Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5220_Библиотеки_им_академика_М_И_Перельмана.pdf
84 6 Common Cutaneous Infections
– Initiating antiviral treatment after 72 hours of onset of shingles may be recom-
mended if new lesions are still occurring or if there are any complications such
as neurologic or motor or ocular complications (Dworkin et al.
– Along with antiviral drugs, any analgesics such as NSAIDs can be given for pain
relief if needed. In author’s experience, most patients did not need anything more
stronger than NSAIDs for pain control.
– Postherpetic neuralgia (PHN) is the most dreaded complication. Although there
is no consensus on what qualifies as PHN, pain lasting for more than 90 days after
the onset of the shingles is conventionally thought to be PHN (Watson
– If PHN occurs gabapentin, pregabalin and amitriptyline are among the oral drugs
that can be tried. If PHN continues, a referral to dermatologist may help.
– The risk of having a second episode of HZ among immunocompetent people is
2017
estimated to be about 6.4% (John and Canaday
– Vaccine for shingles, shingrix can help in preventing shingles in those who were
affected with chicken pox in the past.
).
2007).
2011).
6.10 Cutaneous HPV Infection (Verruca Vulgaris or Warts)
– Warts are benign growths that are caused by human papillomavirus (HPV).
– A common wart is less than 1 cm in size and is hyperkeratotic.
–
Warts often have tiny black/red dots, that represent thrombosed capillaries on the
surface (Fig.
Morphologically warts can be of different types. For instance, flat warts (Fig. 6.11)
–
and filiform warts (Fig.
growths.
Based on the location, warts can be genital or extragenital.
–
6.10).
6.12). Filiform warts are finger-like hyperkeratotic
6.10 Cutaneous HPV Infection (Verruca Vulgaris or Warts) 85
Fig. 6.10 Verruca vulgaris.
Please note thrombosed
capillaries
Fig. 6.11 Flat warts
86 6 Common Cutaneous Infections
Fig. 6.12 Filiform warts
(flat warts can also be seen)
6.10.1 Diagnosis
– Warts can usually be diagnosed clinically. The presence of thrombosed capillaries
that is manifested as black or red dot to the naked eye, if present is helpful in
diagnosis. Palmar and plantar warts can be differentiated from callosities by the
fact that unlike callosities, they interfere with skin lines (dermatoglyphics). In
adults, seborrheic keratosis, squamous cell cancer can sometimes come in the
differential diagnosis of warts. Skin biopsy can be done for histopathological
diagnosis if necessary for the confirmation of the clinical diagnosis of warts.
Warts are self-limiting; most of them clearing within about two years in young
–
people (Williams et al. 1993).
–
In adults, it might persist for years if untreated (Sterling 2019).
6.10 Cutaneous HPV Infection (Verruca Vulgaris or Warts) 87
6.10.2 Management
– Various regimens are used. None of these cures HPV. They mainly act by
destruction or immunomodulation (Arndt
regimens given for extragenital warts:
– Daily application of salicylic acid. It is available as a maximum strength of 40%
without prescription in the US.
– Cryotherapy is often the most common office-based treatment modality employed.
The reported median cure rate for it is about 49%. Cryotherapy is done with liquid
nitrogen with an approximate freeze time of 5–30 s (based on size and site of the
lesion) is repeated every 2–3 weeks (Sterling et al.
– 5% 5-fluorouracil twice daily: The reported cure rate with occlusion for 4 weeks
is about 95% in one study (Sterling et al.
– Imiquimod 5% cream is to be applied 3–5 times/week for a maximum of 16 weeks
(Arndt et al.
– Tretinoin 0.1% cream or gel.
2011).
2011). Given below are some of the
2014).
2014).
– Surgical excision can also be done.
–
Genital warts: Specific treatment includes topical podophyllotoxin 0.5% solu-
tion for 3 days on and 4 days off for 4 weeks or sinecatechins (15% ointment).
Cryotherapy can also be used.
–
Please see Chap. 15, ‘Feet’ Figs. 15.6 and 15.7 for plantar wart and periungual
wart pictures, respectively.
88 6 Common Cutaneous Infections
Fungal Infections
Dermatophytosis
Cutaneous Candidiasis.
6.11 Dermatophytosis (Ring Worm)
– It is a superficial fungal infection that affects the skin, hair and nails.
– It is caused by fungi known as dermatophytes. The causative species belong to
genus Microsporum, Trichophyton and Epidermophyton (Kovitwanichkanont and
2019).
Chong
– The name of the skin condition affected by them is often based on the part of the
body that is involved—Tinea corporis (Body), Tinea capitis (Head), Tinea faciei
(face), Tinea barbae (beard) Tinea cruris (body folds), Tinea manuum (hand),
Tinea pedis (Feet), Tinea unguium (onychomycosis).
– Clinical presentation: The exact clinical presentation can vary depending on the
body site involved.
– The classical description of ringworm is annual erythematous plaques with
central clearing and raised borders with fine scaling.
– Tinea corporis (T. corporis) (Fig. 6.13), tinea barbae, tinea cruris, tinea faciei
presents with classical description.
6.11 Dermatophytosis (Ring Worm) 89
Fig. 6.13 Tinea corporis.
Borders are raised
6.11.1 Tinea Manuum (T. manuum)
– It is the name given to dermatophytic infection that affects either dorum of the
hands or palms or finger web spaces (Chamorro et al.
2024). The affected palms
present with diffuse scaling of palms and the finger creases are usually accentuated
(Craddock and Schieke
The dorsa, if affected, has classical T. corporis presentation. Often only one hand
–
2019).
is involved along with the involvement of both feet—giving it the name—‘Two
feet, one hand syndrome’.
6.11.2 Tinea Cruris (Jock Itch) (T. cruris)
– Is the name given if dermatophytic infection involves either groin or pubic area
or genitalia or perianal or perineal region (Pippin et al.
– It manifests classically as erythematous annular plaques. When groin is involved,
it usually spares the genitalia (Rippon
1988).
– Please see Chap. 13, ‘Genitals and Groin’ for the picture of T. cruris (Fig. 13.1)
and details regarding its clinical manifestations, diagnosis and management.
2024).
90 6 Common Cutaneous Infections
6.11.3 Tinea Pedis (T. pedis)
– Dermatophytic infection of feet is termed tinea pedis.
– Can manifest as either interdigital or moccasin or bullous/vesicular form.
– Interdigital form can present with peeling or maceration or fissuring or scaling
affecting the lateral toe clefts.
– Moccasin type presents as patchy or diffuse scaling on the soles and the lateral
and medial aspects of the feet (Fig.
– Bullous form manifests as blisters on the sole.
– Please see Chap. 15, ‘Feet’ section on tinea pedis for more details on its clinical
presentation, diagnosis and management.
Fig. 6.14 Tinea pedis
(moccasin distribution). Also
note Tinea ungiuum
6.14).
6.11 Dermatophytosis (Ring Worm) 91
6.11.4 Tinea Capitis (T. capitis) (Figs. 6.15 and 6.16)
– Dermatophytic infection of the head is termed tinea capitis. It can be associated
with both alopecia and scaling. Alopecia can be both scarring and non-scarring.
– Several variations of presentations are seen.
– If hair loss is present, it is usually patchy. In the non-scarring type of alopecia, the
clinical picture can vary depending on the level of breakage of hair. For instance,
if the hair is broken at the surface of the scalp, it manifests as patchy hair loss with
‘Black dot’ appearance. Otherwise, it can present as patchy alopecia with ‘gray
scales or patches’ (Craddock and Schieke
– Sometimes, it can also present as diffuse scaling without alopecia (Bershow 2022).
– Favus (seen with yellow crusts) and kerion (present with boggy swelling) are the
inflammatory types of T. capitis and that can result in scarring alopecia (Bershow
2022).
2019;Bershow 2022).
Fig. 6.15 T. capitis with non-cicatricial hair loss
92 6 Common Cutaneous Infections
Fig. 6.16 T.capitis with
cicatricial hair loss. Courtesy
Dr. P.V. Krishna Rao,
Dermatologist, India
6.11.5 Onychomycosis or Tinea Unguim or Nail Fungus
Please see Chap. 16
–
, ‘Common Disorders Of Nails’ for clinical presentation,
diagnosis and management of onychomycosis.
6.11.6 Diagnosis of Dermatophytic Infections
– Skin scrapings can be scraped and examined under potassium hydroxide (KOH)
preparation.
– Scrapings can also be sent for fungal culture.
Skin biopsy can be done for histopathological examination.
–
For T. capitis, culture is preferred. It is best to initiate treatment while waiting on
–
culture results as culture often takes few weeks to report.
6.12 Cutaneous Candidiasis 93
6.11.7 Management of Dermatophytes
– T. capitis: Only topical treatment has no role. Griseofulvin is usually the preferred
choice. Oral terbinafine is another option. Fluconazole and itraconazole can also
be used although they are not FDA approved for this condition. This can be
supplemented with shampoos such as selenium sulfide shampoos (Information
for Healthcare Professionals
2020).
– T. corporis/cruris/manuum/pedis: Topical allylaamines (Terbinafine) and
imidazoles such as ketoconazole, clotrimazole or any other newer topical antifungals can be used. Oral antifungal therapy such as terbinafine 250 mg/day for
2–8 weeks [42] or fluconazole 150 mg/week for 4 weeks (Craddock and Schieke
2019) can be administered in adult cases not responding to topical antifungals or
for extensive lesions.
6.12 Cutaneous Candidiasis
– Candidia albicans is the common organism causing it (Taudorf et al. 2019).
– It is an opportunistic infection.
– Affects mainly intertriginous areas.
– Besides pruritus, there could be tenderness, and pain in the affected areas.
– Typical Distribution: Inframammary, axillae, groins, perineal and intergluteal
cleft.
– Manifests as moist looking, well-demarcated, erythematous patches (Fig. 6.17).
Fig. 6.17 Inframammary
candidiasis