Folliculitis, Carbuncles, and Abscesses
Abscesses can develop from skin organisms introduced into the deeper tissue, from seeding of the skin from hematogenous sources such as bacteremia associated with endocarditis, or contiguously from infectious foci in the lung or gastrointestinal tract. In the former case, hair follicles serve as a portal of entry for a number of bacterial species, though S. aureus is the most common cause of localized folliculitis. Recurrent folliculitis is most common in black males in association with shaving (folliculitis barbae). Folliculitis can progress to small subcutaneous abscesses (furuncles), which either resolve with antibiotic treatment alone or progress to form very large, exquisitely painful carbuncles that require surgical drainage as well as antibiotics. Certain individuals seem predisposed to develop recurrent S. aureus infections (recurrent furunculosis) and most have underlying factors such as poor hygiene, nasal carriage of staphylococcus, or neurodermatitis. Though it is suggested that diabetic patients are prone to such infections, there are few data to support this concept. In contrast, patients with Job's syndrome classically have recurrent S. aureus infections. In addition, these patients have eosinophilia and high levels of immunoglobulin E (IgE) antibody in serum.
Treatment of recurrent furunculosis may require surgical incision and drainage as well as antistaphylococcal antibiotics such as nafcillin parenterally or dicloxacillin orally. Prevention is difficult, but some success has been realized with intranasal bacitracin or mupirocin ointment and hexachlorophene (pHisoHex) baths (in adults). Prophylactic antibiotics should be used only in severe cases.
Sebaceous glands empty into hair follicles and the ducts, if blocked (sebaceous cyst), may resemble a staphylococcal abscess or may become secondarily infected. Chronic folliculitis is uncommon except in acne vulgaris where normal flora, for example, Propionibacterium acnes, may play a role. Hidradenitis suppurativa occurs in either acute or chronic forms and can lead to recurrent axillary or pudendal abscesses.
Impetigo contagiosa is caused by S. pyogenes, and bullous impetigo by S. aureus. Both skin lesions may have an early bullous stage but then appear as thick crusts with a golden-brown color. Streptococcal lesions are most common in children 2 to 5 years of age, and epidemics may occur in settings of poor hygiene and particularly in children from lower socioeconomic conditions in tropical climates. It is important to recognize impetigo because of its potential relationship to poststrepto-coccal glomerulonephritis.
Pyomyositis is usually due to S. aureus, is common in tropical areas but rare in temperate climates, and commonly there is no known portal of entry. The most common presenting features are muscle pain (100%) and fever (81%).46 Blood cultures are positive in 14.3% of cases and common complications are bronchopneumonia (23.1%) and empyema (19.2%) and mortality is low (7.7%). In one series there was an association with tuberculosis of the dorsal-lumbar spine.46 Infection remains localized and shock does not occur, unless strains produce toxic shock syndrome toxin-1 (TSST-1) or certain enterotoxins. In contrast, S. pyogenes may induce a primary myositis referred to as streptococcal necrotizing myositis, which is associated with severe systemic toxicity. Such infections have been described recently as part of the Strep TSS.
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