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external ear canal, conjunctiva, or nasal mucosa.
Assessment:
Diagnosis based on clinical criteria and veried by culture from a primary infection site.
Differential Diagnosis - Erythema multiforme, drug-induced toxic epidermal necrosis, and pemphigus
vulgaris. See related topics.
Plan:
Treatment:
Primary: Supportive: Reliable home care, including cool baths or compresses and oral uid replacement.
Antibiotics: Dicloxacillin 30–50 mg/kg/day po in divided doses. In newborns and infants where extensive
sloughing has occurred: IV oxacillin 200 mg/kg/day q 4 hrs. Apply mupirocin ointment or silver sulfadiazine
(Silvadene) for more irritated and inamed areas.
Follow-up Actions
Reevaluation: Change antibiotics or evacuate if not improving. Ensure normal healing is taking place at
follow-up exams.
Evacuation/Consultant Criteria: Evacuate if unstable or not responding. Consult dermatology as needed.
Skin: Impetigo Contagiosa
MAJ Daniel Schissel, MC, USAIntroduction: Impetigo is an acute, contagious, superficial infection caused by Staphylococcus aureus
(bolus/ulcerative), or group A beta-hemolytic streptococci (vesiculopustular), or both. Although seen in all
age groups, impetigo is most common in infants and children, occurring most frequently on the exposed parts
of the body, especially the face, hands, neck and extremities. Predisposing factors include crowded living
conditions, neglected minor wounds, and poor hygiene.
Subjective: Symptoms
Itching, weeping lesions
Objective: Signs
Using Basic Tools: Lesions: 1– 2 mm erythematous macules, which quickly develop into vesicles or bullae
surrounded by a narrow halo of erythema. The vesicles rupture easily and release a thin, yellow, cloudy fluid
which subsequently dries to a characteristic “honey crust.” Scattered, discrete lesions located most frequently
on the exposed parts of the body, especially the face, hands, neck and extremities. Groups of lesions may
have satellite autoinoculated lesions at the periphery (see Color Plates Picture 8). There may be associated
regional lymphadenopathy.
Using Advanced Tools: Lab: Gram stain of early vesicular lesions reveals gram-positive intracellular cocci
in clusters or chains.
Assessment:
Differential Diagnosis
Varicella, herpes simplex, bullous tinea, allergic contact dermatitis (see appropriate topics in this book).
Plan:
Treatment
Primary: Dicloxacillin 250-500 mg po qid x 10 days
Alternative: Keflex (250 to 500 mg bid to tid); erythromycin (250 mg po qid)
Empiric: A high bacterial load may stimulate a super antigen reaction and aggravate the disease process.
To decrease the bacterial load, wash the area with Hibiclens soap (chlorhexidine gluconate) once daily
until cutaneous lesions clear.