Superficial Pyoderma

Origin of the Disease’s Name

The term pyoderma disease comes from its etiopathogenesis. It is a suppuration skin disease caused by pyogenic coca. Pyon is Greek for pus and derma is Greek for skin. It is most often Staphylococcus aureus and Streptococccus pyogenes ß-haemolyticus. Surface pyoderma is divided into several different nosological units, depending on where it appears. They are all typical efflorescence with characteristic suppuration manifestations.

The Skin’s Natural Defence Mechanism

There are resident bacteria in the hair follicles and sebaceous glands, which represent a permanent settlement and play an important role in the defence of anti-pathogenic bacterium. These include coagulase-negative staphylococci (S. epidermidis, myco-cocci), coryneform microorganisms (Propionibacterium acnes syn. Cutibacterium acnes, Corynebateriaceae). These so-called resident bacteria florae produce lipases that break down the sebum into fatty acids, which directly contribute to eliminating pathogenic staphylococci and streptococci. In addition, they form an acidic coat that promotes the growth of Propionibacterium, producing propionic acid, which is highly antimicrobial. Recent studies show that human keratinocytes produce antimicrobial peptides and proteins (ex. ß-defenzin 2 and ß-defenzin 3) that can prevent the development of growing pathogens if the skin’s barrier functions are intact. ⁽¹⁾

Using traditional soaps and shampoos containing sodium lauryl sulphate has a major destructive effect on the condition of these defence systems. Avoid using these drying detergents during your hygiene routine. ⁽²⁾ It is essential to use soaps and shampoos that don’t contain these ingredients.

A Bit of History

The British dermatology professor, Sam Shuster from the University of East Anglia, claimed that Karel Marx suffered from a chronic skin disease, which also has a demonstrable effect on the patient’s mental health. According to Shuster, Marx suffered from fistulent pyoderma (hidradenitis suppurativa), which is a suppuration inflammation of the large sweat glands that are primarily located in the armpit and the crotch area.

“In addition to his disease limiting his work, which further worsened his already stressful financial situation, it also significantly lowered his self-esteem. This explains the hatred he felt towards himself and the sense of alienation, which then resonated and developed in his writing,” claims Shuster in his new article for the British Journal of Dermatology.

Definition

Pyoderma is a bacterial skin infection that is most often caused by pyogenic (pus-inducing) bacteria. These are usually staphylococci and streptococci. It affects the skin, the corium and even the subcutaneous ligaments. It is usually an acute disease with a recurring tendency.

Origin and Spread Factors

The first agent, Staphylococcus aureus produces coagulase and hemolysins, which facilitate the vertical penetration of the infection along the hair follicles, deep into the sweat and sebaceous glands.

The second agent, Streptococccus pyogenes ß-haemolyticus produces streptokinase and hyaluronidase, thereby facilitating horizontal penetration. Some streptococcus and staphylococci strains can produce exotoxins. The effect of staphylococci epidermolytic toxins lead to dermatitis exfoliativa stahhylogenes syn. Lyell’s syndrome, or the release of other biologically active mediators, like cytokines, which lead to the toxic shock syndrome. Streptococci and staphylococci can also penetrate into the bloodstream and the lymphatic system and cause disseminated manifestations, like coagulopathy and vasculopathy. ⁽¹⁾⁽³⁾

Classification

Pyoderma is classified according to the infection location to the Pyoderma bound to the follicles – ostiofolliculitis folliculitis, furunculus and carbunculus, bound to the sweat glands – hidradenitis suppurativa syn. acne inversa and bound to the nails – paronychia.

It is also classified according to the depth of penetration on the surface, on the depth – ecthyma, erysipel, flegmona and on syndromes caused by bacterial toxins – staphylogennic Lyell’s syndrome and the toxic shock syndrome.

Surface Pyoderma includes impetigo and bullous repens. ⁽¹⁾

Impetigo (syn. impetigo contagiosa)

The name of the disease describes its clinical behaviour. Impetere is Latin for attack and refers to the fact that the disease is highly infectious and spreads rapidly, both intra and inter-individually.

It is a common, contagious, surface bacterial infection, most often visible of the faces and extremities of younger children. It often occurs in children’s groups. It is more prevalent in the summer months and in worse hygiene conditions.

It is either classified as primary impetigo, a direct bacterial invasion of originally normal skin or as secondary impetigo, an infection at the site of skin trauma. Secondary impetigo is referred to as impetiginisation.

The disease manifests itself in two forms, either as a maculovesicular form, which is caused by streptococci or the bullous form, which is caused by staphylococci.

The primary efflorescence of the maculovesicular form is a red macula with small vesicles that rapidly turn into pustules, which rupture and form erythematous deposits covered with honey crust formations of dry secretions (Fig. 1,2,3,4,5).

The primary efflorescence of the bullous form is a clear, blister the size of a lentil or pea at the erythematosus with a cover that peels off easily and forms wet deposits with a scale-like collar around it. ^{(4) (5)}

Surprisingly, the children, who are affected, tend to be in a mentally healthy. ⁽⁶⁾

The diagnosis is determined according to the clinical picture and possible bacteriological examination.

In differential diagnosis, it is necessary to distinguish morsus insecti, eczema nummulare, herpes simplex, tineu, prurigo simple x and autoimmune bullous dermatoses. ⁽⁴⁾

Bulla repens

The name of the disease derived from bulla, which is Latin for blister and repens, which is Latin for sudden.

It is an acute localized bullous staphylococci infection with rapid clinical manifestation (Fig.6).

Very strong blisters, with rough layers form at the erythematosus base, especially on the fingers, palms or soles of the feet. There is usually only one, large blister. When present of the fingers, the blister lines the entire nail and moves to the nail wall. The nail bed is also affected sometimes. In such a case, the entire nail moves freely or completely falls off. The surface of the blister is very hard and cannot be broken. The blister is full of yellowish pus. Subjectively, the disease evokes pain and tension, which however, is less intense than panaricia.⁽⁷⁾

In differential diagnosis, it is worth considering panaricium, which is very painful and requires surgery and herpes simplex, which has many poly-cyclical blisters confined to one area.

Therapy

External therapy includes local treatment using antiseptic solutions and antibiotic ointments.

Using antiseptics is beneficial because of their wide range of effects, they are highly effective in therapy, there is low risk of pathogen resistance in comparison with administering systemic antibiotics and last but not least, the treatment is cost-effective. It is beneficial to use such antiseptics, which have a so-called remanent effect, so the active agents remain at the site of application, thereby significantly prolonging their effect (from this point of view, hydrogen peroxide is not suitable. In contrast, octenidine dihydrochloride is described as having a remanent effect).

Tab. 1 illustrates the most frequently used, mass produced antiseptic medicinal products, along with the indicated use and the ones that are generally recommended by paediatricians. Antiseptics containing iodine (povidonum iodinatum) are not recommended on new-borns and infants younger than six months due to the risk of induced hypothyroidism, especially when treating open wounds, where the risk is higher than when disinfecting the undamaged skin. Its use is associated with the need for a thyroid gland hormone examination. The use of hydrogen peroxide is limited when disinfecting deep wounds and abscess cavities, where there is a risk of tissue emphysema and oxygen embolism.

Table 1

Antiseptic	Type of Antiseptic	Principle of Effect	Sensitive Microorganisms	Resistant Microorganisms
Hydrogen peroxide 3%	Oxidizing agents	Release of reactive oxygen radical	bacteria, weak effect on viruses, spores	Some viruses
Potassium permanganate 0.1–1%	Oxidizing agents	Release of reactive oxygen radical	bacteria, yeasts, viruses	Spores
Octenidine dihydrochloride (ex. Octicide)	Cationic antiseptic / phenoxyethanol combination	Disrupt the cytoplasmatic membrane	G+ and G- bacteria, fungi, yeasts
Chlorhexidine (ex. Cyteal)	Cationic antiseptic	Disrupt the cytoplasmatic membrane	G+ i G- bacteria, fungi, yeasts, some viruses
Benzododecinii bromati solution 10% (ex. Ajatin sol.)	Quaternary ammonium salts		Primarily G+ bacteria significantly higher effect on G+, in higher concentrations also on G-, anti-fungal effect uncertain	Viruses, myco-bacterium, bacterial spores
Carbethopendecinii bromidum (ex. Septonex sol.)	Quaternary ammonium salts	Disrupts the membrane’s transport function	Primarily G+ bacteria significantly higher effect on G+, in higher concentrations also on G-, anti-fungal effect uncertain	Viruses, myco-bacterium, bacterial spores
Povidonum iodinatum (ex. Betadinae sol., ung.)	Halogens – iodine	Significant oxidizing effect, binds to -SH and -OH amino acid and enzyme groups	bacteria G+ and G-, spores, bacteria, mycobacteria, viruses, fungi, yeasts

Selecting the suitable galenic forms (solution, ointment, bath) depends on the range and character of the patient’s diseases or allergies. Less frequent baths with antiseptics can be used by patients, whose body needs to be decolonized from pathogenic bacteria P. aeruginosa, S. aureus, MRSA, Klebsiella spp. and the like.

When used long-term, keep in mind that there is a risk of resistance and depending on the antiseptic used, taking into account the information regarding the risk of resistance stated in the SPC, consider switching to another active agent.

The standard procedure is combining antiseptics with antibiotic ointments (ex. Fucidin ointment, Bactroban ointment),

During therapy, it is recommended to use dedicated natrium lauryl sulphate-free antiseptic syndettes for washing the body (ex. Cutosan® washing gel).

It is suitable to gently remove the crust using keratolytic and ichtamol ointments ⁽¹⁾

We administer systematic antibiotic therapy if external therapy is not effective enough, the patient is suffering from general symptoms (febrility, lethargy, etc.) or the patient is a high-risk patient (atopic eczema, immune disorders, diabetes, autoimmune diseases).

Prevention

Due to the ease of transfer, hygienic measures need to be taken (using your own towel, undergarments, etc.). Immediately isolate sick children from the collective.

Resumé

Surface Pyoderma are diseases with a good prognosis. There is a risk of glomerulonephritis and staphylogenesis Lyell’s syndrome only if treatment is neglected. It is necessary to follow preventive hygienic measures if there is an onset of the disease.

Literature:

1. ŠTORK J. et al. Dermato-venerology, Prague Galén, 2008, p. 83-89
2. BENÁKOVÁ N. Eczema and dermatitis, Prague Maxdorf Jessenius, 2013, 3^rd edition, p. 165-166
3. BARTOŇOVÁ J. Bacterial skin diseases in a paediatric clinic, Clinic 2014; 15(4): p. 206–208
4. BENÁKOVÁ N. et al. Modern pharmacotherapy in dermatology, Prague: Maxdorf: 2020, p. 58-60
5. DANDA V. et al. Selected chapters from dermato-venerology, Hradec Králové: Jan Evangelista Military Medical Academy 1979, p.70
6. BAKER, H. Clinical dermatology, fourth edition, London: Bailliere Tindall 1989, p. 52-53
7. BRAUN-FALCO, O., PLEWIG, G., WOLF, H. Dermatology and venerology, Osveta, s.r.o., Martin, 2001, p. 166

Dermatology Clinic, Černošice

AUTHOR’S MAILING ADDRESS:

MUDr. et MUDr. Pavel Konrád, pavel.konrad@volny.cz

Dermatology Clinic, Mokropeská 2027, Černošice