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Humans are natural hosts for many bacterial species that colonize the skin as normal flora. For most patients with impetigo, topical treatment is adequate, either with bacitracin (Polysporin) or mupirocin (Bactroban), applied twice daily for 7 to 10 days. Folliculitis is a superficial infection of the hair follicles characterized by erythematous, follicular-based papules and pustules. Topical treatment with clindamycin 1% or erythromycin 2%, applied two or three times a day to affected areas, coupled with an antibacterial wash or soap, is adequate for most patients with folliculitis.
Infection begins with vesicles and bullae that progress to punched-out ulcerations with an adherent crust, which heals with scarring.
Erysipelas is a superficial cutaneous infection of the skin involving dermal lymphatic vessels. Group A β-hemolytic streptococcus is the most common pathogen responsible for erysipelas, and S.
Classically, erysipelas is a tender, well-defined, erythematous, indurated plaque on the face or legs (Fig. Diagnosis is by clinical presentation and confirmation by culture (if clinically indicated, ie., bullae or abscess formation).
Necrotizing fasciitis is a rare infection of the subcutaneous tissues and fascia that eventually leads to necrosis. Infection begins with warm, tender, reddened skin and inflammation that rapidly extends horizontally and vertically. Necrotizing fasciitis is a surgical emergency requiring prompt surgical debridement, fasciotomy, and, occasionally, amputation of the affected extremity to prevent progression to myonecrosis.
Dermatophytosis implies infection with fungi, organisms with high affinity for keratinized tissue, such as the skin, nails, and hair. Tinea cruris (jock itch) occurs in the groin and on the upper, inner thighs and buttocks as scaling annular plaques (Fig. Tinea corporis (body), faciei (face), and manuum (hands) represent infections of different sites, each invariably with annular scaly plaques. For most patients, topical treatment with terbinafine (Lamisil), clotrimazole (Lotrimin, Mycelex), or econazole (Spectazole) cream is adequate when applied twice daily for 6 to 8 weeks. Candidiasis refers to a diverse group of infections caused by Candida albicans or by other members of the genus Candida.
Infection is common in immunocompromised patients, diabetics, the elderly, and patients receiving antibiotics.
Candidal intertrigo is a specific infection of the skin folds (axillae, groin), characterized by reddened plaques, often with satellite pustules (Fig.
For candidal intertrigo and balanitis, topical antifungal agents such as clotrimazole, terbinafine, or econazole cream, applied twice daily for 6 to 8 weeks, is usually curative when coupled with aeration and compresses.
Tinea versicolor is a common opportunistic superficial infection of the skin caused by the ubiquitous yeast Malassezia furfur. Infection produces discrete and confluent, fine scaly, well-demarcated, hypopigmented or hyperpigmented plaques on the chest, back, arms, and neck (Fig.
Selenium sulfide shampoo (2.5%) or ketoconazole shampoo is the mainstay of treatment, applied to the affected areas and the scalp daily for 3 to 5 days, then once a month thereafter.
Herpes simplex virus (HSV) infection is a painful, self-limited, often recurrent dermatitis, characterized by small grouped vesicles on an erythematous base. Disease follows implantation of the virus via direct contact at mucosal surfaces or on sites of abraded skin.
Primary infection occurs most often in children, exhibiting vesicles and erosions on reddened buccal mucosa, the palate, tongue, or lips (acute herpetic gingivostomatitis). Viral culture helps to confirm the diagnosis; direct fluorescent antibody (DFA) is a helpful but less-specific test. Acyclovir remains the treatment of choice for HSV infection; newer antivirals, such as famciclovir and valacyclovir, are also effective.
Herpes zoster (shingles) is an acute, painful dermatomal dermatitis that affects approximately 10% to 20% of adults, often in the presence of immunosuppression. During the course of varicella, the virus travels from the skin and mucosal surfaces to the sensory ganglia, where it lies dormant for a patient's lifetime. Herpes zoster is primarily a disease of adults and typically begins with pain and paresthesia in a dermatomal or bandlike pattern followed by grouped vesicles within the dermatome several days later (Fig. Zoster deserves treatment, with rest, analgesics, compresses applied to affected areas, and antiviral therapy, if possible, within 24 to 72 hours of disease onset.
HPV infection follows inoculation of the virus into the epidermis through direct contact, usually facilitated by a break in the skin.
The common wart is the most common type: It is a hyperkeratotic, flesh-colored papule or plaque studded with small black dots (thrombosed capillaries) (Fig.
The disease follows direct contact with the virus, which replicates in the cytoplasm of cells and induces hyperplasia. Molluscum are smooth pink, or flesh-colored, dome-shaped, umbilicated papules with a central keratotic plug (Fig.
Treatment might not be necessary because the disease often resolves spontaneously in children. Impetigo is a superficial skin infection usually caused by Staphylococcus aureus and occasionally by Streptococcus pyogenes. Tinea versicolor is a common superficial infection of the skin caused by the ubiquitous yeast Malassezia furfur. Herpes simplex virus infection is a painful, self-limited, often recurrent dermatitis, characterized by small grouped vesicles on an erythematous base. Staphylococcus aureus and Streptococcus pyogenes are infrequent resident flora, but they account for a wide variety of bacterial pyodermas.
The nonbullous type is more common and typically occurs on the face and extremities, initially with vesicles or pustules on reddened skin.
Furuncles are deeper infections of the hair follicle characterized by inflammatory nodules with pustular drainage, which can coalesce to form larger draining nodules (carbuncles). Systemic antistaphylococcal antibiotics are usually necessary for furuncles and carbuncles, especially when cellulitis or constitutional symptoms are present.2 Small furuncles can be treated with warm compresses three or four times a day for 15 to 20 minutes, but larger furuncles and carbuncles often warrant incision and drainage.


Ecthyma is usually a consequence of neglected impetigo and often follows impetigo occluded by footwear or clothing.
An oral antistaphylococcal antibiotic is the treatment of choice for cellulitis; parenteral therapy is warranted for patients with extensive disease or with systemic symptoms as well as for immunocompromised patients.
Necrotizing fasciitis commonly occurs on the extremities, abdomen, or perineum or at operative wounds (Fig.
Tinea unguium (onychomycosis) is fungal nail disease, characterized by thickened yellow nails and subungual debris (Fig. These organisms typically infect the skin, nails, mucous membranes, and gastrointestinal tract, but they also cause systemic disease. The counterpart in men is balanitis, characterized by shiny reddish plaques on the glans penis, which can affect the scrotum. For thrush, the treatment is nystatin suspension or clotrimazole troches four to six times daily until symptoms resolve. Purported risk factors include oral contraceptive use, heredity, systemic corticosteroid use, Cushing's disease, immunosuppression, hyperhidrosis, and malnutrition. Potassium hydroxide preparation exhibits short hyphae and spores with a spaghetti-and-meatballs appearance.
Alternatively, a variety of topical antifungal agents, including terbinafine, clotrimazole, or econazole cream, applied twice daily for 6 to 8 weeks, constitute adequate treatment, especially for limited disease.11 Systemic therapy may be necessary for patients with extensive disease or frequent recurrences, or for whom topical agents have failed. HSV type 2 infection is responsible for 20% to 50% of genital ulcerations in sexually active persons. After primary infection, the virus travels to the adjacent dorsal ganglia, where it remains dormant unless it is reactivated by psychological or physical stress, illness, trauma, menses, or sunlight.
For recurrent infection (more than six episodes per year), suppressive treatment is warranted. Reactivation often follows immunosuppression, emotional stress, trauma, and irradiation or surgical manipulation of the spine, producing a dermatomal dermatitis. Anogenital warts are a sexually transmitted infection, and partners can transfer the virus with high efficiency. Maceration of the skin is an important predisposing factor, as suggested by the increased incidence of plantar warts in swimmers. Most modalities are destructive: cryosurgery, electrodesiccation, curettage, and application of various topical products such as trichloroacetic acid, salicylic acid, topical 5-fluorouracil, podophyllin, and canthacur.
Infection is common in children, especially those with atopic dermatitis, sexually active adults, and patients with human immunodeficiency virus (HIV) infection.
Treatment is comparable to the modalities outlined for warts; cryosurgery and curettage are perhaps the easiest and most definitive approaches.
Predisposing factors to infection include minor trauma, preexisting skin disease, poor hygiene, and, rarely, impaired host immunity. Impetigo commonly occurs on the face (especially around the nares) or extremities after trauma. The vesicles or pustules eventually rupture to leave the characteristic honey-colored (yellow-brown) crust (Fig. Cellulitis is a warm, tender, erythematous, and edematous plaque with ill-defined borders that expands rapidly. Good hygiene, warm compresses three or four times a day for 15 to 20 minutes, and elevation of the affected limb help to expedite healing. Thrush is oropharyngeal candidiasis, characterized by white nonadherent plaques on the tongue and buccal mucosa.
HSV type 1 is usually associated with orofacial disease, and HSV type 2 is usually associated with genital infection. The Tzanck smear can be helpful in the rapid diagnosis of herpesviruses infections, but it is less sensitive than culture and DFA. Other types of warts include flat warts (verruca plana), plantar warts, and condyloma acuminatum (venereal warts). A quadrivalent HPV vaccine (Gardasil) has been available since 2006, and this represents the newest approach to preventing genital HPV infection and ultimately cervical cancer in women. Most patients have many papules, often in intertriginous sites, such as the axillae, popliteal fossae, and groin. In children, canthacur, applied topically then washed off 2 to 6 hours later, is well tolerated, and is very effective. Occasionally, a pustule enlarges to form a tender, red nodule (furuncle) that becomes painful and fluctuant after several days. Often a continuum of folliculitis, furunculosis (furuncles), arises in hair-bearing areas as tender, erythematous, fluctuant nodules that rupture with purulent discharge (Fig. Untreated staphylococcal or streptococcal impetigo can extend more deeply, penetrating the dermis, producing a shallow crusted ulcer. Cellulitis is often accompanied by constitutional symptoms, regional lymphadenopathy, and occasionally bacteremia (Fig. Within 48 to 72 hours, affected skin becomes dusky, and bullae form, followed by necrosis and gangrene, often with crepitus.
Kerion celsi is an inflammatory form of tinea capitis, characterized by boggy nodules, usually with hair loss and regional lymphadenopathy. Alterations in the host environment can lead to its proliferation and subsequent skin disease. Paronychia is an acute or chronic infection of the nail characterized by tender, edematous, and erythematous nail folds, often with purulent discharge (Fig. For paronychia, treatment consists of aeration and a topical antifungal agent such as terbinafine, clotrimazole, or econazole for 2 to 3 months; occasionally, oral antistaphylococcal antibiotics are needed, coupled with incision and drainage for secondary bacterial infection. Herpes labialis (fever blisters or cold sores) appears as grouped vesicles on red denuded skin, usually the vermilion border of the lip; infection represents reactivated HSV.
The rough surface of a wart can disrupt adjacent skin and enable inoculation of virus into adjacent sites, leading to the development and spread of new warts.
The immunomodulator imiquimod cream (Aldara) is a novel topical agent recently approved for treating condyloma acuminatum, and it might help with common warts as well, usually as adjunctive therapy. The vaccine is safe and 100% effective and is recommended for girls and women ages 9 to 26 years. Different types of hormones control reproduction, metabolism (food burning and waste elimination), and growth and development. Antimicrobial therapy should be continued until inflammation has regressed or altered depending on culture results.


Ecthyma can evolve from a primary pyoderma, in a pre-existing dermatosis, or at the site of trauma.
Left untreated, cellulitic skin can become bullous and necrotic, and an abscess or fasciitis, or both, can occur. Without prompt treatment, fever, systemic toxicity, organ failure, and shock can occur, often followed by death. Cheilitis resolves with aeration, application of a topical antifungal agent, and discontinuation of any aggravating factors. Primary genital infection is an erosive dermatitis on the external genitalia that occurs about 7 to 10 days after exposure; intact vesicles are rare. When zoster involves the tip and side of the nose (cranial nerve V) nasociliary nerve involvement can occur (30%-40%). Sexual partners of patients with condyloma warrant examination, and women require gynecologic examination.
Hormones also control the way you respond to your surroundings, and they help to provide the proper amount of energy and nutrition your body needs to function. Computed tomography (CT) or magnetic resonance imaging (MRI) can help to delineate the extent of infection.
Angular cheilitis is the presence of fissures and reddened scaly skin at the corner of the mouth, which often occurs in diabetics and in those who drool or chronically lick their lips (Fig.
A single 150-mg dose of fluconazole, coupled with aeration, is usually effective for vulvovaginitis.10 Treatment is summarized in Box 1.
Most patients with zoster do well with only symptomatic treatment, but postherpetic neuralgia (continued dysthesias and pain after resolution of skin disease) is common in the elderly. The glands that make up the endocrine system include the thyroid, parathyroid, pancreas, ovaries, testes, adrenal, pituitary and hypothalamus.What is an endocrinologist?An endocrinologist is a specially trained doctor. Prodromal symptoms of pain, burning, or itching can precede herpes labialis and genital herpes infections. They know how to treat conditions that are often complex and involve many systems within your body. Your primary care doctor refers you to an endocrinologist when you have a problem with your endocrine system.What do endocrinologists do?Endocrinologists are trained to diagnose and treat hormone imbalances and problems by helping to restore the normal balance of hormones in your system.
They take care of many conditions including:diabetesthyroid diseasesmetabolic disordersover or under production of hormonesmenopauseosteoporosishypertensioncholesterol (lipid) disordersinfertilitylack of growth (short stature)cancers of the endocrine glandsEndocrinologists also conduct basic research to learn the way glands work, and clinical research to learn the best methods to treat patients with a hormone imbalance.
Through research, endocrinologists develop new drugs and treatments for hormone problems.What type of medical training do endocrinologists receive?Endocrinologists finish four years of medical school and then spend three or four years in an internship and residency program. These specialty programs cover internal medicine, pediatrics, or obstetrics and gynecology. Overall, an endocrinologist's training will take more than 10 years.What are the most common endocrine diseases and disorders?Diseases and disorders of the endocrine system can be grouped into several different areas.
Some endocrinologists focus on one or two endocrine system diseases, such as diabetes, pediatric disorders, thyroid, or reproductive and menstrual disorders. The major areas of endocrinology are described below.DiabetesPatients with diabetes have too much sugar in their blood. Recent studies have found that controlling blood sugar helps prevent serious problems that can be caused by diabetes. These can include problems with the eyes, kidneys and nerves, which can lead to blindness, dialysis, or amputation.
They also work closely with patients to control blood sugar and monitor them so they can prevent health problems.ThyroidPatients with thyroid conditions often have problems with their energy levels. They may also have problems with muscle strength, emotions, weight control, and tolerating heat or cold. Endocrinologists treat patients with too much or too little thyroid hormone (conditions respectively caused by either an overactive or underactive thyroid).
Endocrinologists also receive special training to manage patients with thyroid nodules or thyroid cancer, and enlarged thyroid glands.BoneOsteomalacia (rickets), which causes bones to soften, and osteoporosis are bone diseases that endocrinologists diagnose and treat.
Menopause, in women, and loss of testicle function, in men, and aging may put you at risk for bone fractures.
Endocrinologists diagnose and treat hormone imbalances that can cause infertility, and also assess and treat patients with reproductive problems. Problems treated by endocrinologists specializing in reproductive endocrinology include menopause symptoms, irregular periods, endometriosis, polycystic ovary syndrome (PCOS), premenstrual syndrome, and impotence.Obesity and OverweightEndocrinologists treat patients who are overweight or obese, sometimes because of metabolic and hormonal problems. Endocrinologists also identify factors linked with obesity, such as insulin resistance and genetic problems.Pituitary GlandThe pituitary is often called the master gland of the body because it controls other glands. Over - or under - production of pituitary hormones can cause a hormone imbalance that can lead to infertility, menstrual disorders, growth disorders (acromegaly or short stature) and too much cortisol production (Cushing's syndrome). Endocrinologists control these conditions with medications and refer patients who need surgery.GrowthChildren and adults can have effects from not making enough growth hormone.
Pediatric endocrinologists treat children who suffer from endocrine problems that cause short stature and other growth disorders. Safe and effective growth hormone replacement therapy is available for people with growth hormone imbalance.HypertensionHypertension is high blood pressure, and it is a risk factor for heart disease. Up to 10% of people have hypertension because of too much aldosterone, a hormone produced in the adrenal glands.
Conditions such as the metabolic syndrome or a rare adrenal growth called a pheochromocytoma also may cause a hormone imbalance that leads to hypertension. These conditions also can be treated successfully.Lipid DisordersPatients with lipid disorders have trouble maintaining normal levels of body fats. High levels of these fats are linked to heart (coronary) disease, strokes, and peripheral vascular disease (problems with circulation in the legs). Endocrinologists are trained to detect factors that may be related to lipid disorders, such as hypothyroidism (a hormone imbalance caused by thyroid conditions), drug use (such as steroids), or genetic or metabolic conditions. Lipid disorders can be found in several conditions that require special management, including the metabolic syndrome, polycystic ovary syndrome (PCOS), and obesity.



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