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A 90-year-old man with an uroseptic shock was admitted to the intensive care unit with endotracheal tube insertion and immunocompromised status for months. He developed progressive, blistering eruptions on the upper left side of the chest for 4 days. There was no preceding fever, pneumonia, or orogenital ulcer, and the contact history was negative. On examination, 2 noncontiguous groups of vesicles and bullae were linearly distributed on the left T1 and T7 dermatomes (Fig 1). Tzanck smear cytology revealed multinucleated giant cells from the blisters of both the dermatomes (Fig 2). Open in a separate window Fig 1 Open in a separate window Fig 2 Question 1: What is the most likely diagnosis? A. Allergic contact dermatitis (ACD) B. Linear IgA bullous dermatosis C. Herpes zoster duplex unilateralis D. Bullous impetigo E. Bullous erysipelas Answers: A. ACD – Incorrect. ACD is a type IV delayed hypersensitivity response to an antigen that contacts a sensitized individual's skin. Acute ACD characteristically presents as erythematous, eczematous, or vesiculobullous dermatitis. It may be localized to the contact region and can progress to a more generalized pattern. The clinical manifestation and lack of a contact allergen make ACD less likely in this patient. B. Linear IgA bullous dermatosis – Incorrect. Linear IgA bullous dermatosis is an autoimmune blistering disease with annular rings of vesicles involving the skin and mucosa membranes and is commonly referred to as a “crown of jewels.” On direct immunofluorescence, it is characterized by a linear band of IgA deposition at the dermoepidermal junction. This patient had neither mucosal lesions nor disseminated blistering. C. Herpes zoster duplex unilateralis – Correct. Herpes zoster is a viral infection that occurs due to the reactivation of the latent varicella zoster virus and classically presents as grouped vesicles or bullae on an erythematous base, involving a single or adjacent dermatome unilaterally. The Tzanck examination demonstrating multinucleated giant cells is diagnostic. When 2 noncontiguous dermatomes are simultaneously involved unilaterally, it is called herpes zoster duplex unilateralis. Noncontiguous herpes zoster is very rare (7 days) E. All of the above are correct Answers: A. Patients with this condition have a worse prognosis than classic herpes zoster – Incorrect. Patients with herpes zoster duplex have demonstrated prognosis similar to classic herpes zoster.4 B. Patients with this condition have prognosis similar to classic herpes zoster – Correct. Patients with herpes zoster duplex have demonstrated prognosis similar to classic herpes zoster.4 C. Patients with this condition have a higher tendency to develop postherpetic neuralgia than classic herpes zoster – Incorrect. Herpes zoster duplex has not been shown to increase the risk of postherpetic neuralgia.4 D. Patients with herpes zoster duplex require prolonged treatment (>7 days) – Incorrect. The antiviral dosing and pain control in the management of herpes zoster duplex remain the same as that of classic herpes zoster.4 E. All of the above are correct – Incorrect.

BackgroundNon-bullous impetigo is typically treated with antibiotics. However, the duration of symptoms without their use has not been established, which hampers informed decision making about antibiotic use.AimTo determine the natural history of non-bullous impetigo.Design and settingSystematic review.MethodThe authors searched PubMed up to January 2020, as well as reference lists of articles identified in the search. Eligible studies involved participants with impetigo in either the placebo group of randomised trials, or in single-group prognostic studies that did not use antibiotics and measured time to resolution or improvement. A modified version of a risk of bias assessment for prognostic studies was used. Outcomes were percentage of participants who had either symptom resolution, symptom improvement, or failed to improve at any timepoint. Adverse event data were also extracted.ResultsSeven randomised trials (557 placebo group participants) were identified. At about 7 days, the percentage of participants classified as resolved ranged from 13% to 74% across the studies, whereas the percentage classified as ‘failure to improve’ ranged from 16% to 41%. The rate of adverse effects was low. Incomplete reporting of some details limited assessment of risk of bias.ConclusionAlthough some uncertainty around the natural history of non-bullous impetigo remains, symptoms resolve in some patients by about 7 days without using antibiotics, with about one-quarter of patients not improving. Immediate antibiotic use may not be mandatory, and discussions with patients should include the expected course of untreated impetigo and careful consideration of the benefits and harms of antibiotic use.

Varicella-zoster virus (VZV) infection, also known as chickenpox, is a common childhood affliction. Generalized small itchy single-standing vesicles on erythematous skin are typical. Both cutaneous and systemic complications of the VZV infection may commonly occur. A three-year-old girl with a previous history of mild atopic dermatitis presented in our Pediatric Dermatology Clinic in poor general condition, with a skin rash predominantly consisting of generalized large blisters with hypopyon sign and erosions. On a closer look, scattered erythematous papules and vesicles were also visible. A positive Tzanck smear from an intact pinhead-sized vesicle and VZV PCR confirmed the clinical diagnosis of chickenpox. Cultures from hypopyon material revealed Staphylococcus aureus superinfection. We report an exceptional, not-yet described complication of chickenpox with hypopyon-forming superinfection in an atopic child. In addition, our case nicely underscores the necessity of early VZV vaccination, which has been available and recommended now for more than 10 years in pediatric vaccination programs to avoid severe complications.Die Varicella-Zoster-Virus(VZV)-Infektion, auch Windpocken genannt, ist eine häufige Kinderkrankheit. Typisch sind generalisierte kleine juckende einzeln stehende Vesikel auf erythematösem Grund. Sowohl kutane als auch systemische Komplikationen treten häufig auf. Ein 3‑jähriges Mädchen mit milder atopischer Dermatitis in der Vorgeschichte stellte sich in der Kinderdermatologie-Ambulanz der Universitätsklinik für Dermatologie Wien mit generalisierten großen Blasen mit Hypopyonbildung und Erosionen vor und war in einem reduzierten Allgemeinzustand. Bei näherer Betrachtung waren zusätzlich disseminierte stecknadelkopfgroße erythematöse Papeln und Vesikel sichtbar. Ein positiver Tzanck-Test von einem intakten stecknadelkopfgroßen Vesikel sowie die VZV-PCR (Polymerasekettenreaktion) bestätigten die klinische Diagnose von Windpocken. Kulturen aus dem Hypopyon-Inhalt zeigten eine Superinfektion mit Staphylococcus aureus. Wir berichten hier über eine außergewöhnliche, noch nicht beschriebene Komplikation von Windpocken mit einer hypopyonbildenden Superinfektion bei einem Kind mit atopischer Dermatitis. Darüber hinaus unterstreicht der vorliegende Fall die Notwendigkeit einer frühen VZV-Impfung, die seit mehr als 10 Jahren verfügbar ist und in pädiatrischen Impfprogrammen empfohlen wird, um schwerwiegende Komplikationen zu vermeiden.

Impetigo is the most common bacterial skin infection in children. The disease has two forms: nonbullous and bullous, of which nonbullous is the most common (70 %). Impetigo is caused by Staphylococcus aureus, Streptococcus pyogenes, or their combinations. In nonbullous impetigo, methicillin­resistant strains (MRSA) of S. aureus are most often detected. For the colonization of staphylococcus and streptococcus, the necessary conditions are damage to the integrity of the skin and violation of the composition of the usual microflora of the skin. Patients with inflammatory skin diseases are most often colonized by S. aureus and are at high risk for developing MRSA infections. In bullous impetigo, the rash elements are represented by bullae which quickly burst with the formation of surface erosion and a yellow crust. Nonbullous impetigo is manifested by vesicles, pustules, crusts. Typically, impetigo is clinically diagnosed. Suspicion of MRSA occurs in cases of spontaneous abscess or cellulitis, or if lesions are not eliminated by the recommended initial treatment with antibiotics. Topical therapy is the first line of treatment for uncomplicated nonbullous and bullous impetigo. If the lesion is limited to a small area (up to 6 cm2), the treatment involves soaking the crusts, exfoliating them and applying antimicrobial ointments (fusidic acid or a combination of neomycin and bacitracin) (EBM Guidelines, 2018). With more diffuse lesions, systemic antibiotic therapy is prescribed. In treatment of patients with eczema, topical and systemic antimicrobials with topical steroids are used. The combination of the aminoglycoside antibiotic neomycin and the polypeptide antibiotic bacitracin is presented at the Ukrainian pharmaceutical market as Baneocin drug. This combination has a pronounced synergistic effect on S. aureus, S. pyogenes and P. aeryginosa. An important advantage of Baneocin is its availability in two forms (powder and ointment), which allows the use of this drug at different stages of the infection process.

Introduction: Impetigo is the bacterial infection of the skin most commonly seen in infants and children. Bullous and nonbullous are the two forms of impetigo. It usually presents with vesicles, bullae, crusted erosions, or ulcers. Case report: We report two cases in which the first case showed crusted erosions all over the body and the second one had bullous lesions over the extremities, which eventually lead to gangrene of fingers and toes. These were due to the bacterial infections of the skin. Discussion: Superficial bacterial infection should be one of the differential diagnoses, whenever there is diffuse exfoliation of the skin or peripheral gangrene.

A 13-year-old female patient presented with a 3-month history of recurrent blisters, which ruptured into multiple superficial erosions with overlying crust located on the face, neck, and shoulder. Treatment for presumed bullous impetigo showed no benefit. Samples collected from the patient's home revealed the presence of numerous carpet beetles in a wool rug. Carpet beetle dermatitis resembles papular urticaria but may occasionally present as skin lesions resembling bullous impetigo.

The cell wall‐anchored protein‐encoding spj gene on staphylococcal cassette chromosome mec IVl (SCCmecIVl) was found to vary in size because of its 22‐ and 86‐aa repeat domains. The 22‐aa repeats are the more flexible of the two repeats, comprising three 11‐aa units, and were classified into three groups with eleven types. The 11/22‐aa repeats are longer in individuals with bullous impetigo, shorter in those with invasive disease and were absent in a fatal case, this last one having been rapidly diagnosed by PCR. IS431‐flanking pUB110 (bleO, aadD) is present on SCCmecIVl at 90%. The bacterial surface has the spj product and a unique surface layer.

Background: Vesiculobullous disorders represent a heterogeneous group of dermatoses with protean manifestations. The accurate diagnosis of bullous disorders of the skin and mucous membrane requires evaluation of clinical, histological, and immunofluorescence findings. Objective: The aim of this study was to investigate Tzanck smear findings and to determine the diagnostic value of this test in moist (erosive, vesicular, bullous, and pustular) skin and oral lesions. Patients and Methods: This cross sectional study was conducted on one hundred patients presented with vesicular, bullous, and pustular skin lesions and/or oral lesions. All patients were included from Dermatology Outpatient Clinic at Al-Zahraa University Hospital over the period from March 2018 to March 2019. Results: Positivity of multinucleated giant cells in herpetic infection, acantholytic cells in pemphigus, dyskeratotic acantholytic cells and cocci in bullous impetigo were useful landmarks in Tzanck smear. A decrease in viral shedding from herpetic lesions of longer duration may correlate with the lower sensitivity of the Tzanck smear. Therefore, in this study we excluded the lesions older than 3 days. The percentage of positivity in vesicles was much higher than that of pustules. Conclusion: According to this study, Tzanck smear was an inexpensive, simple, and rapid test and did not require any specialized laboratory equipment for evaluation of various vesiculobullous and pustular lesions either skin or mucosal one.

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) threatens human health. A local CA-MRSA with ST8/SCCmecIVl (CA-MRSA/J) has emerged in Japan, being associated with progression from bullous impetigo to potentially fatal invasive infection. We found that CA-MRSA/J has unique bacterial surface structures, spikes, spikes with a cap, and long spikes, reflecting clinical origins.

1. Lorena C. Dollani, MD*,†,‡ 2. Kalyani S. Marathe, MD* 1. *Children’s National Medical Center, Washington, DC 2. †Washington Hospital Center, Washington, DC 3. ‡Georgetown University Hospital, Washington, DC Bacterial skin infections are among the most common skin diseases in children. These encompass a range of cutaneous manifestations from localized (bullous impetigo) to systemic (staphylococcal scalded skin disease [SSSS]). The most common pathogen in both nonbullous and bullous impetigo is Staphylococcus aureus . Another important pathogen causing nonbullous impetigo is group A β-hemolytic Streptococcus. SSSS specifically refers to a spectrum of skin diseases induced by the exfoliative toxins of S aureus. The most common pathogen implicated in their pathophysiology is S aureus, which is a gram-positive coccus and can commonly colonize the nose, perineum, eyes, axillae, umbilicus, and wound sites. Impetigo frequently involves children younger than 6 years, accounting for approximately 10% of skin problems observed in pediatric clinics. SSSS is a rare blistering manifestation affecting mainly neonates and young children. Impetigo is an extremely contagious infection that can spread quickly via direct person-to-person contact or through fomites, and its peak incidence is in the summer months. Primary impetigo can result from direct bacterial involvement of the previously normal skin, whereas secondary impetigo is caused by a disruption in the skin barrier that allows the bacteria to adhere, invade, and establish an infection. Causes of secondary impetigo include minor skin trauma secondary to abrasions, cuts, or insect bites or skin infections due to herpes simplex virus or varicella zoster virus. Colonization of the nasopharynx, axillae, and perineal skin with S aureus increases the risk of developing staphylococcal infections. Impetigo is classified as nonbullous or bullous. Whereas nonbullous impetigo …

Mastocytosis is a rare disease. The cutaneous form is the most frequent. There are several clinical forms of cutaneous mastocytosis including the bullous form which is rare. We report a case of a 16-month-old girl, presenting pruriginous lesions, evolving since the age of 10 months, treated as bullous impetigo 2 times without improvement. The examination clinic had found post-bullous erosions, resting on healthy skin on the trunk; with hypo-pigmented cicatricial macules, Darier's sign and dermographism were positive. There were no other extra-cutaneous signs. Histology favored cutaneous mastocytosis in its bullous form.

Staphylococcus aureus can cause exfoliative skin conditions, ranging from localized bullous impetigo (BI) to staphylococcal scalded skin syndrome (SSSS). The latter is a potentially life-threatening disorder, which leads to blistering of the upper layer of the skin, by the release of a circulating exotoxin. The disease especially affects infants and small children but has also been described in adults. SSSS usually presents with a prodrome of sore throat or conjunctivitis. The infection is often peri-facial impetigo, here is usually no bacteremia. Bullous impetigo, the toxin produces blisters locally at the site of infection, whereas in cases of the scalded-skin syndrome, it circulates throughout the body, causing blisters at sites distant from the infection.

­ A 14-year-old boy with recent antibiotic treatment for tonsillitis, presented to the emergency department with 1-week history of worsening rash and haemorrhagic bullae involving the bilateral legs, trunk and hands (figures 1 and 2). Laboratory results were significant for proteinuria (2+protein) and haematuria (1+, 5–10 red blood cells/high power field); 24 hours urinary protein and renal function were within normal limits. The patient had an inconclusive skin biopsy. Figure 1 Left and right images show palpable purpura with some overlying bullae and vesiculation coalescing into plaques on both lower extremities. Figure 2 Left image shows rash on abdominal wall and right image shows coalesced haemorrhagic bullae on hands. Questions What is the most probable diagnosis? Bullous Ig A vasculitis Meningococcemia Bullous impetigo Eosinophilic granulomatosis with polyangiitis Cryoglobulinemia What is the best test which will establish the diagnosis in this patient? Renal ultrasound Renal biopsy Abdominal ultrasound Creatinine clearance What is first line of treatment in this patient? Antibiotics Steroids Surgical debridement Multispecialty consultation Immunosuppressants such as azothioprine What other systems can this condition affect besides the skin? Lungs Kidneys Spleen Nervous system A, B and D Answers can be found on page 02.

Background Bullous impetigo (BI) is a common skin infection of early childhood, resulting from desmoglein-1 cleavage by Staphylococcus aureus exfoliative toxins. Due to compromised barrier function and immune dysregulation, children with atopic dermatitis (AD) are at increased risk of cutaneous infections, yet no literature has been published on disseminated bullous impetigo (DBI) in children with atopic dermatitis (AD). We sought to explore the atopic phenotypes, antibiotic sensitivities, and treatment courses of children diagnosed with disseminated bullous impetigo at our institution. Methods We conducted a retrospective case series of 12 children diagnosed with disseminated bullous impetigo at Johns Hopkins from 12/2016 to 5/2017. Results Eleven children (92%) had severe AD. All children were initially misdiagnosed; the majority (67%) were misdiagnosed with AD flares, and other misdiagnoses included scabies, eczema herpeticum, ecthyma, varicella, and eczema coxsackium. All cultures were positive for methicillin-sensitive Staphylococcus aureus (MSSA). Three children (25%) had clindamycin-resistant strains of MSSA, and only one child was positive for both MSSA and methicillin-resistant S aureus. All children were treated with systemic antibiotics and experienced resolution of symptoms within 24-48 hours. Conclusions This case series is the first of its kind exploring children with DBI with the atopic diathesis. Our results indicate that DBI is often misdiagnosed, and increased training is likely needed for pediatricians, emergency room physicians, and dermatologists. Earlier diagnosis of bullous impetigo may prevent dissemination and spare a patient treatment with systemic antibiotics. Given the high rate of clindamycin resistance observed in this series, we recommend cephalosporins to treat uncomplicated cases of DBI.

Background Impetigo is the most common skin infection in pediatric age and has the highest incidence increase relative to other skin infections observed in children. The reported incidences in the literature are between 1.65–2.8%, being evident a seasonal variation with peak of incidence during summer and autumn.The aim of this study is to characterize hospitalizations for this pathology in a pediatric population covered by a level II hospital. Methods Observational cohort study on impetigo hospitalizations over a period of 6 years between 2012 and 2017. Demographic data, clinical manifestations, laboratory evaluation, antibiotic therapy, duration of hospitalization and clinical evolution were analyzed. Results During the total of this period, there were 4163 hospitalizations in the Department of Pediatrics, of which 34 (0.8%) for cases of impetigo. Of these cases, 19 (56%) corresponded to bullous impetigo and 15 (44%) to non-bullous. The proportion of impetigo cases at admission ranged from 0% in 2012 to 2013, up to 1.5% of hospital admissions in 2016. Most (94%) were term newborns, 50% male, with a mean age at diagnosis of 12.7 days. Neonatal onphalitis was the most commonly associated pathology in 41%. In only 26% of cases, culture of the pus or bullous fluidwas performed. The most frequent agent was Staphylococcus aureus, identified in 63% of positive cultures. The most used antibiotic therapy (50%) was the association of flucloxacillin with gentamicin. The evolution was favorable, with complete resolution of the clinical manifestations during hospitalization, in all cases. Conclusions Our study shows a demographic, clinical and laboratory characterization coincident with that described in the current literature. The increase in the proportion of hospitalizations due to impetigo over the years raises the possibility that the incidence of the pathology is increasing or that there is an increase in the severity of the cases. These data should be an alert on the possible influence that the adequacy of the care provided to the newborn, bothinside or outside the hospital, may have in terms of public health.

An elderly Caucasian woman developed bullous pemphigoid (BP) overlying the site of total knee arthroplasty for osteoarthritis 2 days after surgery. The clinical findings were consistent with blistering due to soft tissue swelling, bullous impetigo or allergic contact dermatitis. The blistering spread over weeks to months down the ipsilateral leg and then to the other leg and hips. A biopsy for H&E and direct immunofluorescence established the diagnosis of BP. A concomitantly occurring wound infection was identified and treated. The blistering responded well to superpotent topical steroids and local care.

Staphylococcal scalded skin syndrome (SSSS) is the medical term used to define a skin condition induced by the exfoliative toxins produced by Staphylococcus aureus. The disorder is also known as Ritter disease, bullous impetigo, neonatal pemphigus, or staphylococcal scarlet fever. The disease especially affects infants and small children, but has also been described in adults. Prompt therapy with proper antibiotics and supportive treatment has led to a decrease in the mortality rate. The current case report describes the clinical progress of a patient with generalized erythema and fever, followed by the appearance of bullous lesions with tendency to rupture under the smallest pressure, and with extended areas of denudation. The patient aged four years and six months was admitted to our clinic to establish the aetiology and treatment of a generalized bullous exanthema, followed by a skin denudation associated with fever and impaired general status. Based on clinical and paraclinical examinations a diagnosis of Staphylococcal scalded skin syndrome was established which responded favourably to antibiotic treatment, hydro-electrolytic re-equilibration, and adequate local hygiene. Staphylococcal infection can represent a problem of significant pathological importance sometimes requiring a multidisciplinary approach involving paediatricians, dermatologists, infectious diseases specialists, and plastic surgeons.

Background/Objectives Bullous impetigo (BI) is a common dermatologic condition, particularly in children, yet confusion regarding its diagnosis and treatment persists. This study measured pediatricians' ability to diagnose and appropriately treat BI and explored factors that might influence pediatricians' accuracy in managing BI. Methods We administered an expert-validated survey to 64 pediatrics house staff and faculty at three Johns Hopkins Medicine facilities. The survey requested demographic information, diagnoses for five “unknown” cases, and preferred treatments for localized and widespread BI. Results Overall, BI was diagnosed correctly 31.9% of the time. There was little difference between house staff and faculty performance, although faculty 50 years of age and older demonstrated better diagnostic acumen. Regarding treatment of localized BI, 92% of faculty members and 84.6% of house staff listed mupirocin as first- or second-line treatment. The second most common medication listed for localized BI was bacitracin. Regarding treatment of widespread BI, faculty listed cephalexin or clindamycin as first- or second-line treatment 56.0% of the time and house staff listed one of these two medications 51.3% of the time. Results for faculty 50 years of age and older were comparable. Conclusions Improved pediatrician proficiency in the diagnosis and treatment of BI is needed for safe, cost-effective management. Physician age and experience appear to have a limited effect on the accuracy of BI diagnosis and management. Future educational efforts must be directed at trainees and their instructors.