ECTHYMA

Ecthyma is a variation of impetigo, presenting at a deeper level of tissue.

It is usually associated with Group A (beta-hemolytic) Streptococcus. Ecthyma is a cutaneous infection by Streptococcus pyogenes or Staphylococcus aureus with a dermal extension. As it extends into the dermis, it is often referred to as a deeper form of impetigo.

Risk factors:

• Tissue damage from excoriations, insect bites or dermatitis and a compromised immune system as in diabetes or neutropenia, predisposes to the development of ecthyma. Other causes of immune compromise may include malignancy and HIV.
• Poor hygiene aids spread as do overcrowded living conditions.
• It is more common in hot and humid climates.
• Untreated impetigo with poor hygiene may progress to ecthyma.
• Malnutrition is also a risk factor.

Sign:

1. The most commonly affected sites are buttocks, thighs, legs, ankles, and feet.
2. It starts as a vesicle or pustule over inflamed skin and then deepens to ulcerate with an overlying crust.
3. The crust is grey-yellow and is thicker and harder than the crust of impetigo.
4. A shallow, punched-out ulcer is seen if the crust is removed.
5. The deep dermal ulcer has a raised and indurated margin.
6. Ecthyma lesions may remain of constant size and resolve without treatment or they can enlarge to 3 cm in diameter.
7. Ecthyma heals slowly, usually with a scar.
8. Regional lymphadenopathy is common, even with solitary lesions.

Differential diagnosis:

• Ecthyma gangrenosum (a similar condition caused by Pseudomonas spp.). It tends to be more severe and, if a diagnosis is delayed, there is a significant mortality.
• Streptococcal ecthyma can mimic potentially serious zoonotic infections.
• Ecthyma contagiosum is an alternative name for orf, which can look similar. The diagnosis of orf is usually based on the patient’s history of relevant exposure.
• Also, consider:
  • Insect bites
  • Leishmaniasis
  • Lymphomatoid papulosis
  • Pyoderma gangrenosum
  • Sporotrichosis
  • Venous or arterial ulcers

Investigations:

• Swab for bacteriology.
• Fasting glucose or HbA1c to exclude diabetes.
• FBC for neutropenia.

Treatment:

Non-drug

• Treatment depends on the progression of the disease.
• Hygiene is important. Use bactericidal soap and frequently change bed linens, towels, and clothing.
• Remove crusts and apply an antibiotic ointment daily.
• Povidone-iodine and hydrogen peroxide may be used as antiseptics.

Drugs

• Topical mupirocin ointment is very effective. Fusidic acid is an alternative. Topical antibiotics are usually satisfactory if the infection is localized.
• More extensive lesions require oral antibiotics, possibly for several weeks to obtain full resolution.
• Penicillin should be adequate to treat streptococci.
• If S. aureus is also present, an antibiotic-resistant to penicillinase may be advised.
• Consider parenteral antibiotics if there is widespread involvement.

Complications:

• Ecthyma rarely produces systemic symptoms.
• Invasive complications of streptococcal skin infections can include cellulitis and erysipelas, gangrene, lymphangitis, suppurative lymphadenitis, and bacteremia.
• Non-suppurative complications of streptococcal skin infections include scarlet fever and acute glomerulonephritis. Antibiotics do not appear to reduce the rate of post-streptococcal glomerulonephritis.
• Possible sequelae of secondary untreated S. aureus pyodermas include cellulitis, lymphangitis, bacteremia, osteomyelitis, and acute infective endocarditis. Some S. aureus strains produce exotoxins that can lead to staphylococcal scalded skin syndrome and toxic shock syndrome.

Prognosis:

Healing is slow with scar formation but a response to appropriate antibiotics occurs over several weeks.

Prevention:

In tropical climates, pay attention to hygiene and use insect repellents to reduce bites.