皮肤软组织感染

皮肤软组织感染 Vo1.5,No.10Oct,2005nfections17 Skinandsofttissue EsteeT6r6k ChristopherPConlon Theskinactsasabarrierbetweenthehostandtheenviron. menLItcomprisesseverallayers.Themostsuperficialisthe epidermis,athinavascularlayeroverlyingthedermis,whichis athickerlayercontaininghairfollicles,sebaceousglandsand sweatglands.Subcutaneousfatliesbeneaththedermisandis separatedfrommusclebyatoughlayeroffascia.Infections mayaffectoneormoreoftheselayers. Theskiniscolonizedbyvariousmicro.organismsthatmay invadeandcauseinfection.Skincommensalsincludecoag- ulase?negativestaphylococci,ofwhichStaphylococcusepi? dermidisisthemostcommon.Staph.aureusandgroupA streptococciarethemostimportantpathogensinskinandsoft tissueinfections.Otherorganisms(e.g.Gram—negativebac? teria,anaerobes,viruses,fungi,parasites)mayalsocausein? fection. Infectionsoftheskinandsofttissuesarecommonandaffect allagegroups.Theymayoccurassingleorrecurrentepisodes, andmaybemildandself-limitingorsevereandprogressive, leadingtosystemiccomplicationssuchasbacteraemiaand metastaticinfe:ction. Diagnosis Ademiledhistoryisessentialto sis.Itshouldinclude: establishaspecificdiagno? ?onsetanddurationofsymptoms ?appearanceandanatomicaldistributionofthelesion ?historyoftrauma ?contactwithinsectsandotheranimals 'recentforeigntravel ?pre?existingmedicalconditions(e.g.diabetesmellitus.im? mun0suppressi0n). Whenthediagnosiscannotbedeterminedfromtheclinical featuresalone,investigationssuchasneedleaspiration, biopsyorsurgicaldebridementmaybenecessarytoobtain appropriatespecimensformicrobiologicalexaminationand cuJ1t11re. Impetigo Impetigoisaninfectionoftheepidermisusuallycausedby Staph.aureusorgroupAstreptococci.Itismostcommonin hot,humidconditionsandisoftenassociatedwithovercrowd. ingandpoorhygiene.Itmayoccurinoutbreaksinhouseholds andinstitutions.Childrenaremostcommonlyaffected,and lesionstypicallyoccuronthefaceandhands.Impetigois characterizedbyintra?epidermalvesicles,whichruptureand crusttoformagolden?yellowscab. Management—-impetigoistreatedbyremovalofthecrusts andapplicationoftopicalantibioticssuchasmupirocin. Widespreadinfectionrespondsbettertooralantibiotics (e.flucloxacillin). Ecthyma Ecthymaisaformofimpetigo dermisandmayscar.Itstarts thatpenetratesdeeperintothe asavesicleandprogressesto foriBapunched.outulcersurroundedbyaviolaceousbor- der.Ecthymaoftenoccursonthelegsandisassociatedwith insectbites,eczema,pediculosisandminortrauma.Mostcases arecausedbygroupAstreptococci.Similarlesions,termed . ecthymagangrenosum,sometimesoccurwithPseudomonas aerugtnosabacteraemiainneutropenicpatients. Managementisasforimpetigo,unlesstheecthymaisas? soci.atedwithaeruginosabacteraemia,inwhichcaseap. propriateintravenousantibioticsarerequired(e.grceftazid? ime,tazocin). Folliculitis Folliculitisisaninfectionlocalizedwithinthehairfollicles andischaracterizedbyclustersofsmal1.erythematouspapules orpustules.Itiscausedbyacombinationofocclusionofthe hairfollicleandinfection,usuallywithStaph.aureus.Itmay alsobecausedbyaeruginosaacquiredfromaswimming poolorjacuzzi('hot-tubfolliculitis').FungisuchasCandida andPityrosporumorbicularefMalasseziaCur)cansome. timescausefolliculitisinpatientswhohavediabetesorare receivingprolongedantibioticsorcorticosteroidtherapy. Management—staphvl0c0ccalfolliculitisistreatedwith oralflucloxacillin.Hot-tubfolliculitisisusuallyseIf-limiting. Fungalinfectionmayrequiretopical1%clotrimazoleforabout 1week. Folliculitsoftenaffectsthebeardareainmen.Whenitis severe.topical1%hydrocortisonemaybeneededinaddition toantibiotics.Patientsshoulduseanelectricrazoruntilthe conditionsettles. 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I_lI,n?,lLvrn,,rIl…f.,h]cJ1…-…{-II1Borrelia burgdo(fen"JIisacqulrt?tI}……,(uh…0jlfi'omHtickl…it^ rt?cIcirIldrie…i|eelop~aclIJIratlmmtilesit'lrIhP Il_Lt|-JthtrIPhlul…『?huh?I'?YPr.malaisea『?Jarthral— J?1)iagt,.sisis…?hal_Ft?-dI||IIiI1wilhlJI,VL'1lut Leishmania一?-IIfa?PI?_^l【Iishmarm~sis…quire'I n._?asd…I?vlllItJ')l_lWIbrlrlIeilulIaI1i口ls.t…sd】Jv |hnflHtnnt{lnr.Ltropi~nl,^T,..tbiop~",ruh?mi~ ii^J….^h….1ndiatileMi,hlhEust{theMedlt Leprasy一_lI'lionilhM)cobmterhtmlepraecmls… sl,ec-tMl…lIElini~aldiseaserangillf?1tuberculaid【I) I,~pmmalousleprosyhJtlll,Il?f{lepros~anacsthetit mattdesI,Idaqucspignlenta~ychang~???t{Ihkkenedpe— ripheralnelv睇delop111Jpmmatlm~Jprosy.mj''ules c2005rr0M日0m日Pu?0ComPanyL_门 ep 训卅 一帅???至_量 一一一 uP?r .三_… 一_兰…三_m , 钟…,州 j#% 端 _虿叭_曼T -三,_兰一三 _耋…-三n-三 ?-看_三?罨,,n 兰__兰 一 一豢,一一 …_三 , 一 黜 ?mn , D nfectionsVo1.5,No.10Oct,2005 papules,nodulesandulcerationoccur,resultingincollapse ofthenasalbonesandcoarseningoffacialtissues,producing thecharacteristic'leonine'facies.Thediagnosisisconfirmed bybiopsyandsplit—skinsmears.Treatmentiswithdapsone, clofazimineandrifampicin. Lupusvulgarisisacutaneousinfectioncausedby tubercu—losis.Itmostcommonlyaffectsthefaceandneck. andappearsasfirm,translucent,yellow—brown'applejelly nodules.Untreatedlesionsspread,leadingtodisfiguring scarringandcontractures.Diagnosisisconfirmedbybiopsy, whichshowstuberculoidgranulomatainthemid—dermis. Treatmentiswithantituberculouschemotherapy. Molluscumcontagiosumisabenignconditioncausedby apoxvirus.Itusuallyaffectschildrenortheimmunocompro. mised(e.HIV.infectedpatients).Thelesionsaremostcom. monlyseenonthefaceandtrunk,andarepapularwitha centralpunctum. Orrisaninfectiouscutaneouslesioncausedbyapoxvirus acquiredfromsheep.Itcommonlyaffectsfarmers(particularly thosewhobottle.feedlambs)andveterinarysurgeons.Ared papuledevelops,commonlyonthesidesofthefingers,and growsrapidly,oftenbecomingvesicular,beforedevelopinga centralnecroticarea.Lymphangitis,regionallymphadenopa— thyandfeverarecommon.Recoveryisspontaneous. Scabiesisapruriticskinlesioncausedbyinfestationwith Sarcoptesscabei.Itisassociatedwithpoorsocioeconomiccon— ditionsandovercrowding.Thefemalemitelayshereggsina burrowinthestratumcorneum,generatingalocalhypersen— sitivityreaction;whentheeggshatch,thecycleisrepeat— ed.Diagnosisisconfirmedbyextractionofthemitefroma burrow.Treatmentcomprisestopicalacaricides(e.昏perme— thrin)andwashingofallclothingandlinen.A11membersofthe householdshouldbetreatedatthesametime. cktyphus—Africanticktyphus.causedbyRickettsia conoriand兄口,}c口eiscommonlyseeninpatientsreturning fromsafariinsouthernAfrica.Endemictyphusiscausedby 兄typhiandtransmittedbytheratflea.Epidemictyphusis causedby兄prowazekiiandtransmittedbythehumanlouse. Clinicalfeaturesincludefever,headache,malaise,myalgia, lymphadenopathyandsplenomegaly.Theremaybeaneschar atthesiteofinoculationandamacul0papularrash,though somespottedfeversproducefewifanyspots.Diagnosisis confirmedserologically.Treatmentiswithdoxycycline.? FURTHERREADING BisnoAL,StevensDLSlreDlOcOccaIinfectionsoflheskinandsofl lissues.NEln口/JMed1996;334:240 BrookI.MicrobiologyandmanagemenlofhumanandanimaIbite woundinfections.Pr/mcare2003;30:25—31. EbrightJR,PieperB.Skinandsoftlissueinfectionsininiection drugusers.InfectD『SClinNo肭Arn2002;16:697—12 GuayDR.TreatmenlofbacteriaIskinandskinstructureinfec- MEDlClNElNTERNATIONAL lions.ExpertOpinPharmacother2003;4:1259-75. SeaIDV.Necrotizingfasciitis.CurrOpinInfectD『S2001:14:127— 32. ShwarzMN.ClinicaIpractice.Cellulitis.NEnglJMed2004;350: 904—12. ShwarzM.CellulitisandsubculaneOuslissueinfections.In:Mar卜 del\GL.OwenR.BennettJEeta1..eds.Princ/plesandpractice 0,infectiousdiseases.5thed.NewYork:ChurchilILivingstone. 2000:1037-57. ?2005TheMedicinePublishingCompanyLtd 国际内科双语杂志2005,Vo1.5,No.10感染病学 皮肤软组织感染 Est6eT6r6k? ChristopherPConlon? MEDICINE,2005,33(4):84,88 皮肤是宿主和环境之间的一道屏障.它由数层结 构组成.最面不含血管的薄层是表皮,覆于真皮之 上,真皮层则较厚,包含毛囊,皮脂腺和汗腺.皮下 脂肪位于真皮之下,与肌肉层之间相隔一层坚硬的筋 膜.感染可以侵犯其中一层或几层结构. 许多微生物都可在皮肤上定植,从而可以侵入皮 肤并引起感染.皮肤定植菌包括凝固酶阴性的葡萄球 菌,其中以表皮葡萄球菌最常见.金黄色葡萄球菌和 A组链球菌是皮肤软组织感染最主要的病原菌.其他 生物(如革兰阴性菌,厌氧菌,病毒,真菌,寄生虫) 也可以引起感染. 皮肤软组织感染很常见,各年龄组都可发生.可 发作一次也可为反复发作,病情可以轻微,病程自 限;也可严重并呈进行性加重,以至出现全身并发 症,如菌血症,迁徙性感染灶. 诊断 详细询问病史对确诊具有关键作用.病吏应包括: ?症状的发生和病程 ?病变的外观和解剖分布 ?外伤史 ?昆虫或其他动物接触史 ?近期外地旅游史 ?既往疾病史(如糖尿病史,免疫抑制剂使 用史). 如果单凭临床特点无法确诊皮肤软组织感染,必 要时需行针吸,活检或外科清创术等检查,以获得合 ?EsteeT6r6k是牛津大学越南临床研究中心的临床研究员.利益 冲突:未申明. ?ChristopherPConlon是英国牛津大学感染性疾病和普通内科学 利益冲突:未申明. 顾问医师. MEDICINEINTERNATIONAL 适标本行微生物检查和培养. 脓疱疮 脓疱疮通常是由金黄色葡萄球菌或A组链球菌引 起的表皮感染.最常见于炎热,潮湿地区,并常常与 人口拥挤,卫生条件差有关.它可以爆发于家庭或公 共机构.儿童最常受感染,典型皮损位于面部和手. 脓疱疮的特点是表皮内水泡,破溃后结痂形成金黄色 痂壳. 治疗清除痂壳,并采用外用抗生素如莫匹罗 星.播散性感染采用口服抗生素(如氟氯西林)效果 更好. 深脓疱 深脓疱是脓疱疮的另一类型,侵犯深层真皮,并 可留下疤痕.最初为水泡,逐渐进展形成周围带紫色 边界的穿凿样溃疡.深脓疱常出现于小腿,与昆虫叮 咬,湿疹,虱病和微小创伤有关.大多由A组链球菌 感染引起.中性粒细胞减少病人有时因绿脓杆菌感染 会出现类似病变,称为"坏疽性深脓疱病". 治疗与脓疱疮相同,但绿脓杆菌菌血症引起的 深脓疱需静脉使用合适的抗生素(如头孢他啶,塔唑 西林,即哌拉西林/他唑巴坦). 毛囊炎 毛囊炎是指局限于毛囊的感染,主要表现为成簇 的小红色斑丘疹或脓疱.因毛囊堵塞和感染引起,常 见病原菌为金黄色葡萄球菌.也可由游泳池或喷流式 气泡浴感染绿脓杆菌而引起(称为"热水浴毛囊 长期使用抗生素或皮质激素患 炎").糖尿病患者, 者有时可发生真菌感染如念珠菌,环状糠秕孢子菌 (糠秕马拉霉菌)引起的毛囊炎. 治疗葡萄球菌毛囊炎可予口服氟氯西林.热水 浴毛囊炎通常病程自限.真菌感染需局部应用1%g 霉唑,疗程约1周. 毛囊炎常常发生于男性长胡须的部位.如果病情 严重,除用抗生素外还需局部应用1%氢化可的松. 感染病学国际内科双语杂志2005,Vo1.5,No.10 患者在病情好转前应使用电动剃须刀. 疖和痈 毛囊炎如侵犯真皮层则引起皮下疖肿或脓肿,多 为金黄色葡萄球菌感染.多个疖肿融合而形成的炎性 病灶则称为"痈".痈的特点是多个毛囊融合后可见 局部皮肤红肿热等炎性表现,伴多个脓头(图1).痈 常常发生在皮肤较厚部位,如颈项部,背部和大腿 处.常伴发热和乏力. 疖偶能反复发作.这时应考虑到糖尿病和一些罕 见的免疫缺陷病,如高IgE综合征(Job'S综合征),慢 性肉芽肿疾病. 治疗小的疖肿可自行破溃并愈合,较大的疖 肿则需切开引流.痈通常需要切开引流并需口服或 静脉应用氟氯西林抗葡萄球菌治疗.反复发生疖肿 而免疫功能正常的患者应考虑用2%莫匹罗星软膏 和口服抗生素如利福平,四环素抗菌治疗,以消除 葡萄球菌定植. 丹毒 丹毒是浅表真皮感染伴淋巴受累.一般均由A组 链球菌感染引起,其临床特点是突发的,疼痛的,边 界清楚的红斑或红疹.常伴全身症状,5%患者伴菌 血症.以往丹毒多见于面部(图2),而现在多累及下 肢.易患因素包括静脉淤滞,下肢轻瘫,糖尿病和酗 酒.常见入侵门户包括外伤,溃疡和湿疹,银屑病或 真菌性皮肤病变.丹毒易发生在淋巴回流受阻部位, 又因为其易引起淋巴阻塞,所以容易复发. 治疗治疗应予青霉素G或克林霉素.如果可能 是葡萄球菌感染,则应换用氟氯西林. 蜂窝织炎 蜂窝织炎是指深部真皮或皮下脂肪迅速蔓延的炎 症(图3).最常见的致病菌是A组链球菌和金黄色葡 萄球菌.其他B一溶血性链球菌(C组,G组和B组) 有时也可引起蜂窝织炎.罕见病原菌包括肺炎球菌, 肠杆菌科,嗜肺军团菌,亲水气单胞菌和嗜盐弧菌. 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