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Infections andInfestations oftheLower
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Extremity
Bacteria, viruses, and insects can all wreak havoc on our
skin. To follow are the most common conditions encountered
on the lower extremities that may result from these noxious
agents.
3.1 Bacterial Infections
3.1.1 Abscess
Skin abscesses are localized soft tissue swellings usually
caused by bacteria and accompanied with erythema and
pain. Staphylococcus aureus is the most frequently isolated
pathogen from skin abscesses and the incidence of
methicillin- resistant (MRSA) strains is signicant and a
major global health concern [1]. Diagnosis is usually based
on history and clinical ndings although ultrasound may aid
in differentiation from other soft tissue infections such as
cellulitis [2]. The absence of purulent drainage does not rule
abscess formation.
Abscesses in otherwise healthy individuals are best
treated with incision and drainage [3]. The use of oral antibiotics to treat uncomplicated cases is somewhat controversial
and is often guided by severity of the infection, results of
culture if performed, and incidence of local communityassociated MRSA (Fig.3.1).
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3.1.2 Cellulitis
Cellulitis is a frequently encountered bacterial infection that
has a propensity to affect the lower legs. Common pathogens
are group A streptococcus and staphylococcus aureus; however, the majority of cases are nonculturable and the underlying pathogen is unidentied [4]. The diagnosis is usually
based on history and physical examination which reveals
localized erythema and swelling associated with warmth and
tenderness. More severe cases may be associated with fever.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
T. C. Vlahovic, S. M. Schleicher, Atlas of Lower Extremity Skin Disease, https://doi.org/10.1007/978-3-031-07950-4_3
Fig. 3.1 Painful ankle abscess that required drainage and systemic
antibiotics
Predisposing factors are obesity, diabetes, tinea pedis, and
advancing age [5]. The condition may result from incidental
trauma such as a supercial abrasion.
Empiric treatment of cellulitis often includes a 5-to-7-day
course of oral antibiotics active against both streptococci and
staphylococci [6]. To prevent recurrence, underlying factors
such as lymphedema and tinea pedis should be addressed as
well (Fig.3.2).
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3 Infections andInfestations oftheLower Extremity
Fig. 3.3 Erythrasma is a bacterial condition that uoresces under a
Wood’s light
Fig. 3.2 The lower legs are the most common site of cellulitis
3.1.3 Erythrasma
Erythrasma is a supercial infection of the intertriginous
areas. On the foot the condition is localized to the digital
interspaces. Erythrasma presents as a scaly rash that may be
asymptomatic or macerated, pruritic, and malodorous. It is
most commonly associated with Corynebacterium minutis-
simum which is a member of the normal skin ora capable of
invading the stratum corneum given a warm, moist environment [7]. Corynebacterium produces porphyrins that uoresce coral-red under the Wood’s lamp in contrast to
Pseudomonas, which uoresces green. This procedure is
best performed in a darkened room.
Differential diagnoses include interdigital tinea pedis,
candida infection, and contact dermatitis. Treatment typically consists of topical erythromycin, clindamycin, or
Whiteld’s ointment (Fig.3.3).
3.1.4 Folliculitis
Folliculitis is an inammatory reaction that involves hair follicles. The result is either a pustule or an erythematous papule. Friction, occlusion, and perspiration are contributing
factors and the thighs and buttocks are commonly involved
Fig. 3.4 Folliculitis is an inammation of hair follicles
sites. Most cases are caused by Staphylococcus aureus
including both methicillin-sensitive and methicillin-resistant
strains [8]. Hot tub folliculitis is due to pseudomonas
colonization of hair follicles. The eruption associated with
this disorder typically develops within 48h of exposure to a
contaminated water source. Pityrosporum or malassezia folliculitis is a yeast infection that uncommonly occurs on the
lower extremities [9].
Folliculitis is usually self-limiting and resolves without
therapy although recurrence is not uncommon and may be
minimized by use of antibacterial soaps. Severe or persistent
cases may warrant topical and/or oral therapies directed at
the causative agent (Fig.3.4).
3.1.5 Impetigo
Impetigo is a common skin disorder in children but may
occur at any age [10]. The condition is highly contagious and
predominately affects the lower legs and face. The majority
3.2 Viral Infections
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of cases are caused by Streptococcus pyogenes or
Staphylococcus aureus and cuts and abrasions are common
bacterial entrance points. Contact sports such as wrestling
and football predispose to transmission.
Impetigo is classied as either nonbullous or bullous.
Nonbullous impetigo begins as an erythematous macule that
quickly vesiculates and ruptures. Dried serous uid contributes to the honey-combed, crusted appearance. Rubbing and
scratching lead to spread of lesions. Bullous impetigo presents with supercial, fragile bullae varying in size. Onset is
rapid and spontaneous drainage produces a collarette of scale
and crusts.
The diagnosis of impetigo is usually made clinically.
Lesions should be lightly cleansed to remove supercial
crusting. Topical mupirocin is used to treat isolated lesions
[11]. Oral antibiotics that cover both S aureus and S pyo-
genes may be instituted to decrease duration and extent of
disease (Fig.3.5) [12].
3.1.6 Pitted Keratolysis
Pitted keratolysis is a supercial bacterial skin infection
characterized by malodor and crateriform pitting that affects
the pressure-bearing areas of the soles [13]. The condition
occurs worldwide but is most prevalent in tropical countries.
Those at highest risk are athletes, military personnel, and
industrial workers and the disorder is most common in male
adolescents and young adults. Causative agents include
Kytococcus sedentarius, Dermatophilus congolensis, and
Corynebacterium [14]. These organisms produce proteases
that dissolve the stratum corneum and result in pits. Secreted
sulfur compounds contribute to the malodor. Most lesions
are asymptomatic and itching, burning, and pain on ambulation are infrequently noted.
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Fig. 3.6 Pitted keratolysis manifests as pits of the soles accompanied
by malodor
Diagnosis of pitted keratolysis is based on the clinical
appearance and accompanying odor. Preventative measures
include the use of cotton socks, frequent sock changes,
cleaning and drying of the feet after exercise or bathing, and
minimizing use of occlusive shoes. Successful treatment is
usually achieved with topical antibiotic therapies such as
clindamycin, erythromycin, fusidic acid, and mupirocin
[15]. Nightly application of a drying agent such as aluminum
chloride hexahydrate may help prevent recurrence (Fig.3.6).
3.2 Viral Infections
3.2.1 Hand, Foot, andMouth Disease
Hand, foot, and mouth disease is a contagious disorder that
primarily affects infants and children under the age of 10.
The condition is caused by enteroviruses and coxsackieviruses and is transmitted by fecal-oral, oral-oral, and respiratory droplet contact [16]. The incubation period is up to
6days. A prodrome of fever and malaise is followed in short
order by macules and vesicles arising on the hands and feet.
Shallow ulcers appear on the buccal mucosa and tongue and
these may be painful. Diagnosis is usually made clinically.
Hand, foot, and mouth disease is self-limiting with complete
resolution within 10days. Rare complications include aseptic meningitis and myocarditis (Fig.3.7) [17].
Fig. 3.5 Impetigo is a bacterial infection that presents as oozing,
crusted patches
3.2.2 Herpes Zoster
Herpes zoster, commonly known as shingles, is an acute,
painful, blistering eruption. The condition is caused by reactivation of the varicella zoster virus acquired as a sequela of
chicken pox infection. The virus remains latent in the sen-
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3 Infections andInfestations oftheLower Extremity
Fig. 3.7 Hand foot and mouth disease is a self-limited viral infection
(Courtesy of Lawrence Schiffman, DO)
sory ganglia until triggered by a defect in immune surveillance [18]. Precipitating factors include immunosuppressant
medications and malignancy. Incidence of herpes zoster is
highest in the elderly.
Herpes zoster presents as a painful skin rash in a dermatomal distribution. Shortly thereafter grouped vesicles arise
and these gradually resolve over the course of two to 3weeks.
Pain that persists greater than 30 days is referred to as
postherpetic neuralgia and this dreaded sequela may be
intense and incapacitating. The adjuvanted, recombinant
varicella zoster virus (VZV) vaccine (Shingrix) has demonstrated high efcacy as a preventative of shingles and is recommended for adults aged 50 and above (Fig.3.8) [19].
3.2.3 Molluscum Contagiosum
Molluscum contagiosum is a common skin disorder caused
by a poxvirus [20]. Close contact transmits the virus and
autoinoculation results in spread. Preschool and elementary
school children are predominately affected [21].
Characteristic lesions are dome shaped, esh to pink colored
papules with umbilicated centers. In healthy patients, infection is generally self-limited and resolves within several
months. Spontaneous resolution may be accompanied by an
Fig. 3.8 Herpes zoster presents as painful blisters on an erythematous
base (Courtesy of Alan Weisman, DPM)
inammatory, eczematoid reaction termed the BOTE sign
(short for, beginning of the end) [22].
Treatment with curettage or liquid nitrogen hastens resolution but ablative therapies may be somewhat traumatic to a
child and can result in hyperpigmentation (Fig.3.9).
3.2.4 Plantar Verruca
Plantar verrucae are caused by the human papillomavirus
(HPV). The virus can be found on oors, socks, and sporting
equipment and enters the skin through minor trauma. Upon
entrance into the epidermis HPV inoculates keratinocytes
and continues to replicate [23]. Lesions present as welldened papillomatous growths with overlying hyperkeratosis. Mosaic warts refer to groups of verrucae clustered
together. Pinpoint bleeding upon debridement and disruption
of normal skin lines differentiate warts from a plantar callus.
Further, lateral compression on a wart induces pain, whereas
a callus is most painful with direct pressure.
Preventative measures include avoidance of walking
barefoot in public areas such as swimming pools, locker
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Fig. 3.9 Dome-shaped papules are classic for molluscum contagiosum
Fig. 3.10 Plantar verruca are persistent and often require multiple
treatment sessions
rooms, gymnasiums, and public showers. Treatment may
prove challenging. Most lesions will eventually resolve
spontaneously but patients often seek treatment due to
discomfort or cosmesis [24]. Home remedies include wart
solutions containing salicylic acid and duct tape. Variable
results have been reported with topical agents including cantharidin, imiquimod, and 5-uorouracil. Liquid
nitrogen cryosurgery and laser ablation are ofce based
destructive therapies that usually require multiple sessions (Fig.3.10).
3.3 Infestations
3.3.1 Bed Bugs
Bed bugs are bloodsucking ectoparasites that are members of
the Cimicidae family [25]. The insects feed throughout the
night targeting exposed areas of skin such as the arms and
legs. Once feeding has ended, bed bugs will relocate to the
crevices of a bed or couch. Unengorged insects have at,
reddish-brown oval shaped bodies.
Skin lesions manifest as erythematous papules and are
extremely pruritic. Bites are often grouped in a linear array
of three, the pattern descriptively termed “breakfast, lunch,
and dinner” [26]. Individual bites respond to topical steroids
and typically resolve within several days. Steam cleaning or
treatment with insecticides is usually necessary for complete
eradication (Fig.3.11).
3.3.2 Fleas
Fleas (Siphonaptera) are bloodsucking ectoparasites and
over 2500 species are found worldwide [27]. Domestic cats
and dogs are the primary intermediaries to humans. The
body of eas is studded with pointed bristles that facilitate
movement within fur. Fleas cannot y but are impressive
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Fig. 3.11 Bed bug bites in groups of threes, referred to as breakfast,
lunch, and dinner
Fig. 3.12 Fleas are often transmitted to humans by their pets
3 Infections andInfestations oftheLower Extremity
Fig. 3.13 Scabies is a contagious skin condition caused by the mite
Sarcoptes scabiei
3.3.3 Scabies
Scabies is an intensely pruritic skin infestation caused by the
host-specic mite Sarcoptes scabiei var hominis. The condition is most commonly encountered in institutions such as
nursing homes and prisons [29]. The most prominent clinical
feature is intense itching especially worse at night. The pruritus is the result of a delayed type-IV hypersensitivity reaction to the mite, feces, and eggs [30]. Classic ndings are
burrows and small erythematous papules replete with excoriations and hemorrhagic crusts. A dark triangular structure
can be visualized on dermoscopy. The most common sites of
involvement are the nger and toe webs, wrists, buttocks,
genitals, and the breasts in women. Norwegian scabies is a
clinical variant that manifests thick crusts that are most
prominent on the hands and feet. Immunocompromised and
debilitated, elderly individuals are at greatest risk.
Successful treatment requires eradication of the mites and
may be accomplished with topical or oral anti-scabetic
agents [31]. Close contacts should be treated simultaneously
(Fig.3.13).
jumpers with hind legs allowing them to leap up to 150 times
their body length. Flea-bite dermatitis is an allergic reaction
caused by substances in their saliva [28]. Cat eas have a
predilection for biting ankles. Bites present as erythematous
papules that are often excoriated.
Fleas can transmit a number of illnesses including bubonic
plague, spotted fever rickettsiosis, and murine typhus.
Ridding a home of eas entails treating pets, washing bedding, and vacuuming carpets (Fig.3.12).
3.3.4 Ticks/Lyme Disease
Lyme disease is a tick-borne illness caused by Borrelia burgdorferi, a spirochetal bacterium. Cases are primarily located
in northeastern and mid-Atlantic states and are most frequent
between the months of May and September [32]. History
usually includes recent outdoor activity in a wooded area
with development of a rash following a tick bite. The annular
References
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Fig. 3.14 The characteristic rash of Lyme disease, erythema migrans,
resembles a “bull’s eye”
erythematous patch with central clearing, termed erythema
migrans, occurs at the site of the bite and is found in approximately 80% of cases. At least 24h of attachment is required
for disease transmission [33] and the incubation period
ranges from 3 to 20days.
Diagnosis of early Lyme disease is facilitated by recognition of the classic rash and history of tick bite in endemic
areas, with conrmation established by serologic testing.
First line treatment for early disease is doxycycline.
Untreated, the condition may lead to arthritis, carditis, and
neuropathy (Fig.3.14).
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Xerotic andHyperkeratotic Disorders
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oftheLower Extremity
Skin barrier function is dependent on the integrity of the stratum corneum. Xerotic and hyperkeratotic disorders are the
result of barrier dysfunction. Hydration and free fatty acids
contribute to skin integrity. Increased transepidermal water
loss causes dehydration of the stratum corneum. Loss of free
fatty acids accompanies the aging process and is accentuated
by frequent bathing and harsh detergents. Decreased free
fatty acids and dehydration lead to cell contracture.
Corneocytes curl upwards creating the clinical appearance of
scale.
4
4.1 Xerosis
Xerotic or dry skin may be classied as mild, moderate, or
severe in presentation [1]. On the foot, xerosis can be present
within the skin lines of the plantar surface or may be localized to scaling patches such as those seen in moccasin tinea
pedis. The condition most commonly occurs in the aging
population. Xerosis may be induced by environmental factors such as low humidity and may accompany medical conditions such as thyroid disease, diabetes, and kidney failure.
Pruritus is frequently an associated nding. Emollients and
keratolytics are the mainstays of therapy (Figs.4.1 and 4.2).
4.2 Corns andCalluses
Corns and calluses (also referred to as clavi, heloma, tyloma,
and keratoma) are hyperkeratotic lesions that arise in areas
of mechanical stress [2]. Corns refer to lesions on the dorsum
of the foot, whereas calluses describe plantar foot lesions.
Intractable plantar keratosis (IPK) refers to a focal hyperkeratotic plantar lesion that is a conical thickening of the
stratum corneum. The cone points deep into the foot. Both
mechanical trauma and genetic predisposition may play
roles in causality [3].
Fig. 4.1 Mild xerosis with scale visible within skin lines
Treatment of dorsal and hyperkeratotic lesions of the foot
includes sharp debridement, padding of the area to reduce
pressure, insole/orthotic devices, appropriate tting shoe
gear, keratolytic topical agents, and surgical correction of
any underlying bony deformity contributing to the corn/callus formation [3] (Fig.4.3).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
T. C. Vlahovic, S. M. Schleicher, Atlas of Lower Extremity Skin Disease, https://doi.org/10.1007/978-3-031-07950-4_4
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Fig. 4.2 Severe plantar xerosis
4 Xerotic andHyperkeratotic Disorders oftheLower Extremity
Fig. 4.3 Punctate keratoses on the plantar foot
4.3 Asteatotic Eczema (Erythema
Craquele)
Asteatotic or xerotic eczema is a common form of dry skin
encountered on the lower extremities. It is also termed
Fig. 4.4 Asteatotic eczema on the medial aspect of the leg
eczema craquelé due to a similar appearance to the ne
lines seen in porcelain [4] and winter itch due to its
increased severity in the winter months. Asteatotic eczema
commonly presents on the anterior aspect of the leg as pruritic, annular, scaling patches that can resemble tinea infection. It may also appear as ssures mimicking a dry
riverbed. Treatment consists of decreasing bathing frequency and application of moisturizing emollients after
bathing. More severe cases may warrant topical corticosteroid steroid therapy (Fig.4.4).
4.4 Keratoderma Climactericum
(Haxthausen’s Disease)
Keratoderma climactericum presents as cracking and ssuring of the plantar heel which may progress distally along the
sides of the foot. Post-menopausal females may also develop
cracking and ssuring of the heels plantarly [5]. The palms
of the hands may also be involved. The condition has a strong
correlation to obesity. Patients will often complain of pain
with ambulation especially in the presence of heel ssures.
Treatment consists of application of a keratolytic and an
emollient to decrease the thickness of the skin and improve
the epidermal skin barrier (Fig.4.5).
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