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Chapter 48: Skin and Soft Tissue Infections

Matthew P. Kronman

DEFINITIONS AND EPIDEMIOLOGY

Skin is composed of an outermost, avascular layer of epidermis with an inner layer of dermis made up of elastic tissue, collagen, and reticular fibers. Subcutaneous tissue includes fat cells, connective tissue, and muscle. Blood vessels pass through subcutaneous tissues to reach the dermis (Figure 48-1).

FIGURE 48-1.

Basic skin anatomy.

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Bacterial skin and soft tissue infections (SSTIs) can be subdivided into two groups: superficial and deep; another classification scheme is to distinguish between purulent and nonpurulent infections. Superficial infections tend to evolve from local spread of organisms, but can also represent circulating toxin-mediated disease (see section on special considerations). Common superficial infections include impetigo, folliculitis, carbuncles, furuncles, paronychia, cellulitis, and erysipelas (Table 48-1). Deeper infections include abscesses, necrotizing fasciitis, and pyomyositis. These infections can arise from either local spread of organisms and traumatic inoculation (abscess, necrotizing fasciitis) or hematogenous spread (pyomyositis). This chapter focuses on impetigo, cellulitis, cutaneous abscess, necrotizing fasciitis, and pyomyositis (Table 48-2). Other rashes are reviewed in Chapter 17.

TABLE 48-1Common Superficial Skin and Skin Structure Infections
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TABLE 48-1 Common Superficial Skin and Skin Structure Infections
Disease Definition Most Common Causes Less Common Causes to Consider Common Treatments
Impetigo Well-localized superficial skin infection with or without bulla formation MSSA, GABHS Group B Streptococcus, other streptococci (e.g., group C or G) Topical mupirocin or retapamulin for 5 days; oral clindamycin, cephalexin, erythromycin, or amoxicillin plus clavulanic acid for 7 days
Folliculitis Collection of superficial infections in hair follicles without deeper involvement MSSA Pseudomonas, coagulase-negative staphylococci Warm compresses, topical mupirocin, retapamulin, or chlorhexidine; oral cephalexin or dicloxacillin for severe cases for 7–10 days
Furuncle Microabscess arising at a hair follicle in slightly deeper tissue than folliculitis MSSA, MRSA   Hot, wet compresses; surgical drainage; oral clindamycin (if MRSA suspected) or cephalexin for 7–10 days
Carbuncle Organized collection of adjacent furuncles; may have multiple areas of drainage MSSA, MRSA   Hot, wet compresses; surgical drainage; oral clindamycin (if MRSA suspected) or cephalexin for 7–10 days
Paronychia Infection of the skin surrounding the nail bed MSSA, GABHS Candida, anaerobes, viridans group streptococci, Pseudomonas, Proteus, Moraxella, Klebsiella, Eikenella Warm compresses; surgical drainage (for deeper lesions); oral clindamycin or amoxicillin–clavulanate for 7–10 days
Erysipelas Superficial form of cellulitis with distinct margins and involving lymphatics GABHS MSSA, S. pneumoniae, Klebsiella pneumoniae, Yersinia enterocolitica Local skin care; parenteral penicillin initially, oral cephalexin or clindamycin (if staphylococci suspected) for a total of 5–10 days

Abbreviations: GABHS = group A β-hemolytic streptococci; MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-sensitive Staphylococcus aureus.

TABLE 48-2Etiology of Deeper Skin and Skin Structure Infections
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TABLE 48-2 Etiology of Deeper Skin ...

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