolabial herpes due to herpes simplex virus type 1 (HSV-1). Similarly, intercurrent infections, such as upper respiratory viral infections or other febrile diseases, can cause outbreaks, hence the historic terms “cold sore” and “fever blister”. Generalized psychological stress and anxiety are also triggers.

Symptoms

Herpes infections, whether initial or recurring, are usually first felt as a tingling and/or itching sensation in the affected location. These initial feelings are usually followed, depending on how severe the infection is, by the emergence of a raised or swollen area on the skin. This swollen area then becomes painful in general, but acutely sore when touched, stretched or moved. Eventually the sore area will abscess, and emit a virus laden clear fluid for several days before scabbing over. Once scabbed over the lesion will usually heal completely within a period of a week to ten days. In immuno-compromised individuals this cycle can be significantly protracted.

From the onset of infection/outbreak, many patients experience headaches, fatigue (sometimes extreme), and peculiar twitching sensations in the nerves that lead to the area of the outbreak. The fatigue associated with herpes infections can concatenate with depression brought on by the cosmetic or sexually compromising nature of the infection, to yield a deeply gloomy overall mental state that some believe can contribute to increasing the length and severity of an infection.

Transmission

Herpes is contracted through direct skin contact (not necessarily in the genital area) with an infected person, and less frequently by indirect contact (for instance, by sharing lip balm or a virus infested shared towel). The virus travels through tiny breaks in the skin (or mucous membranes in the mouth and genital areas), so, healthy skin and mucous membranes are normally an effective barrier to infection. However, in the case of mucous membranes, even microscopic abrasions are sufficient to expose the nerve endings into which the virus splices itself. This is why most herpes transmission happens in mucous membranes, or in areas of the body where mucous membranes and normal skin merge (e.g., the corners of the mouth).

Treatment

Currently, there is no cure for herpes. There is no treatment that can eradicate herpes virus from the body at reactivations of the virus. Non-prescription analgesics can reduce pain and fever during initial outbreaks.

Anti-viral medication: There are several prescription antiviral medications for controlling herpes outbreaks, including aciclovir (Zovirax), valaciclovir (Valtrex), famciclovir (Famvir), and penciclovir.

A boil (furuncle) is a skin disease caused by the inflammation of hair follicles, resulting in the localized accumulation of pus and dead tissues. Individual boils can cluster together and form an interconnected network of boils called carbuncles. In severe cases, boils may develop to form abscesses.

Symptoms

The symptoms of boils are red, pus-filled lumps that are tender, warm, and/or painful. A yellow or white point at the center of the lump can be seen when the boil is ready to drain or discharge pus. In a severe infection, multiple boils may develop and the patient may experience fever and swollen lymph nodes. A recurring boil is called chronic furunculosis.

In some people, itching may develop before the lumps begin to develop. Boils are most often found on the back, underarms, shoulders, face, thighs and buttocks, but may be found elsewhere. Boils on the ear tend to be more painful, and can create shooting pain in the entire ear when touched.

Sometimes boils will emit an unpleasant smell, particularly when drained or when discharge is present, due to the presence of bacteria in the discharge.

Causes

Boils are generally caused by an infection of the hair follicles by Staphylococcus aureus or staph, a strain of bacteria that normally lives on the skin surface. It is thought that a tiny cut of the skin allows this bacterium to enter the follicles and cause an infection. This can happen during bathing or while using a razor.

People with immune system disorders, diabetes, poor hygiene or malnutrition (Vitamin A or E deficiency) are particularly susceptible to getting boils. However they may also occur in healthy, hygienic individuals.

Hidradenitis suppurativa causes frequent boils.

Boils in the armpits can sometimes be caused by anti-perspirant deodorants.

Treatments

Most boils run their course within 4 to 10 days. For most people, self-care by applying a warm compress or soaking the boil in warm water can help alleviate the pain and hasten draining of the pus (colloquially referred to as “bringing the boil to a head”). Fire cupping can be utilised to facilitate this procedure. Once the boil drains, the area should be washed with antibacterial soap or antibacterial herbs (chickweed poultice) and bandaged well.

For recurring cases, sufferers may benefit from diet supplements of Vitamin A and E.

In serious cases, prescription oral antibiotics such as dicloxacillin (Dynapen) or cephalexin (Keflex), or topical antibiotics, are commonly used. For patients allergic to penicillin-based drugs, erythromycin (E-base, Erycin) may also be used.

However, some boils are caused by a superbug known as community-acquired Methicillin-resistant Staphylococcus aureus, or CA-MRSA. Bactrim or other sulfa drugs must be prescribed relatively soon after boil has started to form. MRSA tends to increase the speed of growth of the infection.

Magnesium sulfate paste applied to the affected area can prevent the growth of bacteria and reduce boils by absorbing pus and drying up the lesion.

Prognosis

For most cases, there are no serious complications and a full recovery is expected.

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One of the most common skin diseases in the United States is acne and 60 million Americans have this condition. Acne is an inflammatory, non-contagious skin disease that affects the pores covering the face, back, chest and arms and the oil glands attached to them. Too much oil, formally known as sebum, is produced by the sebaceous gland and causes a greasy, course complexion. When the pores that hold our hairs become blocked by dead skin cells and oil, eruptions known as acne pimples are formed.

The most common form of this disease is mild acne, which is clinically referred to as acne vulgaris, and includes blemishes such as blackheads, whiteheads, papules and pustules. Blackheads develop when a pore is partially clogged and some of the trapped bacteria, sebum and dead skin cells drain to the surface and your skin’s pigment reacts with the oxygen in the air and causes a black color. Whiteheads occur when a pore is fully blocked and traps bacteria, sebum and dead skin cells with a white appearance. Pustules are like whiteheads, however, they appear as an inflamed red circle with a yellow or white center. Finally, papules are tender, red, inflamed bumps that have no head at all.

Severe acne vulgaris is defined by the appearance of nodules and cysts. Nodules are big, hard bumps under the surface of the skin that can last for month and feel painful. Cysts are filled with pus and can have a diameter of 5mm across or more. This type of acne would require treatment from a skin doctor, known as a dermatologist.

If you have mild acne, it is important to cleanse your skin two to three times per day with a cleanser developed for oily skin. Regular use of astringents and masks can be helpful in keeping the pores from getting clogged. A light moisturizer can also help your skin. Avoiding oily skin care products and foods will minimize the existence and production of oil in your skin. A healthy lifestyle that includes a well-balanced diet, exercise and sleep will reflect in your skin. Ensuring that you drink plenty of water and incorporate all vitamins into your diet will also improve the health of your skin.

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