Pyoderma

PYODERMIA, pyoderma (from Greek pyon—pus and derma—skin), a group name for acute and chronic superficial (epidermal) and deeper (epidermodermal and hypodermal) inflammatory processes caused by pyogenic cocci—staphylococci and streptococci. These microorganisms are present on the skin of every person, but far from everyone falls ill with pyoderma, which largely depends on the presence of various predisposing causes that lower the normal resistance of the organism and, in particular, of the skin against pyoderma pathogens. The leading cause of pyoderma is the peculiarity of the external (occupational) environment, which creates the possibility of minor trauma; the immediate causes are the lack of proper skin care, contamination, maceration, and subsequent traumatization (even negligible, such as friction from a collar). Certain forms of pyoderma, mainly furunculosis, are predisposed by metabolic disorders, especially diabetes and gout, gastrointestinal diseases, exhausting diseases, and others. As a rule, in pyoderma, pyococci penetrate the skin from the outside (e.g., in scabies, pediculosis, and eczema). Violation of the integrity of the stratum corneum by scratching favors the occurrence and spread of pyoderma. Most often, the portals of entry for infection are hair follicles. Pyoderma is frequently observed among workers in a number of industries; the main reasons for this are, on the one hand, the still insufficient rationalization and mechanization of production, and on the other hand, insufficient measures for skin cleansing after work. According to the Main Social Insurance Directorate of the RSFSR (Bronstein) for 1930, the specific weight of pyoderma diseases among all cases and days of temporary disability in a number of industries is as follows: in ferrous metallurgy (in the RSFSR), pyoderma diseases accounted for 8% of all temporary disability and 7.1% of all days of disability; in mechanical engineering, 8.2 and 7.4% respectively; in basic chemistry, 10.1% and 8.5%; in oil extraction (North Caucasus Krai), 11.4% and 10.3%. In 1932, at the Serp i Molot metallurgical plant in Moscow, a special medical brigade from the State Institute of Venereology and the Institute of Industrial Hygiene and Sanitation worked on the issue of pyoderma; it revealed a significant incidence of pyoderma among the plant's workers. Across 10 main workshops in 1930, 375 sick leaves were issued for furunculosis alone, totaling 3,525 days. In 1931, 630 sick leaves were issued for 5,350 days. For other pyoderma diseases (abscesses, panaritiums, paronychia, etc.) in 1931, 1,249 sick leaves were issued across the entire plant for 10,733 days. The average number of patients with boils relative to the average population of the plant in 1930 was 6.56%, and in 1931, 5.2%. By applying rational preventive and therapeutic measures, the brigade managed to somewhat reduce the incidence of pyoderma at the plant and almost halve the average number of days of disability based on dispensary material (from 9.4 days in 1930 and 8.5 in 1931 to 5.4 days in 1932). The clinical picture of pyoderma is extremely diverse, which depends on 1) the nature of the pathogen, 2) the duration of the process, 3) the depth of its penetration into the thickness of the skin, 4) the labor and living conditions of the patient, 5) the individual properties of the skin and organism of the patient, and 6) the localization of the lesion. There is no unified classification of clinical forms of pyoderma. The most accepted classification in dermatological literature is by pathogen: staphylodermias and streptodermias. Such a classification allows many authors (Jadassohn, Darier) to include surgical diseases such as phlegmons, abscesses, panaritiums, and others in the pyoderma group, which is practically inexpedient, as is the classification of clinical forms by the depth of the lesion (surface and deep pyoderma). Typical staphylococcal pyodermias include Bockhart's impetigo, staphylococcal folliculitis (folliculitis staphylogenes); non-parasitic sycosis (sycosis non parasitaria), boils, hidradenitis suppurativa, pseudofurunculosis, gangrene. Streptococcal pyodermias most frequently include: impetigo (Fox), bullous impetigo (angulus infectiosus), ecthyma. There are pyodermias caused by a mixed infection—staphylococci and streptococci [e.g., vulgar impetigo (see) and impetiginous eczema (see)]. A separate clinical variety includes pyoderma of smooth skin and certain chronic diseases of hair-bearing areas described below, characterized by clinical polymorphism, duration, and persistence of the course. Acne vulgaris (see Acne vulgaris), classified by some authors as pyoderma, cannot be considered as such, since in it staphylococci, not being the cause of the disease, merely participate in the pathological process, thereby modifying the clinical picture. Folliculitis et perifolliculitis abscedens et suffodiens Hoffmann. On the scalp, many deep inflammatory ridge-like, rapidly softening nodes appear, which then form deep fistulous tracts that "undermine" the skin and merge in the depths, leaving wide linear scars, often keloidal. The pathogen is staphylococcus. Histologically, it is an inflammatory granuloma with mono- and multinuclear leukocytes. Acne conglobata is often present simultaneously, as is acne keloid (see Acne).—To shallower pyodermias belong the closely related folliculitis decalvans and ulerythema sycosiforme. In folliculitis decalvans of the scalp, inflammatory folliculitis appears, leaving flat scars upon regression that resemble atrophy in pseudopelade (see). The process frequently serpiginates, healing on one side and spreading to another. Histologically, it is a perifollicular lymphocytic infiltrate.—Ulerythema sycosiforme Unna (sycosis lupoides Brocq) occurs on the hair-bearing parts of the cheeks, temples, and head, and is characterized by the constant presence of two zones. The central zone represents a continuous, smooth, white, hairless scar, sometimes partially keloidized, while the peripheral ridge is covered with isolated follicular pustules. Histologically, it is an infiltrate of plasmoma character, occupying almost the entire thickness of the dermis. The pathogen is staphylococcus. The best treatment is roentgenotherapy. Chronic vegetative wart-like and ulcerative pyoderma (vegetating pustular dermatitis, pyodermia chronica ulcerosa vegetans; pyodermia chronica serpinginosa, etc.).—The clinical picture of this pyoderma is very diverse; often the same patient has different forms of pyoderma in different places (pyodermia politypica Kogoj), and sometimes eruptions of a chronic, subacute, and acute character are present simultaneously (Chernogubov). The onset varies: from a follicular pustule, from non-follicular phlyctenae, from large abscesses, and others. The pathogen is staphylococcus and streptococcus. Individual eruptions mostly merge, forming serpigenetic disks on larger or smaller areas with slightly undermined edges and a purulent floor, surrounded by inflammatory phenomena; sometimes a whole network of purulent cavities and tracts is formed, connected to each other under the skin. Gradually, the central parts heal with a scar resembling either scrofuloderma or tuberculoid syphilid. At times, cases of chronic pyoderma cannot be clinically distinguished immediately from syphilis, tuberculosis, or deep skin mycoses—blastomycosis and sporotrichosis. Differentiation is possible only through careful histological, bacterioscopic, and bacteriological studies, as well as through trial treatment.—The histological picture is most diverse—ranging from ordinary vulgar infiltrate to typical granuloma. Chronic pyoderma develops mostly in weakened and exhausted individuals, sometimes from ordinary acute pyoderma due to lowered bodily resistance. In chronic pyoderma, an allergic state of the entire skin is frequently observed. Intradermal injection of autovaccine in such cases causes a strong local reaction. Isolated cases of allergic rashes in pyoderma have been described (lichen pyodermicus) (Schreus and Goehl). Prevention of pyoderma. The higher the cultural level of the population, the fewer pyoderma diseases occur. Personal prevention consists of observing skin hygiene rules: daily washing of exposed body parts, a weekly bath or shower, frequent changes of underwear, and comfortable, non-rubbing clothing and footwear. If a separate pyoderma eruption is already present, adjacent healthy skin should be protected by wiping it twice a day with camphor alcohol, an alcohol solution (vodka, etc.). Diseases of internal organs require treatment. The fight against pyoderma in industry includes combating minor trauma, rationalization and mechanization of production processes, and compliance by both management and workers with all occupational safety rules (wearing appropriate work clothing, providing showers for washing the whole body with warm water and soap after work, with a change of clothes; ensuring good ventilation in the workspace, etc.).

Great importance in the fight against pyoderma is held by the following measures: the active inclusion of a dermatologist in the work of conducting the sanitary minimum at the plant, the posting in all workshops of health education posters drawing the attention of workers to the need to monitor minor injuries that underlie the occurrence of pyoderma, the development and publication of instructions for doctors and nurses of workshop health stations on providing assistance for minor injuries and at the very beginning of the occurrence of pyoderma, and the organization of a special dermatological clinic in the venereology department of the single dispensary. The further growth of industrialization in the USSR, associated with the mechanization of production processes and the simultaneous improvement of the social and living conditions of workers, predetermines the intensified development of the fight against pyoderma. Local treatment of pyoderma consists of 1) measures aimed at the rapid elimination of existing eruptions, and 2) measures aimed at preventing the spread of the process to healthy skin. Therefore, patients are forbidden to wash in a bath or tub and to wash affected areas with water. 1–2 times a day during dressings, the healthy skin around the affected areas is wiped with an alcohol solution (40–60%) or camphor spirit. It is necessary to neatly trim the nails, which serve as a carrier of infection. Locally, various remedies are used for various forms of pyoderma. Thus, for impetigo, boric-tar, mercurial, and other ointments are successfully used, and for furunculosis, pure ichthyol. In pyoderma of hairy parts, if lice are present, the elimination of the latter is necessary. In pyoderma on the extremities and torso, one must always think about the possibility of scabies or pediculosis as the underlying disease. Scabietic pyoderma will never go away unless the scabies is treated. (For details on the local treatment of various forms of pyoderma, see the corresponding articles.) General treatment of pyoderma is diverse. In cases where there are reasons to assume a connection between pyoderma and some general disease (diabetes, gout, etc.), it is necessary to treat the primary condition as well. Internal drug treatment for pyoderma is used little (sulfur for furunculosis, arsenic, etc.). Protein therapy is more widespread, being one of the best remedies for certain forms of pyoderma (furunculosis, erysipelas, etc.). In addition, brewer's yeast internally, autohemotherapy, vaccine therapy, autovaccine therapy, local immunization with Besredka's antivirus, broth vaccines, treatment with bacteriophages, and others are used. The best of these methods are protein and autovaccine therapy, especially when administered intradermally.

L. Mashkilleyson. Pyoderma in childhood, especially in early childhood, is encountered much more frequently than in adults, which is related, on the one hand, to the histological features of the skin (thinness of the epidermal layer, its easy vulnerability, poor connection with the dermis proper; abundance of the skin in lymph and blood vessels, etc.; see Skin), and on the other hand, to the immunobiological data of the child's organism. Relative immunity to the most frequent agents of purulent skin diseases—staphylococci and streptococci—is developed with age through the repeated endurance of minor purulent skin processes. If we exclude from the number of purulent skin diseases specific infections accompanied by pyoderma, such as for example smallpox and chickenpox, as well as pemphigus neonatorum, impetigo contagiosa, ecthyma, scabies, and comparatively rare diphtheritic skin lesions, then the most characteristic clinical forms for childhood, especially early childhood, are the following: 1. Furunculosis, which differs in no way from such a disease in adults, occurring in well-nourished children and being an acute skin infection, more precisely of the hair follicles; the disease is frequently caused by the introduction of infection through scratching in pruritic skin diseases, for example in prurigo. 2. Vesiculopustulosis, in which very superficial vesicles develop, involving the skin no deeper than the Malpighian layer. Exudate is formed in the papillary layer of the skin and accumulates between the epidermis and the dermis proper. These vesicles are very small, the size of a pinhead or slightly larger, containing at first a transparent content which very quickly (after a few hours) becomes turbid, then purulent. The vesicle bursts after 2-3 days and the content dries into a crust. New vesicles usually erupt around it. The eruption occurs on various parts of the body in groups, but predominantly on the back of the head and neck in small children due to sweating (pustulosis sudaminosa) and on the buttocks due to irritation by urine and feces. On the buttocks, under long-continuing unfavorable care conditions, one can note the transition of pustulosis into papular erythema with ulcerations, giving rise to confusion with a syphilitic lesion. This disease is encountered both in debilitated children and in well-nourished children with poor care. Etiologically, pustulosis is associated with direct exogenous infection of the skin by staphylococcus. 3. Multiple skin abscesses, in the form of nodules up to the size of a hazelnut, which seem embedded in the skin. Initially, the skin covering such a nodule, which is hard to the touch, is of normal color and mobile, but after 2-3 days it becomes pink, red, and finally acquires a bluish tint; upon pressure on the nodule, a yellowish coloration of the skin in the center is already obtained. Upon incision made at this time, a significant amount of rather thick green pus is usually discharged. Rapid scarring follows the incision and evacuation of the pus. If the abscess is not opened, it increases in volume, persists for about two weeks, and usually opens by itself with subsequent rapid scarring. Many such abscesses erupt simultaneously in different places on the skin, independently of the localization of the first abscesses; sometimes more than fifty of them exist simultaneously. The process develops exclusively in hypotrophic or atrophic children and is related to the reduced resistance of the organism to staphylococcal infection; the pathway of spread is obviously through the lymphatic or vascular system of the skin. The disease frequently proceeds without an increase in temperature. The etiology is most frequently staphylococcus. 4. Deep abscesses (phlegmons), having a localization already in the subcutaneous cellular tissue. The skin covering them remains of normal color for several days. A small phlegmon is difficult to palpate even at the beginning, but then the induration increases, rises above the general level, the skin over it reddens, becomes bluish in the center, thins out, and fluctuation begins to be felt. Autopsy or opening reveals significant detachment of the skin in the area of the cellular tissue; sometimes on the back of a small child the detachment occupies a space larger than an adult's palm. The edges of the wound continue to disintegrate, and an extensive ulcer with undermined edges is formed. When such a process develops on the scalp, swelling of the skin over a large area appears first, which disappears again after the opening of the abscess. Finkelstein believes that the swelling is related to thrombosis of the small veins of the head, but apparently it is rather related to the structural features of the subcutaneous cellular tissue in the cranial region. Very frequently, the superficial layers of the bones of the cranium are also involved in the process with necrosis (gangrene) of them. The disease is usually accompanied by elevated temperature, poor general condition, weight loss, and dyspeptic phenomena. In atrophic children, the process may proceed without an increase in temperature. All the described forms can exist simultaneously, which indicates the commonality of their origin (most frequently Staphylococcus aureus) and development conditions (nutritional decline, reduced immunity). The prognosis is always doubtful, even in pustulosis, since one can always expect the development of a general septicopiemic process with metastases, lesions of the endocardium, kidneys, pleura, etc., but, on the other hand, the great regenerative capacity of tissues in young children enables the organism to eliminate these purulent processes very quickly under favorably altered conditions of nutrition and care, and in the place of former multiple abscesses and even phlegmons, almost no trace remains after 1-2 years. Prophylaxis should be directed in the first place toward the proper nutrition and care of the child, the elimination of sweating and prolonged skin contamination, the elimination of itching and scratching in children with exudative diathesis, and the broad use of air, light, and water. Attention should be paid to the first insignificant manifestations of vesiculopustulosis and prickly heat in order to prevent the further development of the process. Treatment. If it is a question of a child under 1 ¹/₂ years of age, the introduction of milk into the diet significantly contributes to raising the resistance of the organism. The introduction of vitamins into the food is necessary. In caring for the child, it is desirable to use sterilized (or ironed on both sides with irons) linen. Protein hemotherapy, as well as autovaccinotherapy, is used with success by many authors. Skin care in the presence of furuncles is conducted by conventional methods. For the treatment of pustulosis, many methods have been proposed, but the main principle consists, besides general measures, in the rapid drying of existing vesiculopustules and the prevention of the development of new ones. Baths with potassium permanganate, but not with corrosive sublimate, fulfill this task best (add a 5% solution of potassium permanganate to the bath until the water turns pink). Irradiation with a quartz lamp exerts a good influence. Multiple abscesses are opened as soon as possible with a lancet-shaped (double-edged) knife, making up to 30 punctures at one time and applying, after the removal of pus and cessation of bleeding, a light bandage which can already be removed after 24 hours. Phlegmons are widely opened according to general rules.

G. Speransky