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Impetigo

Category: Illness or disabilities

Type

Involuntary

Introduction and description

 

Impetigo is a highly contagious bacterial skin infection, caused by Staphylococcus aureus and Streptococcus pyogenes. It produces patches of red inflamed skin, sores and blisters and occasionally ulcerous lesions around the face, hands, armpits, back of the knees, neck and genitals, which can erupt and develop yellow-brown crusts.  The lesions may be painful or itchy.  There may even be bruising in extensive infections as capillaries are broken and infected.

A person is more prone to impetigo if they are suffering from other skin diseases like eczema, psoriasis and dermatitis, or insect bites, cuts or other skin wounds.  Although impetigo is very clearly defined as infection by Staphylococcus aureus and Streptococcus pyogenes, the bacteria causing impetigo enter the body through cuts, scratches, and open wounds, as such they can also enter easily if the person is suffering from other skin diseases which result in these wounds. 

 

Note that other skin diseases may have similar symptoms or even identical symptoms to those of impetigo, but have other causes - toxins, fungi, parasites, viruses such as herpes, and other bacterial infections.  The diagnosis can even be confused because more than one pathogen can be present – for example Herpes and Staphylococcus aureus.  A person may have an allergy to a substance, for example, the foaming agent in shampoo, and as a result of the skin’s reaction develop impetigo. 

A weakened skin lets bacteria in – of all sorts.

Impetigo affected over 160 million people (2% of the world population) in 2010. It can occur at any age, but is common in young children because it is highly contagious and children often have more cuts, scratches, insect bites, stings and open wounds.  In some places the condition is even known as "school sores".

Impetigo was originally described and differentiated by William Tilbury Fox. The word "impetigo" is the generic Latin word for "skin eruption", and stems from the verb impetere, "to attack" (as in "impetus").

Symptoms

 

Impetigo is the most common bacterial skin infection in children two to five years of age. There are two principal types:

  • nonbullous (70% of cases) and
  • bullous (30% of cases).

Both types should resolve within two to three weeks without scarring, but the condition may persist if the immune system has been weakened in any way by emotional problems, nutritional deprivation or exhaustion, or if there are co-morbidities that have not been addressed.  We will discuss this shortly in more detail under the heading ‘causes’.

Nonbullous impetigo

Nonbullous impetigo, or impetigo contagiosa, is caused by Staphylococcus aureus or Streptococcus pyogenes, and most often begins as a red sore which breaks leaking pus or fluid, forming a scab characterized by honey-coloured crusts on the face and extremities. Lymph nodes in the affected area may be swollen, but fever is rare. Sores may be painful and are usually itchy. Touching or scratching the sores may easily spread the infection to other parts of the body.  Skin ulcers with redness and scarring also may result from scratching or abrading the skin.

 

Bullous impetigo

Bullous impetigo, which is caused exclusively by S. aureus, results in large, flaccid bullae.  A bulla is a fluid-filled sac or lesion that appears when fluid is trapped under a thin layer of your skin. It's a type of blister. These are more likely to affect intertriginous areas. In medicine, an intertriginous area is where two skin areas may touch or rub together. Examples of intertriginous areas are the axilla of the arm, the anogenital region, skin folds of the breasts, and between digits.

Bullous impetigo, when seen in children younger than 2 years, usually involves fluid-filled blisters, mostly on the arms, legs, and trunk, surrounded by red and itchy (but not sore) skin. The blisters may be large or small. After they break, they form yellow scabs.  In adults and older children, the blisters and skin lesions can be painful.

Complications

Poststreptococcal glomerulonephritis

Complications are rare, with the most serious being poststreptococcal glomerulonephritis.
Glomerulonephritis (GN), also known as glomerular nephritis, is a term used to refer to several kidney diseases (usually affecting both kidneys). Many of the diseases are characterised by inflammation either of the glomeruli or of the small blood vessels in the kidneys.  Post-infectious glomerulonephritis can occur after essentially any infection, but classically occurs after infection with the bacteria Streptococcus pyogenes. It typically occurs 1–4 weeks after infection with this bacterium, and is likely to present with malaise, a slight fever, nausea and a mild nephritic syndrome of moderately increased blood pressure and gross haematuria.  Haematuria is the presence of red blood cells (erythrocytes) in the urine and leads to smoky-brown coloured urine.

The kidney problems result from the bacteria entering the blood stream and thus travelling round the body to end up in the kidneys.  Either the bacteria or the end result of the immune battle with the bacteria may end up in the glomerules leading to an inflammatory reaction.

Ecthyma

Ecthyma is a skin disease presenting at a deeper level of tissue.  Ulcers penetrate deep into the dermis and are painful.  Ecthyma may be accompanied by swollen lymph nodes in the affected area, there may be fever - an indication of more serious infection.  If not treated they can lead to sepsis or even gangrene.  The fact that the infection has penetrated more deeply means it is potentially more serious. 

The condition of Ecythma is not exclusively one developing from impetigo.  Although it can be a complication of impetigo – in which case it is caused by the same bacteria, it can be caused by other pathogens.   In published cases, P. aeruginosa has been detected, in yet others fungi were detected, thus this highlights the need for proper diagnosis before treatment is given.  Put simply, if the Ecythma is caused by fungal infection or viral infection, not only is an antibiotic going to do no good, it may well do harm

Cellulitis

The worsening effects of an infection

Cellulitis is an infection of the deep dermis and subcutaneous tissue, presenting with expanding erythema, warmth, tenderness, and swelling.   It is worth noting that Cellulitis has become a common global health burden, with more than 650,000 hospital admissions per year and an estimated 14.5 million cases annually in the United States alone.

The majority of cases of cellulitis are nonculturable and therefore the causative bacteria are unknown. In the 15% of cellulitis cases in which organisms are identified, most are due to β-hemolytic Streptococcus and Staphylococcus aureus – as such they are complications of Impetigo.

The diagnosis of cellulitis is based primarily on history and physical examination. Treatment of uncomplicated cellulitis should be directed against Streptococcus and methicillin-sensitive S. aureus. Failure to improve with appropriate first-line antibiotics should prompt consideration for resistant organisms, secondary conditions that mimic cellulitis, or underlying complicating conditions such as immunosuppression, chronic liver disease, or chronic kidney disease.  PMID:  27434444

Causes

Impetigo is primarily caused by Staphylococcus aureus, and sometimes by Streptococcus pyogenes. Both bullous and nonbullous are primarily caused by S. aureus, with Streptococcus also commonly being involved in the nonbullous form.  The incubation period is 1–3 days after exposure to Streptococcus and 4–10 days for Staphylococcus.

But why do some people get this disease and others don’t when both bacteria are very widespread?  The principle reason appears to be that the immune system has been in some way compromised by, for example, other illnesses, exhaustion, stress, grief and other extreme negative emotions, by nutritional deprivation, bad hygiene, poor living conditions, and frequent contact with carriers.

 

Impetigo is a highly contagious disease that can spread to anyone who comes in close contact with an infected person, thus being in buildings where materials like towels, clothes etc of an infected person are present can cause Impetigo - like nursing homes, old people’s homes and hospitals.  Herpes gladiatorum, tinea corporis gladiatorum, impetigo, and furunculosis are sometimes found in ‘epidemic proportions’ in athletes and sportspeople because they both come into close contact and get physically hurt.

Another major cause appears to be the use of immunosuppressants.  By definition immunosuppressants suppress the immune system, as such they may appear to remove those annoying symptoms of disease which tend to show themselves when the immune system is actually working, but by suppressing the immune system we have of course allowed the pathogen to gain a hold and spread.  An increasing number of pathogen caused diseases are being re-classified as auto-immune diseases, and, in an unfathomable act, treated with immunosuppressants; as such we should expect the incidence of drug related impetigo to be rising.  It is.

Note that some stents are treated with immunosuppressants to stop them being rejected, thus those with heart failure and drug coated stents may be susceptible.

Treatment

Diagnosing the bacteria and other pathogens that are the root cause

Impetigo CANNOT  be diagnosed from appearances alone.  Because of the problems with complications, as well as the likelihood of more than one pathogen being present, more than one swab culture and blood tests need to be performed to see which pathogens are present.  If there is an allergy, for example, the infection is likely to persist even after treatment, because the original reason for the skin problems has not been tackled.  The same is true with Herpes another disease which is often co-morbid with Impetigo. 

[Note that Herpetiformis Impetigo, despite the name "herpetiformis," is not caused by a herpes virus and despite the name Impetigo is a form of pustular psoriasis that's triggered by pregnancy.  At times one does get the feeling that the medical community have entirely lost the plot.]

Self care

Treat cuts, scrapes, insect bites and other wounds right away by washing the affected areas to prevent infection. 

To prevent the spread of impetigo to other people, the skin and any open wounds should be kept clean and covered with dressings. Care must be taken to keep fluids from an infected person away from the skin of a non-infected person.   Dressings should be disposed of frequently and carefully.

Gently wash the affected areas with warm running water at least every day, dry thoroughly and then cover lightly with non stick dressings.   Wash an infected patient's clothes, linens and towels every day and don't share them with anyone else in the family.

Scratching can spread the sores; thus keeping the patient’s nails short will reduce the chances of spreading.  Encourage the patient to wash his or her hands frequently.

Medicines

 

Unless the cause has been very specifically diagnosed with all the pathogens present identified, treatment using any form of pharmaceuticals needs to be delayed.  In the sections on Staphylococcus aureus and Streptococcus pyogenes, the healing observations provide a number of possible plants that have proven efficacy in dealing with each bacteria.

Treatment by the medical community includes topical antibiotics such as mupirocin, retapamulin, and fusidic acid. Unless the infection – bacteria –is widespread, having worked its way round the whole body or deep into the skin, then topical treatments are usually the treatment of choice

There is good evidence that topical mupirocin and topical fusidic acid are equally, or more, effective than oral treatment. ….. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics.  PMID:  22258953

But it would seem that the overuse and mis-use of antibiotics, by medics and the farming community, will soon render these treatments entirely useless …….

Empiric treatment considerations have changed with the increasing prevalence of antibiotic-resistant bacteria, with methicillin-resistant S. aureus, macrolide-resistant streptococcus, and mupirocin-resistant streptococcus all documented. Fusidic acid, mupirocin, and retapamulin cover methicillin-susceptible S. aureus and streptococcal infections.  PMID:  25250996

Gentian violet

For generations, impetigo was treated with an application of the antiseptic gentian violet and there is still support in the medical community for this use:

The term pyoderma encompasses a variety of distinct entities including impetigo (bullous and nonbullous), erysipelas, cellulitis, folliculitis, and staphylococcal scalded skin syndrome. Treatment of pyodermas centers around wound care and appropriate antibiotic selection. Triphenylmethane dyes, such as gentian violet, represent a unique group of compounds that act as antiseptics and have shown clinical efficacy as antibiotics in a variety of pyodermas, including those secondary to methicillin-resistant Staphylococcus aureus. Given their low cost, ease of application, and favorable side effect profile, triphenylmethanes must be considered legitimate treatment options for pyodermas, particularly in the face of continued and emerging bacterial resistance.  PMID:  21095530

 

Crystal violet or gentian violet has antibacterial, antifungal, antihelminthic, antitrypanosomal, antiangiogenic, and antitumor properties. The medical use of the dye has been largely superseded by more modern [expensive] drugs, although it is still listed by the World Health Organization.  The name refers to its colour, being like that of the petals of a gentian flower; it is not made from gentians or from violets.

It is used medically for treating Candida albicans and related fungal infections, such as thrush, yeast infections, various types of tinea (ringworm, athlete's foot, jock itch); as well as for treating impetigo; it was used primarily before the advent of antibiotics, but still useful to persons who may be allergic to penicillin.

In resource-limited settings, gentian violet is used to manage burn wounds, inflammation of the umbilical cord stump (omphalitis) in the neonatal period, oral candidiasis in HIV-infected patients and mouth ulcers in children with measles.  It must not be swallowed.

Gentian violet's common side effect is the staining of skin and cloth, “but it can easily be washed off skin with a solution of bleach and water. However, if used on ulcerations or open wounds, it can cause tattooing.”

Other treatments

Address anything that may be causing a compromise the immune system – stress, fear and so on.  Sleeping and rest are exceptionally helpful, as are promoters of relaxation – music and love.

 

 

References and further reading

  •  
    Am Fam Physician. 2014 Aug 15;90(4):229-35.  Impetigo: diagnosis and treatment.  Hartman-Adams H1, Banvard C1, Juckett G1.West Virginia University Robert C. Byrd Health Sciences Center, Morgantown, WV, USA.
  • JAMA. 2016 Jul 19;316(3):325-37. doi: 10.1001/jama.2016.8825.  Cellulitis: A Review.  Raff AB1, Kroshinsky D1.   Harvard Medical School, Massachusetts General Hospital, Boston.
  • Cochrane Database Syst Rev. 2012 Jan 18;1:CD003261. doi: 10.1002/14651858.CD003261.pub3.  Interventions for impetigo.  Koning S1, van der Sande R, Verhagen AP, van Suijlekom-Smit LW, Morris AD, Butler CC, Berger M, van der Wouden JC.  Department of General Practice, ErasmusMedical Center, Rotterdam, Netherlands
  • BMJ. 2004 Oct 23; 329(7472): 979. doi:  10.1136/bmj.329.7472.979  PMCID: PMC524121           Treatment of impetigo  Paint it blue - Roderic S MacDonald,

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