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Objective: We evaluated pertinent features of impetigo in French Guyana due to the increasing number of therapeutic failures with macrolides and fusidic acid., Patients and Methods: A prospective study study was conducted over a 14-month period in the dermatology unit of the Cayenne hospital. Two groups of patients were identified: group 1 included patients with impetigo and group 2 patients with infected skin reactions. Epidemiological, bacteriological, toxinological (exofoliatines, leukocidine) and antibiotic data were recorded., Results: Forty-one patients with impetigo and 31 patients with infected skin reactions were included. Staphylococcus infection alone was identified in most patients (68 p. 100) in the impetigo group. Exfoliatine-producing strains were strongly associated with Staphylococcus-induced bullous and non-bullous impetigo (93 p. 100) compared with other origins (impetigo with streptococcal infection or infected skin reactions). Resistance to macrolides was high (erythromycin 41 p. 100, fusidic acid 42 p. 100) for all isolated strains of Staphylococcus aureus., Conclusion: A sub-group of patients with impetigo was identified. These patients had pure staphylococcal infections characterized by strong association with exfoliatine production. The rate of resistance to macrolides was particularly high in this sub-group. Resistance to fusidic acid was high for all Staphylococcus strains isolated.

Nikolsky's signs refers to the ability to induce peripheral extension of a blister as a consequence of applying lateral pressure to the border of an intact blister. Although initially used in reference to the pemphigus group of blistering dermatoses, a positive Nikolsky's sign can be seen in other bullous diseases such as toxic epidermal necrolysis and staphylococcus scalded skin syndrome. Appreciating whether the blister is 'wet' or 'dry' at the site of a positive Nikolsky's signs may have both diagnostic and prognostic significance which I illustrate with several clinical cases. Lastly, I review the significance of a positive Nikolsky's sign.

The practicing dermatologist is faced with an ever-changing epidemiologic spectrum of cutaneous bacterial diseases. Studies have stated that bacterial skin infections may account for up to 17% of clinical visits. It is hoped that the information presented in this article will enable the practicing dermatologist to provide improved patient care in the diagnosis and management of bacterial infections of the skin.

Bacterial complications of varicella in 84 patients younger than 16 years of age (48 females; median age, 2.9 years) who required hospitalization between 1985 and 1995 were retrospectively analyzed. The purpose of the study was to describe demographics, clinical manifestations, bacteriology, and factors affecting outcome. Seventy-six percent of patients were younger than 5 years of age. The eldest children in households were significantly underrepresented (P = .00025). Skin infections occurred in 61 patients (73%), and deep-seated infections and/or shock occurred in 23 (27%). The latter complications were significantly associated with thrombocytopenia (P = .011) and bacteremia (P = .014) at the time of admission, prolonged fever (P = .001), prolonged hospitalization (P < .0001), intensive care management (P < .0001), and fatal outcome (P = .019). Group A beta-hemolytic streptococcus (59% of isolates) and Staphylococcus aureus (28%) were the predominant isolates. Before and after 1990, five (31%) of 16 and 13 (62%) of 21 streptococcal complications, respectively, were invasive infections (P = .09). These data underscore the need for universal immunization against chickenpox.

Unlabelled: Problems in the judgement of child abuse due to thermal violence are discussed by means of two examined cases. In a baby dermal lesions in the course of a bacterial infectious disease (bullous impetigo) were first misinterpreted as heat effects (cigarette, hot instrument). In the case of an infant presenting with marked imprints of a hot iron abuse was to be differentiated versus an accidental causation., Conclusions: In the interpretation of possible thermal injuries in children natural preexisting disorders of the skin should be taken into consideration. In cases of doubt an appropriate clinical diagnosis or a subsequent follow-up examination, respectively, is recommended. Thus, the course of events can be observed and an unjustified incrimination of persons having custody is avoided.

The pathophysiology, clinical features, and therapy of the common pyodermas, those caused by Staphylococcus aureus and Streptococcus pyogenes, are reviewed.

For skin diseases such as impetigo and furunculosis in which infection with S. aureus is the primary pathologic event, control of that infection is obviously paramount in the management of the clinical situation. The available antistaphylococcal agents are highly effective, and topical mupirocin has been a valuable recent addition. In conditions such as AD the position is less clear. Because the presence of the underlying disease is a prerequisite for the staphylococcal colonization, the exact role of staphylococcal damage is difficult to separate from the underlying disease activity. The definitive experiment, whereby staphylococcal colonization is eradicated over a prolonged period of time by a nonirritant method, remains to be performed. Until that time it is reasonable to pursue a policy of treating S. aureus colonization when it is believed to be of clinical significance and not simply on the basis of bacteriologic findings.

The past five years have seen numerous advances in the field of pediatric infectious diseases, and many of these have a substantial impact on the practice of dermatology. We review some of these advances and discuss their implications on etiology, diagnosis, therapy and complications of some relatively common conditions. The etiologic agent of exanthum subitum (roseola infantum) has been clearly implicated as a herpesvirus-6. Although in the classically described situation high fever in a young child is followed by defervescence and rash, two new scenarios have been described associated with this virus. The first is fever without rash and the second is rash without fever. The etiologic agent of erythema infectiosum ("slapped cheek") has been shown to be a human parvovirus B19. The virus has also been associated with aplastic crises (in hemoglobinopathies), hydrops fetalis, and a syndrome of subacute arthralgias in women. The etiologic agent in cat-scratch disease has recently been shown to be a small pleomorphic bacillus that also can produce pyogenic granuloma-like lesions in patients with acquired immunodeficiency syndrome. The number of cases of congenital syphilis, particularly in large cities, is increasing tremendously. Many of these infants have received no prenatal care because of drug abuse problems in their parents. Finally, we describe the changing etiology of impetigo that is predominantly associated with Staphylococcus aureus. We further describe the growing resistance to erythromycin and several new erythromycin drug-drug interactions.

Because neonates and very young children have little or no immunity to common streptococci and staphylococci, skin infections caused by these organisms must be regarded warily. Prompt and proper treatment may be critical in preventing progression of the lesions and averting systemic complications.

Two clinical cases of Hebra's impetigo herpetiformis are described. This rare dermatosis is regarded as a variant of pustular psoriasis and is difficult for differential diagnosis.

The localized form of staphylococcal scalded skin syndrome, bullous impetigo, occurs commonly in children but rarely in adults. We will describe a case of bullous impetigo in an adult which developed while the patient was receiving short-term therapy with orally administered corticosteriods. Scalded skin syndrome in this case was characterized by isolation of phage group 2 staphylococci from intact bullae and by the presence of an intraepidermal, subgranular cleavage plane in histological sections. Features that differentiate the localized form of scalded skin syndrome from generalized forms include the presence of dermal infiltrate and the absence of cutaneous erythema and tenderness. On the basis of available experimental evidence, the rarity of both localized and generalized scalded skin syndrome in adults can be attributed to immunologic competence or enhanced capacity of adults to metabolize the staphylococcal exfoliatin.

A massive outbreak of the staphylococcal scalded skin syndrome due to an organism with an unusual phage pattern, occurred during a 115-day period and involved 68 newborns. Generalized exfoliative dermatitis was seen in 24 babies, and Staphylococcus aureus was isolated from 23. Fourteen isolates were phage typed, with 13 reported as the epidemic strain 29/79/80/3A/3C/54/75. Eight babies had generalized scarlatiniform eruption without exfoliation (staphylococcal scarlet fever). Cultural data were available from six, all positive for S aureus. Four organisms were typed and reported as the epidemic strain. Of 34 infants with bullous impetigo 20 had cultures that were positive for S aureus, and four were phage typed, revealing the epidemic strain. Illness was mild in all patients; there were no deaths and no invasive forms of staphylococcal infection. The male to female ratio of generalized exfoliative disease was 5:1. The concept of a neonatal staphylococcal scalded skin syndrome, comprised of a triad of skin disorders induced by an exotoxin elaborated by certain strains of coagulase positive S aureus, is confirmed.

The diagnostic value of the Tzanck smear was investigated in 76 patients of a pediatric hospital population suffering from vesicular, erosive or bullous skin disorders. Examination took place by two investigators together (AB), besides the smears were examined by two others (C and D) double blind. Sensitivity for patients with clinical herpetic infections was greater than 80%, specificity for those without herpetic infections was greater than 90%. These figures are higher than expected from literature. Reliability was also high; between the three investigators no significant differences were found. The Tzanck smear is simple, inexpensive, easy to perform and rapid; it does not require a specialized laboratory, but experience and correct technique of sampling is required.

Fifty children who were referred to the child abuse team in Leeds over the 10 years 1976-86 with suspected non-accidental injury were found to have conditions which mimicked non-accidental injury. These included impetigo (nine children) and blue spots (five children). Five children who presented with multiple bruising had haemostatic disorders. Eight children had disorders of the bone. Five children had been previously abused physically. Four showed evidence of neglect. One had evidence of non-accidental injury as well as the condition mimicking abuse. It is emphasised that when child abuse is suspected a sensitive and thorough assessment should be carried out by a paediatrician who is experienced in this.

Soft-tissue bacterial infections range from the superficial, relatively benign form, readily treated by oral administration of antibiotics, to the highly lethal variety which requires extensive surgical débridement, administration of broad-spectrum antibiotics and patient monitoring in the intensive care unit. The key to patient survival in the latter group is early diagnosis and treatment. Those at risk of serious infections include diabetic and cirrhotic patients and trauma victims who have been treated either surgically or medically. In addition to awareness of the possibility of serious infection, x-ray films of the soft tissue to show gas, aspiration of fluid collections for Gram's staining and local incision of the tissue to inspect fascia and muscle are all useful aids in diagnosis. This review attempts to classify soft-tissue infections and to recommend an approach to diagnosis and management.

Three cases, one of bullous impetigo, one of a Mongolian spot, and one of constriction of the toe by a hair, were mistakenly diagnosed as cases of child abuse. The diagnosis of child abuse is not usually simple and requires a careful evaluation of the injuries and the family if cases are not to be either overlooked or overdiagnosed.

Sixty patients with impetigo were seen in a private practice. Cultures of specimens from all but one patient grew coagulase-positive Staphylococcus aureus. The culture of one patient grew pure group A beta-hemolytic streptococcus. The cultures of six patients were mixed, having streptococci and S. aureus. In all but one instance the staphylococci were resistant to penicillin and ampicillin. We recommend that all centers treating patients with superficial skin infections have a method of screening or spot checking their patient population to determine antibiotic sensitivities and the frequency and distribution of these infections. Then, if bacteriologic and antibiotic sensitivity studies mandate, a switch in antibiotics should be contemplated.

The scalded skin syndrome or Lyell syndrome can now be divided into two distinct forms. One form is associated with staphylococci that are usually phage group II Staphylococcus aureus, are penicillin resistant, and produce a protein exotoxin which produces epidermolysis by causing a split to develop in the epidermis between the stratum granulosum and the stratum spinosum. The other form is associated usually with drug reactions and is characterized by necrosis of the epidermis with a split between epidermis and dermis. The staphylococcal Lyell syndrome should be treated with penicillinase resistant antibiotics and not with corticosteroids; the non-staphylococcal form of the Lyell syndrome often requires systemic corticosteroids. Therefore the correct diagnosis must be established early. This is possible since the histopathology of the two forms is different.

Erythema neonatorum is the most common exanthematous eruption in neonates, which is always associated with an eosinophilic infiltration of the skin. Erythema neonatorum can be present at birth. It is of great importance in the differential diagnosis of pustular eruptions in newborns due to virus or bacteria, of miliaria pustulosa, and of incontinentia pigmenti.