Infections of the skin include many common bacterial, viral and fungal causes as well as some unusual pathogens.   Most skin infections will present as reddened areas of skin, with or without pus, with pain and swelling.   A board-certified dermatologist is the best option for prompt diagnosis and treatment of these disorders.  A culture may be taken of the area to ensure the correct antibiotic is chosen.  The following are the most common skin infections.

Staph Infection

Cellulitis

Dandruff

Herpes

Shingles

Warts

Molluscum contagiosum

Pityriasis rosea

Fungal infection (Ringworm)

Tinea versicolor

Scabies

Staphylococcal (Staph)

Infection can be seen anywhere on the skin.  It frequently affects the hair follicles on the trunk, scalp, or beard areas with small red papules which may contain pus.  This condition is called folliculitis.  It can be spread by scratching, sharing towels, shaving or repeated facials with microdermabrasion which thins the skin's barrier. Occasionally a cyst will become infected with Staph, forming a large abscess which will require drainage by the dermatologist.   If the Staph causing the infection is not sensitive to penicillin, it is referred to as MRSA, which simply means Methicillin-resistant Staph aureus.   While there are fewer antibiotics to choose from, MRSA is still treatable; however, exposure to others can cause them to become susceptible to MRSA as well, so strict adherence to handwashing and not sharing towels should be practiced.

Cellulitis

is a bacterial infection of the skin which can occur in any location but usually is seen on the feet or legs. It begins as a small area but rapidly spreads out from the initial site. Cellulitis begins when bacteria enter a break or crack in your skin, such as where you've had recent surgery, cuts, puncture wounds, an ulcer, athlete's foot or dermatitis.  Other causes of broken skin are insect and spider bites and severely dry, cracked skin. Older people with circulatory problems, those with a weakened immune system (HIV, cancer), people with diabetes or diabetic foot ulcers, or IV drug abusers are all at higher risk.  If you think you may have cellulitis, try to see your physician the same day.  If this is impossible, seek care at an Urgent Care or Emergency Room because cellulitis can rapidly develop into a bloodstream infection and spread throughout your body. Your doctor may have to make sure you do not have a blood clot in the leg since the symptoms of swelling and pain can be similar.  Cellulitis is caused by the same organism that produces the "flesh-eating disease" so your doctor will take cultures and evaluate you for this condition also.

Treatment of cellulitis always requires antibiotics.  If the physician feels it's more urgent, intravenous antibiotics may be ordered or the patient may be hospitalized.  It is important to finish the entire course of antibiotic even though the symptoms look better after a few days.

Seborrheic dermatitis

also known as dandruff,  is a common, scaling rash that often itches. While not contagious, it is caused by an organism that lives on the skin.  It occurs usually in the scalp, eyebrows, around the nose and ears and in the mustache area.  When present in the scalp, it appears as an oily type of dandruff.  It may occur at any age, including infancy, and may last for months or years. Improvement in the summer months has been reported.  Aggravation by certain drugs is well-known and it is more common in patients with Parkinson's Disease and HIV infection.

The cause of seborrheic dermatitis is unknown but appears related to a yeast that normally resides on the skin. This same yeast causes the infection known as Tinea versicolor.  Interestingly, this yeast also causes severe itching in some breeds of dogs.

Herpes

is a virus infection.  Other viruses cause colds, mumps, the flu and measles.  Different forms of the herpes virus cause chickenpox, mononucleosis (the “kissing disease”), shingles or herpes zoster.

Many people (some say more than 50%) get herpes and do not know they have it because they never have symptoms.  Others may develop small, sometimes painful sores on or around the mouth (usually type 1) or genitalia or buttocks (usually type 2).  Both types of herpes act the same way.  The information in this article is about both types.  Either type can be found on any part of the body and if it returns it usually comes back in the same place.

The herpes lesion usually starts after a cold, sun exposure or trauma such as cutting the lip while shaving.  It appears as a red patch or group of small blisters and is accompanied at first by itching, tingling or tenderness (called "prodrome" symptoms).  Within hours, the lesion enlarges and can be quite painful, especially if the blisters are broken. At this stage, the lesion can take several weeks to heal.  If oral prescription antiviral medication is taken in the early stage before the blisters form, the episode can be aborted within 12-24 hours, so it's important to have a supply of the prescription medication with you.  Most people who get herpes have only two or three episodes a year but some people get repeated infections and this is an indication for chronic suppressive therapy every day with a prescription antiviral medication. Acupuncture can sometimes help as well.

Active virus can be present on the skin from the first warning signals (prodrome) until the sore completely disappears.  If you touch an active herpes lesion, the viral particles can infect the skin of your fingers, a condition called herpetic whitlow.  Viral particles can also be spread to the cornea leading to keratoconjunctivitis, a serious infection of the eye.  Finally, herpes in the newborn is a serious infection passed from the mother during birth which can result in meningitis and death of the infant.

The first infection can occur between 2 and 30 days after exposure.  The first infection, usually the most severe, can also occur months or even years after exposure.  The sore untreated lasts 2-3 weeks.  Along with the sore, you might have swollen glands, fever, and overall aches like the flu.  Treated sores resolve in a few days to a week.

The sores go away, but the virus does not.  It enters nerve cells close to the area where the sores were and stays there.  There are no symptoms or signs that the virus is present.  The virus is in the “inactive” stage.  Most of the time you cannot give the virus to someone else while it's inactive, nor can it infect another part of your own body.    Some people (about 1/3) have one herpes outbreak and never experience it again.  The virus stays inactive forever.  Others have recurrences – that is, the virus becomes active again and the sores come back in the same place.

Treatment of herpes is most effective when started at the first signs of an outbreak.  The sooner you start the medication the better it works.  If you are aware of the prodromal symptoms, this is when you should begin the treatment.

Treatment consists of the following: 

1. Valtrex (prescription required) two tablets twice a day until the blisters or sores disappear.  If you are in doubt or think you are developing herpes lesions use Valtrex for 12-24 hours and discontinue if no sores develop.  Take with lots of water and some juice or food to avoid stomach irritation.  DO NOT USE IF YOU ARE PREGNANT!  It is probably better if men do not take this pill if they are planning to have children during the months they are taking this tablet.  It does not seem to have any effect on the sperm that we know of, but it is better to be on the safe side.  Nursing mothers should not take this pill.

2. Some people find that two aspirin, two Tylenol or two Advil begun during the first signs of discomfort will decrease the pain.

3. Avoid sexual contact or personal contact from the time you feel symptoms until the lesions are clear.  Use condoms as long as there are any sores present.

4. Side effects from the medication are very rare.  If you experience nausea, vomiting and/or headache, please discontinue the medication and let your doctor know about it.  The following reactions are also possible but very unusual: diarrhea, dizziness, loss of appetite, mild fatigue, skin rash, leg pain or a medicinal taste in your mouth or throat.

5. This medication is used to treat herpes virus in any location on the body.  The pill seems to be relatively safe in that it acts only on those skin cells that have the herpes virus growing in them.  It does not affect normal cells in the body. 

6. In some people, taking homeopathic Apis can abort an episode.

7. It's important to treat the area gently, using a topical lubricant such as Aquaphor ointment.  It is NOT recommended to use such over-the-counter remedies as Blistex, Carmex or others containing phenol, menthol or camphor since these will delay healing.

8. Vitamin C 1-3 grams per day can also improve your resistance to viral infections.

UNDERSTANDING HERPES SIMPLEX

Unfortunately, there is an extensive amount of misinformation in the general public in regard to the herpes simplex virus.  Much of this information is not totally accurate.  It can be misleading, frightening, and confusing to people with Herpes simplex.  It is unfortunate that herpes is labeled as a venereal disease.  Venereal means a disease that is spread from one person to another through sexual contact.  The herpes virus is carried by most people and acquired during infancy.  It remains silent in our body and usually does not give us symptoms.  We have antibodies too that keeps its activity suppressed.  It is felt that when a person’s resistance to the virus drops, they will develop an attack of herpes virus.  It is possible to spread herpes from one person to another from a fresh sore.  It is very unlikely that herpes virus is spread from one person to another when no active sores are present, however, current research is investigating whether Herpes simplex is contagious when it is in its inactive stage.

When people are under stress or tension or their resistance is down, they are more likely to develop an attack of herpes. The sun, excessive exercise, or heat can also trigger herpes simplex attacks especially on the face and lips.  Excessive friction or rubbing to the skin such as sexual contact can also trigger a herpes lesion in a mucous membrane area.  In the couples that we care for with recurrent Herpes simplex it is very rare for both partners to have recurrent herpes.  Usually only in a very small proportion of the people that we care for do both partners have herpes.  This is evidence that one partner has lower resistance to the herpes virus and the other has good immunity and never develops the infection.

The statement in the public press that herpes is an incurable disease and that once you have it you never get rid of it is false.  Most people have been exposed to the virus and have antibodies or resistance against it.  It is possible to give someone one attack of herpes if you have contact with them and they touch your fresh blisters.  Most contact with fresh blisters does not produce a transmissible sore to another person.  As a rule, people do not spread recurrent herpes from one person to another.  Your general immunity to the herpes virus has to be reduced in order for you to develop recurrent Herpes simplex sores.  It is important for us to emphasize that it is very rare for two partners who have frequent sexual contact to both have recurrent Herpes simplex. Remember, be safe, always practice safe sex, and use condoms, especially during questionable or definite herpes outbreaks.

Herpes zoster or Shingles

is a nerve infection caused by the chicken-pox virus.  Shingles results from activation of chicken-pox virus that has remained in your body since you had chicken-pox perhaps many years ago.  The virus activation begins in a nerve root.  That accounts for the pattern of the rash, which usually stops at the body’s midline.  The nerve involvement explains the stinging, burning, or pain common in shingles.  Some patients have discomfort before the rash appears.

The rash of shingles begins as red patches that soon develop blisters.  The blisters may remain small or can become large.  They will follow the path of the affected nerve and remain limited to either the left or the right side of the body.  The rash may form on the scalp, face, neck, arm, leg or trunk.  It may occur before, after or at the same time the patient notices the nerve pain and many times.  Patients often don't realize the rash and the pain are connected.  The blisters heal in two to four weeks or they may leave scars and many people are left with chronic nerve pain in the area that doesn't respond even to narcotics.

Some patients mistakenly believe that “nervousness” causes shingles.  This is incorrect; shingles is a viral infection of a nerve and has nothing to do with being “nervous”.

Is it contagious?

You don’t have to quarantine yourself.  Until your rash has healed, however, you should keep away from persons who have never had chicken pox such as infants or young children, those who are ill, or are unable to fight infection because of a disease or a medication.  Persons who have not had chicken pox can occasionally catch chicken pox from someone with shingles.  Contact with healthy adults appears safe.  

Treatment

Call your doctor as soon as you think you may have shingles; the sooner you start treatment, the better it works. Antiviral drugs such as Valtrex pills (prescription required) can help to heal the skin eruption if started early enough after the rash first appears.  If the rash is still present, treatment with antiviral medication should be undertaken to prevent or minimize the  nerve damage.

The pain can be reduced with homeopathic Hypericum, aspirin, Tylenol, or ibuprofen.  If these are insufficient, the doctor can prescribe something stronger.  Pain is often difficult to control and may persist for months or years after the blisters have healed.

While blisters and oozing are present, cool compresses will make you feel more comfortable.  Mix ¼ cup of white vinegar in two quarts of water.  Soak a washcloth or towel in the solution.  Then lightly wring out the towel so it is not dripping.  Apply this to the blisters for ten minutes several times per day.  Stop this when the blisters have dried up.

If the trunk or extremities are affected, pain may be reduced by covering with cotton and then wrapping firmly with an elastic (Ace) bandage.

Prevention 

A relatively new vaccine is available for persons 60 and older called Zostavax; however one study concluded that people who practice tai chi exercises were protected against shingles about as well as people who got the vaccine.  Taking Vitamin C in doses of 1-3 grams per day improves the immune system and may also be antiviral.

Warts

are skin growths caused by viruses.  Wart viruses can be passed to others by direct contact, or indirectly in such places as locker rooms and public showers.  They can also spread on the same individual by picking, or scratching. 

All warts are caused by specific types of viruses that have an attraction for skin.  They can grow on just about any part of the body.  Their appearance depends on their location.  Warts are slightly contagious and may spread from one part of the body to another or from one person to another.  We do not understand why some people seem to be resistant to developing warts while others grow warts very easily.

Warts often resolve spontaneously without any treatment, especially in children.  While the majority of warts can be successfully treated, some warts are extremely difficult to eradicate (especially those around the fingernails and on the bottom of the foot). Sometimes new warts will form while existing ones are being destroyed.  At other times, untreated warts will disappear when other warts are treated.  Warts may also return after an apparent cure.  Do not be alarmed as this is very common.  These can be treated more vigorously with a different method. Occasionally a wart may actually be a skin cancer so you should have all warts checked if they do not resolve within a month or two.

Laser treatment using the NdYAG laser is the most effective treatment for warts, even those on the palms and soles. One to three or more treatments may be necessary to fully eradicate the wart.  Because the treatment is painful, local anesthetic is usually injected beneath the wart just before the laser treatment.

Liquid nitrogen is often very effective, especially for tiny warts on the hands or face. Treatment will often need to be repeated several times, about every 2-3 weeks.  

Retin-A cream (prescription required) is effective in treating some cases of warts especially those on the face.

Salicylic acid plasters (example: Compound W) are available without a prescription.  Scrape off the dead tissue daily with an emery board, pumice stone or file.  Soak the wart in warm water for 10 minutes, then apply the plaster.  Use a piece only slightly larger than the wart so that the surrounding skin is not irritated.  Place adhesive tape over it to ensure that it sticks.  Continue treating until the wart is gone, which may take weeks to months.

Cantharidin, an extract of a blister beetle, may be applied to the wart by the physician.  Leave the tape on for 24 hours (or 48 hours if the wart is on the pams, soles or around the nail).  However, if burning occurs before this time, remove the tape and wash off the medicine.  The goal of therapy is to cause blister formation.  Treatment may have to be repeated.

Genital warts are spread by sexual contact so patients and partners should use condoms until all warts have been eradicated.  Genital warts are commonly treated with Cantharone or liquid nitrogen cryotherapy (applied by a physician).  The normal action of these treatments is to form a blister underneath the wart.  This occurs within 24 hours of application.  Occasionally, there may be some blood in the blister fluid so don’t be alarmed if this occurs.  The blister may also be painful, inflamed and itchy.  Your physician will recommend appropriate medication to counteract this.

Treatment progression (what you can expect after treatment with Cantharone) 

4 HOURS:    Mild discomfort may occur; control with bathing and Tylenol for pain.

24 HOURS:  Blister usually formed within 24 hours.

4 DAYS:      Crusted blisters fall off leaving superficial erosions.  Medication may

                   be needed to control nighttime itching.

7 DAYS:      Healed with temporary residual inflammation/redness.  Any resistant 

                  lesions will be re-treated by your physician at your next appointment.

                  Temporary loss of normal pigmentation often occurs. 

Re-examination/re-treatment  

Most people are cured after 2-4 treatments depending upon the size and number of warts.  All warts must be destroyed or they will grow back.

Next appointment 

You should return to the clinic in two weeks for re-evaluation.  Occasionally warts occur inside the urethra, vagina or rectum.  Your physician will need to examine these areas to ensure that all warts have been eradicated.  Untreated, venereal warts may lead to cervical or penile cancer.

Molluscum contagiosum

is a virus that causes a skin infection appearing as small white or pink bumps. It is generally a benign infection.  Molluscum is contagious. It can be spread by human to human contact in daycare centers or it can be a sexually transmitted disease. If a person has the virus, they can also spread the infection to other parts of their own body by touching a lesion and then touching another part of their body, or by using contaminated towels. Diagnosis is made by a dermatologist, who can usually recognize this condition without a scraping or biopsy. If you have lesions, you are able to spread the infection to others.  Treatment is recommended to avoid infecting other parts of your skin or others. Treatments include liquid nitrogen cryotherapy, curettage (scraping), or application of a chemical called Cantharone by the physician. Follow up is recommended at 1-2 week intervals until the infection is resolved. 

Pityriasis Rosea

Spring and fall are the peak seasons to see pityriasis rosea (PR), a common but little known skin rash. PR is now believed to be caused by one of the Herpes virus group.  Pityriasis rosea is probably spread from coughing and sneezing but  is not very contagious since few family members ever develop the rash.

What does the rash look like?

The eruption of pityriasis rosea typically arises after an upper respiratory infection type of illness. Most, but not all patients will develop a “herald patch” or “mother spot”. This lesion is usually larger than the others and can precede the development of the rash by days or a few weeks. The rash appears as salmon pink oval patches which are slightly scaly on the chest and back. A few lesions may also develop on the extremities, neck and face. This rash can have a somewhat different appearance in patients with darker complexions.

How is it treated?

In all, PR usually lasts approximately 6 weeks. There are occasional patients who have a longer course but this is unusual.  Prescription antivirals may be ordered by your dermatologist.  Occasionally itching is the main complaint and treatment is aimed at controlling the itching with  Benadryl, topical cortisone creams and Aveeno oatmeal baths . Blood tests may be performed by your physician since, in adults, the appearance of PR can be mimicked by secondary syphilis.  Finally one form of psoriasis may mimic this condition so a small skin biopsy may rarely be needed.

Fungal Infection (Ringworm)

Tinea corporis is the medical name for fungus appearing anywhere on the body.  This organism prefers warm, moist skin; this is why the infection is often worse in warm weather.  Not all skin rashes on the body are due to fungus.  Eczema can appear very similar to a fungal infection.  Fungal infection of the feet is call Tinea pedis or "athlete's foot."  Fungal infections can also involve the beard, scalp, groin or nails.

This fungus usually starts as a scaly, round, red patch of skin most people call "ringworm."  It can be very itchy.  Many people try over-the-counter cortisone creams on the rash which will make it spread or worsen.

Can it be treated?

Yes, but proper treatment requires the correct diagnosis.  You should seek an opinion from a skin specialist who will take a scraping and examine it under the microscope for the presence of fungal forms.  A culture may also be sent to a lab to determine the type of fungus.  After the diagnosis is confirmed, a prescription medication will be ordered by the physician.

Is it contagious?

Yes.  Many types of fungus are spread from animals to humans.   You may need to have your pet treated at the same time by a veterinarian to ensure you don't get the infection again. 

Human to human contact can also spread this fungus as in wrestlers, children in daycare centers and using others' towels or combs. 

Soil contains fungi and occasionally gardeners can develop Tinea infections.

Treatment

A topical prescription antifungal cream is usually prescribed except for deep-seated infections of the scalp or in immunosuppressed patients, when an oral treatment is indicated.  Medications must be continued for a week after the skin heals to ensure all fungal organisms are dead.

Systemic antifungal treatments will require blood tests before you start the medication and after you finish the drug to check liver function.  Since these drugs are metabolized by your liver, you will want to avoid alcohol and other drugs which can damage the liver.  Treatment with these drugs usually last one to two months.

Recurrent infections are unusual if the source is determined and treated or avoided.

Nail infections are very difficult to treat and require months of therapy with oral antifungal drugs.  It usually is not worth the risk to your health to treat these infections.  A new laser is available to treat fungal nail infections that will clear nails in one to two treatments without the need for medications. Occasionally a nail will partially break off or grow so thick that it has to be surgically removed.   This is performed in the dermatologist's office under local anesthesia.  Removal is relatively painless and there is minimal pain afterward.  The nail sometimes will grow out normally after it is removed.

Tinea Versicolor

is a fungal infection of the skin in which small, oval, white, reddish brown or tan patches are spread over the upper trunk, abdomen, arms and legs.  Most patients complain of cosmetically disturbing, abnormal pigmentation and failure to tan in the summer leading to a spotted appearance.  Occasionally, mild itching is also noted.  The infection is not contagious but the organism is present on the skin of almost everyone, and about 20% of the population is genetically susceptible to the infection.   The organism thrives in warm, moist conditions and in the presence of skin oils, therefore, young adults are more commonly affected.

How is Tinea Versicolor treated? 

Treatment is aimed at eradicating the yeast organism with topical prescription selenium sulfide lotion or prescription oral antifungal drugs such as ketoconazole.  After the yeast is eradicated, the former infected sites remain lighter than normal skin for 1-2 months until the pigment production returns.

Recurrence of the infection is common, so periodic retreatment with either selenium sulfide lotion or oral prophylaxis may be recommended.

In a subgroup of patients who are immunosuppressed, the infection can occur in the armpits or on the face.  Treatment is identical but recurrences are more common.

Scabies

is an intensely itchy rash caused by a tiny bug called a mite. The mite is too small to be seen without magnification.  The rash usually involves the finger webs, the wrists, breasts, genital area, elbows, armpits and buttocks.  It is transmitted by close personal contact.  All members of your family and any sexual partners should be treated at the same time, regardless of whether they have a rash.

How Should I Take the Medication?

Ivermectin (prescription required) is the current drug of choice for treatment of scabies. The patient and all close or household contacts should be treated at the same time. Pregnant or breastfeeding women should not use these medications without consulting their physician.

Ivermectin will need to be repeated at one week to kill immature mites which have hatched after the first dose.  Your physician will let you know the number of pills to take.   These are usually taken in a single dose.  Each family member needs to take his or her dose at the same time.

You will be rechecked by your physician usually in two weeks.  Itching after treatment does not necessarily indicate treatment failure because some people develop allergic reactions to the embedded mite and this could be the cause of itching rather than active infection.  If persistent skin lesions are seen at one month after treatment, this is likely a reinfection or treatment failure, and retreatment of patient and all contacts is necessary.

All bed linen and clothing should be washed in hot water in order to remove eggs and mites.  Mites can live on clothing or bedding for 3 days.  Articles that cannot be washed should be placed in sealable plastic bags for 3 days.