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Ecthyma - Skin Disorder

Ecthyma is an ulcerative pyoderma of the skin that usually arises on the lower extremities and it is caused by group A beta-hemolytic streptococci. Because ecthyma extends into the dermis, it is often referred to as a deeper form of impetigo. In fact, untreated impetigo contagiosa can turn into ecthyma. The exact incidence worldwide remains unknown and no racial or sexual predisposition has been recognized, although it is know that ecthyma has predilection for children, persons with diabetes, and neglected elderly patients.

Ecthyma Picture

During wartime in tropical climates, ecthymatous ulcers are commonly found on the ankles and dorsi of the feet. Ecthyma begins similarly to superficial impetigo. Group A beta-hemolytic streptococci may initiate the lesion or may secondarily infect preexisting wounds. Infection may start at the site of an injury with preexisting tissue damage such as scratch, insect bites, dermatitis or excoriations. Immunocompromised states including diabetes and neutropenia predispose patients to the development of ecthyma.

This condition may begin with a pus-filled blister, similar to that seen in impetigo. The vesicle or pustule overlying an inflamed area of skin that deepens into a dermal ulceration with overlying gray-yellow crust and is thicker and harder than the crust of impetigo. Ecthyma rarely leads to systemic symptoms or bacteremia but lesions are painful and can have associated lymphadenopathy. However, the infection goes through the outer layer of epidermis and into the deeper layer, then an ulcer with raised borders develops. Secondary lymphangitis and cellulitis can occur while the ulcer is covered by a hard crust. Unlike impetigo, ecthyma conditions can sometimes result in scarring.

Ecthyma Picture

Ecthyma heals with scarring with a rate of poststreptococcal glomerulonephritis is approximately 1 percent. A shallow, punched-out ulceration is apparent when adherent crust is removed. The deep dermal ulcer has a raised and indurated surrounding margin and can remain fixed in size, or progressively enlarge measuring 0.5 to 3 centimeters in diameter with a heavy crust that covers the surface of the area. Specific causes are unknown but ecthyma can appear in areas of previously sustained tissue injury, patients who are immunocompromised and individuals exposed to important factors that contribute to the development of streptococcal pyodermas such as poor hygiene, crowded living conditions, high temperature and humidity.

Ecthyma Picture

This condition is treated with oral antibiotics or combined with topical solutions, but the treatment depends on the progression of the skin lesions. Gram stain and culture of ecthyma lesions reveal gram-positive cocci that represent group A streptococci. Prior group A, streptococci infection can be also detected by anti-DNase beta testing. Most Skin lesions show dermal necrosis and inflammation with a deep and superficial granulomatous perivascular infiltration along with endothelial edema. Topical therapy with mupirocin ointment is usual for localized ecthyma. However, more extensive lesions require oral antibiotics.

Hygiene is important and the duration of treatment varies because ecthyma ulcers may require several weeks of therapy before completely resolving. Remove crusts and apply an antibiotic ointment daily, observing cleanliness by using bactericidal soap and frequently changing bed linens, towels, and clothing. Oral antistaphylococcal agents such as erythromycin, dicloxacillin, cephalexin, and clindamycin have been used for a long time in the presence of possible secondary infections. Penicillin is also adequate to treat ecthyma and consider parenteral antibiotics for widespread involvement.

Topical antibiotics free of polyethylene glycol should be considered adjunctive therapy in addition to systemic antibiotics for the treatment of ecthyma since they can be used safely and there are no contraindications in renally impaired patients. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.

Complications associated with ecthyma present a possible sequelae of secondary untreated S aureus pyodermas include lymphangitis, bacteremia, cellulitis, osteomyelitis, and acute infective endocarditis. S aureus strains produce exotoxin which leads to toxic shock syndrome and staphylococcal scalded skin syndrome. Regional lymphadenopathy is common, even with solitary ulcer lesions.

Invasive complications of streptococcal skin infections include sequels of gangrene, lymphangitis, cellulitis, erysipelas, suppurative lymphadenitis and bacteremia, while nonsuppurative complications of streptococcal skin infections may present scarlet fever and acute glomerulonephritis. In both cases, prompt antibiotic therapy does not appear to reduce the rate of poststreptococcal glomerulonephritis.

Ecthyma ulcers rarely produces systemic symptoms so the best practice is to adopt prevention measures that must include maintaining general cleanliness, as this is a critical factor for preventing ecthyma. Soak a clean cloth in a mixture of half a cup of white vinegar in a liter of tepid water and apply the compress to moist areas for about ten minutes several times a day, and then gently wipe off the crusts. You may also use insect repellents to prevent bites with the consequent decrease of the prevalence of this infection.

These skin lesions are slow to heal and commonly produce a scar, particularly in patients who may need to treat larger areas of skin, but in most cases Ecthyma responds to appropriate antibiotics over several weeks and sometimes resolving without treatment.

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