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Microbial Diseases of the Skin

Chapter 21

Objectives
Know the general structure of the skin
Normal microbiota of the skin
Some major microbial diseases (Bacteria,
Viral & fungal)
Differentiate staphylococci from
streptococci, and name skin infections
caused by them
Know some arthropods infestation of the
skin

Skin of the Skin


Structure and Function
Occupies ~1.9m2 & .05 to 3 mm
thickness
Two major layers
Epidermis
Dermis
Chemical defenses
Salt inhibits microbes
Lysozyme hydrolyzes
peptidoglycan
Fatty acids inhibit some
pathogens
Defensins are antimicrobial
peptides
Fig. 21.1

Mucous Membranes
Line body cavities
Gastrointestinal, respiratory, urinary, and
genital tracts
Often folded to maximize surface area, ~400
m2
Epithelial cells attached to extracellular matrix
Cells secrete mucus
Acidic
May contain lysozyme (tears)
Some cells have cilia
Ciliary escalator

Normal Microbiota of the Skin


Gram-positive, salt-tolerant
bacteria, group into small clumps
Micrococci
M. luteus
M. roseus
Staphylococci
S. epidermidis
S. aureus
Diphtheroids (pleomorphic rods)
Corynebacterium xerosis
(aerobic)
Propionibacterium acnes
(anaerobic)
Opportunistic pathogens

Bacterial Diseases of the Skin


Cause by two major genera
Staphylococcus
Streptococcus
These bacteria are well adapted to
skin physiological environment
They also produce invasive enzymes
and toxins

Staphylococcal Skin Infections


Broadly divided into two groups,
coagulase (-) and
coagulase (+) (coagulates fibrin)
S. epidermidis: coagulase(-).
Describe organism: ______
Very common on skin (90%)
Opportunistic infection (broken skin or
catheter)
Produce biofilm

S. aureus: coagulase (+) +ve).


Describe organism: ______

Most pathogenic of staphylococci


Problem in hospitals (MRSA)
Produce leukocidin - an exfoliative toxin
Produces toxins that kills phagocytes
Resistant to opsonization,
Produces superantigen

S. aureus skin infections


Folliculitis:

Infections of the hair follicles (often called pimples)


Sty:
Folliculitis of an eyelash
Furuncle (boil)- localized
More serious hair follicle infection
A type of abscess (pus surrounded by inflamed tissue).
Carbuncle: more extensive damage
Inflammation of tissue under the skin
Usually accompanied by fever

Impetigo: Infectious skin lesions with crusted centers

Mostly affects children (2 to 5 yrs)


Highly contagious
Sometimes both S. aureus and Streptococcus pyogenes are involved

S. aureus Skin Infections


Staphylococcal Scalded Skin Syndrome
(SSSS)
In babies (problem in nurseries)
Due to exfoliative toxin

Toxins cause a separation of skin layers

Toxic Shock Syndrome (TSS)

Life threatening
Toxin (with superantigenic properties) enter the bloodstream
Characterized by high fever, low blood pressure, malaise and
confusion, can progress to coma and multi-organ failure

Treatment for Staphylococcus


infections? Vancomycin, last line of antibiotic
defense (polypeptide antibiotic)

Figure 21.4

Streptococcal Skin Infections


Streptococci cause a wide range of diseases
Meningitis, pneumonia, sore throats,
endocarditis, puerperal fever, otitis, etc.
Not a normal flora of the skin
Produce hemolysins (and )
-hemolytic are often associated with disease
and have A to T serological groups
S. pyogenes
Describe the bacteria: ____
Group A -hemolytic streptococci (GAS)
Produce several virulent factors:
Capsule of hyaluronic acid (poorly
immunogenic)
M proteins (prevents activation of
complement, evade phagocytosis and
Learn
assist adhesion on mucous membranes);
These
>80 serotypes based on M protein
Virulent
Factors! Streptokinases (dissolve blood clots)
Deoxyribonucleases (degrade DNA)
Streptolysins (lyse RBC and toxic to
neutrophils)

Figs. 11.19 & 21.5

Streptococcal Skin Infections

Erysipelas
Reddish patches with raised margins (more
superficial-not very deep)
Impetigo
In older children
Sometime occurs together with S. aureus

Treatment for streptococcal infections? (-lactamtype antibiotics, e.g. cephalosporin )

Necrotizing fasciitis (flesh eating disease)

Produces an extra toxin


Exotoxin A, acting as a superantigen,
causing the immune system to contribute to
the damage
Streptococcal toxic shock syndrome that
leads to bacteremia

Treatment (broad spectrum antibiotics and surgery)

Figs. 21.7, 21.8

Infections by Pseudomonads
Pseudomonads

The most important is P. aeruginosa

Describe the organisms:


Produces pyocyanin, blue-green pus as bacterial pigment

Pseudomonas aeruginosa

Opportunistic infection
Major problem in cystic fibrosis patients (accumulation of thick
and sticky mucus)
Deep burn patients
Adhesin for colonization
Exotoxins (proteases and hemolysins) for tissue damage,
bloodstream invasion and dissemination
Biofilms, against complement, phagocytosis, and antibiotics
Endotoxin
Relative resistance to antibiotics

Pseudomonas dermatitis

Self limiting rash associated with swimming pools, saunas, and hot
tubs
Otitis externa (swimmers ears)
Treatment: Quinolones and antipseudomonal -lactam antibiotics

Names:

Acne

Pimples, spots, zits, or acne.


Most common skin disease in humans

Comedonal acne (blackhead)- mild

Sebum channels are blocked by shed


cells

Inflammatory acne- moderate

Caused by Propionibacterium acnes

Characteristics of organism:
Gm (+) rods, aerotolerant anaerobes
Breakdown sebum inflammatory
reaction

Nodular cystic acne- severe

Form nodules or cysts (inflamed pus


filled lesions in skin)
Leave scars on face and upper body
(psychological scars?)

http://en.wikipedia.org/wiki/Acne_vulgaris

Mild Acne
Topical applications: salicylic acid and vitamin A derivative
(tretinoin, tazarotene)

Moderate and Severe Acne


Accutane (Isotretinoin)
reduces sebum formation
However, it is teratogenic (not for pregnant women)

Antibiotics to target P. acnes; Erythromycin


Benzoyl peroxide
Effective against P. acnes
Also loosen clogged follicles

Visible (blue or red) light (kills P. acnes)

Infection in the Gym


Jason, a 21-yr-old college football player, goes
to a health center with a redness on his right
leg. It was swollen, warm & tender when
touched. His temp was normal and is given
sulfamethoxazole-trimethoprim
After 2 days, he returned. Examination
revealed a broader area of redness and was
diagnosed as cellulitis
The pus was sent to a lab for Gram stain &
coagulase test
Antibiotics sensitivity testing was done with
penicillin, methicillin, erythromycin,
vancomycin & trimethoprim-sulfamethoxazole
Treatment: vancomycin

Viral Skin Infections


Warts
Caused by papillomaviruses
Characteristics of virus: dsDNA,
nonenveloped
Spread by direct contact (see genital warts
later)
Treatment
Physical removal: extreme cold, dry or burn them
Chemical
Salicylic acid,
Imiquimod (stimulates interferon production)
Interferon

Smallpox
During the Middle Ages, ~80% of the
population of Europe contracted this
disease
Caused by an orthopoxvirus
Two basic forms: variola major (> 20% mortality and
variola minor (< 1% mortality)
Transmitted by the respiratory route
First infect internal organs before they move into
bloodstream and eventually infect the skin
Eradicated by vaccination

First disease to which immunity was


artificially induced and to be eradicated
Vaccination in US ended in 70s due to no animal host
reservoirs for the disease
Candidate for bioterrorism
Figure 21.9

Chickenpox (varicella-zoster virus)


Human Herpes virus (HHV-3)
What are the viral characteristics: _________

Transmitted by respiratory route


Causes pus-filled vesicles (face,
throat, lower back, chest &
shoulders)
Virus may remain latent (enters the
peripheral nerves and moves to a
central ganglion)

Adaptive immunity cannot get rid


of latent virus

Lower immune competence activates


the viruses in the form of shingles

Treatment: Acyclovir

Live & attenuated vaccine


Figure 21.11

Cold Sores

(Fever Blisters)

Human herpes virus 1, HSV-1

Also Herpes simplex virus (Genital herpes mostly caused by


HHV-2)
What are the viral characteristics?
______________________________

Transmitted direct contact (also oral or


respiratory routes)
Infection rates range from 70% to 100% (90%
of US population infected)

Virus remains latent in nerve cells

Causes cold sores (fever blisters) and can cause


encephalitis when reactivated

Treatment:

Acyclovir (encephalitis)
No vaccine available

Measles (Rubeola)
Measles virus
Viral characteristics; ________________
Highly contagious (extremely dangerous disease
in infants & very old people)
Characterized by macular rash
Symptoms similar to smallpox & chickenpox,
resembling those of common cold
Frequently complicated by middle ear infection &
pneumonia

Transmitted by respiratory route


Prevented by vaccination
Type of vaccine?
Live attenuated viruses
Administered as MMR (measles, mumps,
rubella)
Figure 21.14

Rubella (German Measles)


Rubella virus
Viral characteristics:
A milder viral disease than measles

Macular rash and light


fever, complications are
rare
Congenital rubella syndrome
causes severe fetal damage
(35% of serious fetal damage)

Prevented by vaccination
Type of vaccine?
Figure 21.15

Cutaneous Mycoses
Dermatomycoses
Tineas or ringworm
Athletes foot
Metabolize keratin
keratinase
Trichophyton
hair, skin, & nails
Epidermophyton
skin & nails
Microsporum
hair & skin

Treatment
Oral griseofulvin
Topical miconazole

Candidiasis
Caused by

Candida albicans (yeast)

Candidiasis
Can result from suppression of
competing bacteria due to
antibiotics use
Occurs in skin
On mucous membranes of
genitourinary tract and mouth
Thrush is an infection of mucous
membranes of mouth

Topical treatment:
Antifungal agents

Miconazole or nystatin.

Scabies
Also known as the itch
Characterized by intense itching, a generalized rash and can lead to secondary infection

Caused by mites (Sarcoptes scabiei)


Burrows in the skin to lay eggs

Treatment with topical insecticides

http://en.wikipedia.org/wiki/File:Sarcoptes_scabei_2.jpg

Figure 21.18

Pediculosis
Pediculosis

Contagious
Feed on blood
Lay eggs (nits) on hair
Cause itching
Treated with topical insecticides

Two major types:

Pediculus humanus capitis (head louse)


Do not spread disease

P. h. corporis (body louse)


Can spread disease (epidemic typhus)
Figure 21.19