August 6, 2024 • 29 mins
The human body is outnumbered by bacteria almost 10 to 1, and in general, we live in harmony with them. It’s a truly symbiotic relationship, however, what happens when we get an imbalanced microbiome?
In this episode, your hosts Dr George Moncrieff and Dr Roger Henderson will answer just that, as they cover some of the common and rarer bacterial infections seen in primary care. Listen along to hear:
- Their top six facts about bacteria
- How to spot common bacterial infections including, impetigo, folliculitis and furuncles along with the not so common ones like carbuncles, Staphylococcal Scalded Skin Syndrome and ecthyma
- Their management and treatment strategies, along with their prescribing choices
- General tips and advice for patients
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
Find out more: https://aproderm.com/aproderm-emollient-starter-pack/
LI: https://www.linkedin.com/company/fontus-health-ltd/
Got some feedback for us? Please rate and review Rash Decisions to help us keep creating educational podcasts for you.
Is there a dermatology topic you’d like us to explore? Email us at info@aproderm.com, and we’ll do our best to cover it.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:08):
Hello and welcome again to thisRash Decisions podcast where
we look at skin-related issues,conditions and treatments in an
interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
(00:30):
Now today, George and I are going tobe talking about the common problem
of bacterial skin infections, and itwill surprise no one, to learn that
this is an enormous topic, and sowe're going to be doing three podcasts
about it, with this being the first.
Now in the third podcast, we're also goingto be joined by a very special guest,
so don't forget to tune into that one.
(01:00):
But before we look at some of thecommon bacterial skin infections we
see so often in our practices, Georgeand I were talking, we put our heads
together and came up with a top factslist, which was such good fun to do.
We thought we had to sharethem with you, and we thought
six was quite a good number.
So in no particular order, I justwant to kick off with one of my
favourites, and it's about thenumber of cells in our bodies.
(01:24):
We've got around a hundredtrillion cells in our bodies.
Now, I don't know what that numberis, but it sounds a hell of a lot.
But over 90% of those are bacteria.
So we're actually outnumberedby bacteria by almost 10 to 1.
Mostly in the gut, but also on our skin.
(01:44):
So that's a nice one to kick off, I think.
It is, isn't it, and actually, justthinking about it, that's 200 times the
number of stars that are in the Milky Way.
Ooh, good one.
It's just a phenomenal number, isn't it?
Isn't it extraordinary thatwe are outnumbered so much?
Those bacteria are quite small,so they only constitute about 1 or
2 kilograms, which in an averageadult, weighing about 75 kilograms,
(02:07):
that's a very small percentage.
But nevertheless, their cell numbersoutnumber us in this extraordinary ratio.
Fact 2, 99% of these bacteria are notpathogenic under healthy conditions.
After all, there's no advantage in abacterium killing its host, is there?
(02:27):
We live not only with them, butwe live in harmony with them.
Indeed, our very existence andour health is dependent on them.
For example, they compete with thepathogenic bacteria for nutrients, and
without them, we would be in trouble.
It is a truly symbiotic relationship.
(02:48):
Ooh, I love that one.
Go on, have a crack at another.
That's great.
Okay.
An unhealthy, imbalanced microbiome,something that's called dysbiosis, is
associated with a vast number of diseases,but also a vast number of skin diseases.
For example, atopic eczema, acne,psoriasis, even hidradenitis,
(03:10):
and going on even further, I wasastonished to read that vitiligo and
alopecia areata are also aggravatedand associated with a dysbiosis.
Wow.
For example, in atopic eczema,there's an unbalanced microbiome with
overgrowth of Staphylococcus aureus.
Pathogenic Staphylococci play a criticalrole in atopic flares, as well as
(03:32):
probably driving the itch itself directly.
Regarding acne, there are 6 clades ofthe bacteria that's associated with
this, called Cutibacterium acnes.
IA1 is the predominant clade of C.
acnes that is associated withinflammatory lesions of acne.
Some of the others mayeven protect against acne.
(03:56):
Antibiotics don't discriminate betweenthese clades, so we should really ask
ourselves, is it in fact, our overuseof antibiotics knocking out these
healthy bacteria, which allows the morepathogenic strains to take dominance,
and then cause the increasing prevalenceof so many skin diseases, like acne.
(04:18):
And indeed, the IA1 clade is themost resistant to antibiotics.
So, antibiotics do untold harm toour skin and our gut microbiomes.
Ooh, that's my favourite so far.
That's a, that's a cracker.
Well, if we think about gut microbiomesthen, fact 4, I suppose, we now
(04:40):
know that the gut microbiome playsa massive role in the aetiology and
prevalence of numerous diseases.
I'm thinking of things like inflammatorybowel disease, we know it's involved.
Cancers, diabetes, heart disease, evendementia, and there's an absolutely
critical relationship betweenthe skin and the gut microbiomes,
(05:01):
of which I'm sure we're going tohear a lot of in the coming years.
The gut-skin axis, that's a nameto remember as a fact, I think.
Our skin actually is naturallypretty hostile to bacteria.
It's relatively dry and nutrient poor.
It has this surface acid mantle,which we've spoken about before,
(05:21):
and it's in contact with air.
I was amazed to hear from an oldprofessor at medical school, a
professor of microbiology, thatthe vast majority of pathogenic
bacteria are obligate anaerobes.
So it's not a niceenvironment for bacteria.
Although the surface of our skinis actually only 2 square metres,
if you include all the appendages,the infundibular openings and
(05:45):
the sweat glands, etc., then thisincreases to 25 square metres.
That's about as large as 2 car parkingplaces, and it's equivalent to the
surface area of the entire gut.
It offers a wide diversity of habitatsfor various bacteria, fungi, and yeasts.
That's great, and a final fact, frommy point of view, we're going to be
(06:07):
talking about infections, obviously.
An infection actually occurs wheneither a particularly virulent
pathogen is encountered, or there'sa disturbance of the normal symbiotic
balance, which we've mentioned.
In other words, when the host's immunityis compromised, and so we're thinking
of, for example, damage to the skinbarrier, such as from a cut, or from
(06:30):
scratching, or from eczema itself.
Now those were a nice little seriesof facts that George and I, sort
of, put our heads together andcame up with, and I hope you found
them as interesting as we did.
We probably could have found somemore, but uh, we'll probably have
to leave it there, and I suspect youmay hear some more 'George and Roger
top facts' again in future podcasts.
(06:51):
Anyway, onto the common conditions,and I'm going to kick off with
one of the GP common currencies wesee so often, which is impetigo.
You mention that word, everyGP is going to know about that
and have seen so many cases.
The word impetigo actually comes fromthe Latin verb, impetere meaning to
attack, and the two main patterns we seeare 'bullous' and 'simple' or 'crusted'.
(07:15):
I sometimes differentiate the two,George I don't know about you, by
the fact that bullous impetigo, in myexperience, is really quite dramatic.
Typically presenting in a youngchild, often under the age of two,
with large areas of inflamed skin.
Whereas if you have a look atthe child, say maybe two to five,
that little bit older, crustedimpetigo is the most common.
(07:38):
That's what I've seen over the years.
Is that your experience too?
Absolutely.
Yep.
That's how they tend to appear andthey both appear quite abruptly,
and I agree, bullous impetigoeven more abruptly than crusted.
I remember, for example, a little girlaged about 15 months, whose parents
were separated and didn't get on at allwell, and this little girl had spent
(08:03):
the weekend staying with her father,and came back on the Monday morning with
some eroded areas, round, small, erodedareas in her armpit, and her mother
said, I think these are cigarette burns.
She was trying to build a case to,sort of, suggest that her ex-partner
(08:23):
was causing non-accidental injuries,and I was totally taken in.
I think the point that would haveprobably alerted me was that the child
seemed totally unperturbed by them.
They weren't remotely painful.
She was perfectly well, and there wasno hint of a frozen stare or any other
features, but nevertheless, I admitted herunder the paediatricians', as a possible
(08:44):
situation of non-accidental injury.
I can't remember why Iadmitted her, but I did.
I was actually somewhat embarrassedwhen the discharge summary said bullous
impetigo, because in the acute phase,you get intact, very thin-walled, quite
delicate, blisters filled with clearand perhaps just slightly serous fluid.
(09:04):
As I've just said, it's relativelypainless, but otherwise could
easily be mistaken for other things.
This is caused by a Staphylococcusaureus, almost invariably that's
Staph aureus phage type 71, and asyou said, it typically affects very
little children under the age of two.
It's non-scarring, which is good news,and it usually resolves quite quickly,
(09:26):
just within a few days or at most a coupleof weeks, back to normal looking skin.
Yeah.
I don't normally, I don't know aboutyou Roger, but I don't normally
recommend an antibiotic unlessthe child is particularly ill.
I have a lower threshold for usingan antiseptic lotion, so I'd probably
simply use something like Dermol®Lotion, and that I think is ideal.
(09:47):
I know the PCDS recommend using thatwhen there's recurrent impetigo, but they
have a lower threshold for recommendingtopical or oral antibiotics than me.
Yeah, completely agree.
Although we both probablyexperience pressure from parents
to prescribe antibiotics.
Yeah, indeed.
Unless the child is ill, I tend toexplain why I'm not prescribing.
(10:08):
If we then look at the other commontype, you know, the simple or crusted
impetigo, and you've got preschool toprimary school, but I have seen this
in adults, I suspect you have as well.
Yes I have too.
Absolutely.
I find it much more common, probably aratio of about 70:30, than the bullous
type, but then you get the vesicles withthe erythema that rapidly breaks down, and
(10:29):
then you get that honey-coloured crust,and it's the honey-coloured crust that
you teach medical students about, and it'sthat that's really highly contagious, and
if you take scrapings of that and lookat it, then it's usually a combination
of Staph aureus or a beta-haemolyticstrep, or a combination of both.
But again, you know, even with thecrusting going on, the patient is rarely,
(10:53):
really very unwell in my experience.
They're normally not too bad at all.
No, it doesn't make people ill.
It's a relatively painless condition,like bullous impetigo, rarely ill.
Going on from how do we manage it,you may not be surprised, as you
know me well, to hear that I disagreewith NICE regarding its management.
Hold the front page.
(11:15):
[Laughing]
Yeah.
They recommend fusidic acid, and do youknow, I just think there's absolutely no
point, any longer, using fusidic acid.
It was a lovely antibiotic butit virtually only covers staph
and resistance rates are so highnow that I think it's pointless.
They also suggest mupirocin, other nameis Bactroban™, but I really do feel
(11:39):
that we should be responsible with that.
I wouldn't use it except in extremecircumstances, as this antibiotic
nicely covers MRSA, and I thinkmupirocin is far too important an
antibiotic to be using on impetigo.
They also recommend oral flucloxacillin,which has good activity against
strep as well as against staph.
But you know, I think it just doesn'twork, because, have you ever tried it?
(12:02):
It is foul.
It is foul.
It is disgusting, and besides notbeing that great an antibiotic
generally, it needs to be takenaround the clock, four times a day.
I think trying to persuade a smallchild, a sort of preschool child, to take
flucloxacillin solution four times a day,it's just going to be a nightmare for
the parents, and it's not going to work.
(12:24):
No, the parents really don't like you,as they're battling to try and get
fluclox down their very resistant child.
I mean, I would almost dialit up to 11 here and say, "do
we need an antibiotic at all?"
I mean, most members of the publicwould automatically by default think,
"oh yes, we should have an antibiotic."
Obviously, some of our colleaguesare happy to, sort of, prescribe
antibiotics almost by default, butyou know, we could be saying here,
(12:48):
just do not prescribe unless thereare some serious red flags going.
Yeah, I agree.
My views are at odds with NICE here.
I think the only advantage of prescribingan antibiotic, either topically, which
I prefer, or systemically, is that itwould shorten the period of contagiousness
and thereby enable a child to return toschool or somebody to return to work, or
(13:09):
if they're in the military, for example,they can get back to work quicker.
So I think that's the main advantage.
When the impetigo is caused by a group Astrep, a swab can be very useful because
if it shows a group A strep, then Iwould be much more inclined to treat
that with an antibiotic for that reason.
(13:29):
Yes.
I'd also consider treating higher riskindividuals, for example in pregnancy, or
somebody who's immune compromised, or inthe elderly with impetiginized lesions.
But there, I'd probably consider a topicalantibiotic, for example, clindamycin.
You could use Dalacin® lotion, butI'd probably prefer the vaginal
cream 'cause that's less stingyand will be better tolerated.
(13:52):
So I'd probably try thevaginal clindamycin cream
The only caveat I'd have is that Iwouldn't recommend clindamycin vaginal
cream in the first trimester of pregnancy.
I don't think it does any great harm,but it's not licensed in that group.
But besides, impetigo in thatgroup of people is uncommon.
(14:13):
Right.
However, I passionately believe we mustreserve antibiotics for our sick patients.
Yeah.
Or for conditions like Lyme disease, whichwe'll be coming onto in a later podcast
in this series, where there are seriouscomplications if it's left untreated.
The rise in antimicrobial resistance, Ithink is really alarming and furthermore,
(14:38):
antibiotics do untold damage to boththat gut and the skin microbiomes,
which I'm really keen to look after.
So if I were to prescribe an antibiotic,I'd probably go in with Dalacin® lotion
topically, or if I was going to give oneorally, I'd probably use clarithromycin,
which I think is a great antibioticand that can just be used twice a day.
(14:58):
Twice a day, yeah.
I appreciate that the clindamycinor in fact Dalacin® vaginal cream
is not licensed under three years,but I'm sure that's more to do
with the fact that the hymen in achild that age may not be intact.
So not really appropriate as a vaginalcream, but I can't see any harm from it.
However, it is anoff-licence product here.
(15:19):
I just think it's a nicer productto use than the Dalacin® T lotion.
I massively prefer using anantiseptic though, and NICE
recommend 1% hydrogen peroxide.
That's Crystacide®, which I'vealready mentioned, and that's
all right, but the one I reallylike nowadays is hypochlorous.
(15:41):
Patients can buy this, they can get itfrom a chemist or you can buy it from
Amazon, and the product is called, theone I like, is called Clinisoothe+.
I accept that impetigo is most common inchildren under three, and Clinisoothe+ is
not recommended for children below three.
(16:04):
However, I cannot see any harm fromit, topically, and I would be more than
happy, for example, to put it onto myown grandchild's skin, aged under three.
Can I just digress and saywhy I like hypochlorous?
Yeah, crack on.
Yep.
It's a bit like hypochlorite,which is Milton® or bleach,
but it's very different.
(16:24):
Yeah.
It's not just dilute hypochlorite.
Hypochlorous was actually discoveredabout 200 years ago, but was very
unstable and only lasted for a coupleof days before becoming inactive.
But there's been intensive researchover the last 20 years or so, and
they've now managed to stabilise itin a solution, an aqueous solution,
which has over 90% hypochlorous in it.
(16:48):
That's about the highest concentrationof hypochlorous in any of the
competitor products as well.
That is, um, stable.
On the, uh, on the packaging it saysfor two years, but they say it's
at least two to three years, andthey're almost certainly going to be
providing data shortly, confirmingthat it's stable for up to four years.
It destroys pretty well all skinpathogens, including bacteria, viruses,
(17:11):
including COVID-19, and fungi, andimportantly, fungal spores, and it
does this remarkably rapidly, muchmore rapidly than bleach, and it's many
fold more potent than hypochlorite.
I know a lot of surgeons, aestheticsurgeons and plastic surgeons, who
are now using it to sterilise theskin prior to starting surgery.
They're not using iodine-basedpreparations, they're using hypochlorous.
(17:33):
Wow.
And it's working really well for that.
Hypochlorite is a very, very strongalkaline, which, even diluted,
one capful in a bath, stillrenders the bathwater alkaline.
So it's caustic and it's damagingto the skin and the skin barrier.
Critically, hypochlorous, thesolution, is not a potent alkaline.
(17:57):
Indeed, it's mildly acidic, mimickingthe normal acid mantle on the skin's
surface, and that acid mantle is soimportant as it helps to maintain,
not only the healthy skin barrier,but also the normal skin microbiome.
And this is the interesting bit.
Hypochlorous is produced naturally by ourneutrophils as part of our innate immune
(18:21):
system, and therefore it's no surpriseit's non-toxic to mammalian cells.
There've been no cases of allergyto it, it rarely causes much
irritation, and even on inflamed anddamaged skin, it's well tolerated.
Indeed, I've used hypochlorousfor its anti-inflammatory
properties on things like sunburn.
So it has powerful anti-inflammatoryeffects as well as antimicrobial, and
(18:44):
although it can sometimes have a slightsort of swimming pool type smell,
it doesn't have the nasty smell ofbleach, and it doesn't bleach clothes.
Or in fact, what the company says thatafter the several million canisters that
they have now dispensed and sold, they'veonly had half a dozen people who've
(19:06):
complained of any bleaching of clothes.
For me, it's the perfect antiseptic,and I'm mentioning it now more
and more and more to my patients.
There are various preparations ofhypochlorous, but I honestly think
that the Clinisoothe+, or the one thatdoctors tend to use, which is identical,
called Clinisept+, is absolutelythe best for a variety of reasons.
(19:28):
Firstly, it has the minimal amount ofhypochlorite, less than the competitors.
It is not actually possible to producehypochlorous without producing some
hypochlorite, but also it's made by aunique chemical process which guarantees
a consistently high purity and a stablehypochlorous solution, which has this
(19:49):
fantastic efficacy and a long shelf life.
So that's what I'll beusing nowadays for impetigo.
Oh, that is a fantasticmasterclass, George.
I'm going to have to pick someof that up for my, for my shelf.
I would actually, yep.
I'd have it there for when you'vegot any grandchildren coming to stay.
It's great for stinging nettles.
Oooh, [laughing] that'ssomething that they don't like.
(20:11):
We mustn't also forget, tomention to our patients just how
highly contagious impetigo is.
So personal hygiene is essential.
So I'll tell you what I recommendto my patients, George, I always
advise them that towels andflannels shouldn't be shared.
I mean, that's a given really, but it'samazing the number of times that they are.
Use a clean cloth each time youdry the affected area, and you wash
(20:34):
your hands regularly, and definitelyevery time you touch the impetigo.
Also don't forget, sort of things likehard surfaces, countertops, mobile
phones, door handles, that sort of thing.
They're absolute breeding groundsif they're not sterilised, and,
you know, as often as you canremember, you know, warm water and
a little bit of antiseptic is fine.
(20:55):
Wash the towels and pillowcases andsheets every day, which is a bit of
a pain, but wash them every day forthe first couple of days, you know.
Probably in a hot wash, I mean, I thinkwe're looking at 60 rather than 30 here.
There's often a big debate aboutkeeping children off school, and I'm
sure you've been asked this question.
Keep them off school until the areashave healed, in my view, or until 48
(21:17):
hours after they've started antibiotics.
Those are my two sort of guidelines, andI always mention this right at the top
of my conversations with patients andparents of kids with impetigo, to make
sure I don't forget to mention them.
So I think that's a nice sort of overviewof where we both are with impetigo
(21:37):
and I hope that sort of raised someinteresting points for our listeners,
and made them think about, well, maybewe should try this or, or try that.
I saw a case of something completelydifferent last week that made me
think we've got to talk about this,because I had to admit this patient
to hospital, and it's StaphylococcalScalded Skin Syndrome, and I think
(21:58):
we've really got to touch on it.
Even though people are not goingto see it very commonly, I do
think it's worth a mention.
I agree.
I haven't seen a case for years.
That's amazing.
This is typically seen in newborn babies.
So, often before they even get out ofhospital, they go down with this, and
essentially, it's a widespread, dramaticbullous impetigo, where the gram-positive
(22:20):
cocci can produce these nasty exotoxins.
These are different to the endotoxinsthat are found in the cell wall of
gram-negative bacteria, but theseexotoxins, A and B, are produced by
Staph aureus, and they destroy thebonds that hold the skin cells together
in the epidermis, causing huge sheetsof skin to cleave on gentle pressure.
(22:41):
You just stroke the skin and the skincomes away, the so-called Nikolsky's
sign, and this, as you rightly did,needs urgent admission if they're
not already in hospital, and thisdoes need systemic antibiotics.
There is a rare, deeper form ofimpetigo called ecthyma, and here
the infection is deep down in thedermis, and it typically presents with
(23:03):
large, coin-shaped, crusty craterswith a bit of surrounding erythema.
It's usually caused by the same bacteriathat cause simple impetigo, but it does
occur if there's a less vigorous immuneresponse, so, allowing that bacteria
to get in and go down a bit deeper.
So we typically see in individualswith a compromised immune system
(23:23):
or homeless people, or perhaps inthose with just general poor hygiene.
Very rarely, there's a much moreaggressive form, which is quite
necrotic, and this is called ecthymagangrenosum, and that's usually caused
by pseudomonas, though it can be causedby staph, and I've even heard of it
being caused by aspergillus, but,it's a particularly nasty pattern.
(23:47):
Ecthyma, I think again, should be treatedwith an oral antibiotic, and again,
I'd probably recommend clarithromycin.
In my experience, it typicallyclears quite rapidly and there's
no scarring and it heals reallyquite well in a couple of weeks.
However, I'm intrigued to note that bothDermNet NZ and the PCDS say that treatment
varies and it can take several weeksto clear and there's often scarring.
(24:10):
That's not been my experience.
Oh, that's so reassuring, George.
That's the one I always go for, soI'm really pleased to hear that.
So again, I tend to advise in thissituation with my patients about,
in the short-term, use separatetowels and flannels and in the
longer-term, obviously good hygieneadvice that we'd all normally give.
Now, you and I have both been in themedical game a long time, George, and over
(24:34):
that time, one interesting observationI've thought of and seen, over the last
sort of 40 years or so, is the absoluterise and rise in body shaving, pretty much
from top to toe, and with it, more casesof folliculitis than I used to see, and
there are a number of causes for this.
Well, yes there are, including bacteria,which is the usual one that shaving
(24:55):
triggers, but you can get a yeastfolliculitis caused by pityrosporum,
so, pityrosporum folliculitis.
Even mites, Demodex mites can causea folliculitis, and there's a rare
form, which isn't due to a pathogen,as far as I know, called eosinophilic
folliculitis, which we see, sometimesin Eastern Asian people, for example,
(25:15):
Japanese ethnic backgrounds, or in HIV.
It's a funny condition,but very rare, mercifully.
The commonest bacterial cause isStaphylococcus aureus again, and here
it's just involving a single hairfollicle, often with just a small
bead of pus around the infundibularopening, with some surrounding erythema,
(25:36):
can become a bit scaly actually.
They can occur anywhere on the bodywhere we have hairs, so you don't, for
example, see it on the palms or the soles.
Yep.
But often occurs as a result offriction or more commonly shaving.
The proper name for it isBockharts, B-O-C-K-harts impetigo.
So you see it, for example, under the chinin men or sometimes down the lower legs,
(25:57):
or if people shave in the genital area.
So I'd recommend stoppingshaving if possible.
That's the most important thing.
Or, if they can't, use a fresh,ideally disposable razor every time.
Perhaps they could shave through anantiseptic, such as Dermol® Lotion,
and I certainly did that for a while.
Use that as your shaving gel, far betterthan putting a detergent on your face.
(26:19):
If it's particularly bad, I might suggestafter shaving, they could put some
Clinisoothe+ on, perhaps just apply iton a dressing and hold it against the
skin for, say, ten minutes, twice a day.
Very rarely I have seen a widespreadgram-negative folliculitis, and
I've seen this mostly in my patientswho've been started on isotretinoin,
(26:40):
Roaccutane®, for their acne, typicallytowards the start of their course.
That needs, usually, to cut backon the dose of isotretinoin,
occasionally needs a short courseof steroids, which is the last thing
you want to do if you can help it.
I've been advised to use, by theconsultants, and therefore prescribe
it, high dose trimethoprim,300 milligrams, twice a day.
(27:02):
I'm intrigued by some reports I'vecome across though, showing that
isotretinoin can be used as a treatmentfor gram-negative folliculitis.
So that's an area I'm quite keen tolook into, what's going on there,
but in my experience, it's mostlycaused by starting a course of
isotretinoin in someone with acne.
That's really, really interesting.
We're just finishing off then, George.
Let's quickly mention, because I thinkit's helpful, the difference between a
(27:24):
furuncle and a carbuncle, as these cansometimes cause confusion, can't they?
Yeah, and I don't think it really greatlymatters, to be honest, but a furuncle,
or boil, is a noncommunicating infectionof just one individual hair, whereas a
carbuncle is a more serious infection.
It's an abscess around severalhair follicles, with quite
marked induration and erythema.
(27:45):
Abscesses can occur anywhere on the body,including the skin, not in relation to
hair follicles, but a carbuncle is whereit's associated with hair follicles,
and these, as we all know, are painful.
The patient is usually ill with a fever,and it needs, the most important thing
it needs, is incision and drainage, butalmost certainly one would recommend
(28:06):
a systemic antibiotic for that.
And finally, with all these skininfections from folliculitis, and
even impetigo, I think it's a goodidea to exclude any underlying
or poorly managed diabetes.
Yeah, it's a great pointto finish on George.
Always check the blood sugarof someone with unexplained
or persistent skin infections.
That's one of my messages from thewayside pulpit to medical students.
(28:31):
So I do hope that people havefound this overview of the simple
bacterial skin infections wesee in our surgeries helpful.
And we also look forward to you joiningus in a couple of weeks time, when
we'll be talking about more deeper skininfections and how to manage these.
We'd also like to thank our sponsor,AproDerm®, for all the help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
(28:51):
Absolutely, and if you do like whatyou hear, take a moment to rate and
review us wherever you get your podcast.
It really does help us put together thecontent that you want to hear, and let us
know what facts surprised you the most.
That would be fun.
But until the next time,it's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
Goodbye.
Hello and welcome again to thisRash Decisions podcast where
we look at skin-related issues,conditions and treatments in an
interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I'm a former Chair
of the Dermatology Council for England.
(00:30):
Now today, George and I are going tobe talking about the common problem
of bacterial skin infections, and itwill surprise no one, to learn that
this is an enormous topic, and sowe're going to be doing three podcasts
about it, with this being the first.
Now in the third podcast, we're also goingto be joined by a very special guest,
so don't forget to tune into that one.
(01:00):
But before we look at some of thecommon bacterial skin infections we
see so often in our practices, Georgeand I were talking, we put our heads
together and came up with a top factslist, which was such good fun to do.
We thought we had to sharethem with you, and we thought
six was quite a good number.
So in no particular order, I justwant to kick off with one of my
favourites, and it's about thenumber of cells in our bodies.
(01:24):
We've got around a hundredtrillion cells in our bodies.
Now, I don't know what that numberis, but it sounds a hell of a lot.
But over 90% of those are bacteria.
So we're actually outnumberedby bacteria by almost 10 to 1.
Mostly in the gut, but also on our skin.
(01:44):
So that's a nice one to kick off, I think.
It is, isn't it, and actually, justthinking about it, that's 200 times the
number of stars that are in the Milky Way.
Ooh, good one.
It's just a phenomenal number, isn't it?
Isn't it extraordinary thatwe are outnumbered so much?
Those bacteria are quite small,so they only constitute about 1 or
2 kilograms, which in an averageadult, weighing about 75 kilograms,
(02:07):
that's a very small percentage.
But nevertheless, their cell numbersoutnumber us in this extraordinary ratio.
Fact 2, 99% of these bacteria are notpathogenic under healthy conditions.
After all, there's no advantage in abacterium killing its host, is there?
(02:27):
We live not only with them, butwe live in harmony with them.
Indeed, our very existence andour health is dependent on them.
For example, they compete with thepathogenic bacteria for nutrients, and
without them, we would be in trouble.
It is a truly symbiotic relationship.
(02:48):
Ooh, I love that one.
Go on, have a crack at another.
That's great.
Okay.
An unhealthy, imbalanced microbiome,something that's called dysbiosis, is
associated with a vast number of diseases,but also a vast number of skin diseases.
For example, atopic eczema, acne,psoriasis, even hidradenitis,
(03:10):
and going on even further, I wasastonished to read that vitiligo and
alopecia areata are also aggravatedand associated with a dysbiosis.
Wow.
For example, in atopic eczema,there's an unbalanced microbiome with
overgrowth of Staphylococcus aureus.
Pathogenic Staphylococci play a criticalrole in atopic flares, as well as
(03:32):
probably driving the itch itself directly.
Regarding acne, there are 6 clades ofthe bacteria that's associated with
this, called Cutibacterium acnes.
IA1 is the predominant clade of C.
acnes that is associated withinflammatory lesions of acne.
Some of the others mayeven protect against acne.
(03:56):
Antibiotics don't discriminate betweenthese clades, so we should really ask
ourselves, is it in fact, our overuseof antibiotics knocking out these
healthy bacteria, which allows the morepathogenic strains to take dominance,
and then cause the increasing prevalenceof so many skin diseases, like acne.
(04:18):
And indeed, the IA1 clade is themost resistant to antibiotics.
So, antibiotics do untold harm toour skin and our gut microbiomes.
Ooh, that's my favourite so far.
That's a, that's a cracker.
Well, if we think about gut microbiomesthen, fact 4, I suppose, we now
(04:40):
know that the gut microbiome playsa massive role in the aetiology and
prevalence of numerous diseases.
I'm thinking of things like inflammatorybowel disease, we know it's involved.
Cancers, diabetes, heart disease, evendementia, and there's an absolutely
critical relationship betweenthe skin and the gut microbiomes,
(05:01):
of which I'm sure we're going tohear a lot of in the coming years.
The gut-skin axis, that's a nameto remember as a fact, I think.
Our skin actually is naturallypretty hostile to bacteria.
It's relatively dry and nutrient poor.
It has this surface acid mantle,which we've spoken about before,
(05:21):
and it's in contact with air.
I was amazed to hear from an oldprofessor at medical school, a
professor of microbiology, thatthe vast majority of pathogenic
bacteria are obligate anaerobes.
So it's not a niceenvironment for bacteria.
Although the surface of our skinis actually only 2 square metres,
if you include all the appendages,the infundibular openings and
(05:45):
the sweat glands, etc., then thisincreases to 25 square metres.
That's about as large as 2 car parkingplaces, and it's equivalent to the
surface area of the entire gut.
It offers a wide diversity of habitatsfor various bacteria, fungi, and yeasts.
That's great, and a final fact, frommy point of view, we're going to be
(06:07):
talking about infections, obviously.
An infection actually occurs wheneither a particularly virulent
pathogen is encountered, or there'sa disturbance of the normal symbiotic
balance, which we've mentioned.
In other words, when the host's immunityis compromised, and so we're thinking
of, for example, damage to the skinbarrier, such as from a cut, or from
(06:30):
scratching, or from eczema itself.
Now those were a nice little seriesof facts that George and I, sort
of, put our heads together andcame up with, and I hope you found
them as interesting as we did.
We probably could have found somemore, but uh, we'll probably have
to leave it there, and I suspect youmay hear some more 'George and Roger
top facts' again in future podcasts.
(06:51):
Anyway, onto the common conditions,and I'm going to kick off with
one of the GP common currencies wesee so often, which is impetigo.
You mention that word, everyGP is going to know about that
and have seen so many cases.
The word impetigo actually comes fromthe Latin verb, impetere meaning to
attack, and the two main patterns we seeare 'bullous' and 'simple' or 'crusted'.
(07:15):
I sometimes differentiate the two,George I don't know about you, by
the fact that bullous impetigo, in myexperience, is really quite dramatic.
Typically presenting in a youngchild, often under the age of two,
with large areas of inflamed skin.
Whereas if you have a look atthe child, say maybe two to five,
that little bit older, crustedimpetigo is the most common.
(07:38):
That's what I've seen over the years.
Is that your experience too?
Absolutely.
Yep.
That's how they tend to appear andthey both appear quite abruptly,
and I agree, bullous impetigoeven more abruptly than crusted.
I remember, for example, a little girlaged about 15 months, whose parents
were separated and didn't get on at allwell, and this little girl had spent
(08:03):
the weekend staying with her father,and came back on the Monday morning with
some eroded areas, round, small, erodedareas in her armpit, and her mother
said, I think these are cigarette burns.
She was trying to build a case to,sort of, suggest that her ex-partner
(08:23):
was causing non-accidental injuries,and I was totally taken in.
I think the point that would haveprobably alerted me was that the child
seemed totally unperturbed by them.
They weren't remotely painful.
She was perfectly well, and there wasno hint of a frozen stare or any other
features, but nevertheless, I admitted herunder the paediatricians', as a possible
(08:44):
situation of non-accidental injury.
I can't remember why Iadmitted her, but I did.
I was actually somewhat embarrassedwhen the discharge summary said bullous
impetigo, because in the acute phase,you get intact, very thin-walled, quite
delicate, blisters filled with clearand perhaps just slightly serous fluid.
(09:04):
As I've just said, it's relativelypainless, but otherwise could
easily be mistaken for other things.
This is caused by a Staphylococcusaureus, almost invariably that's
Staph aureus phage type 71, and asyou said, it typically affects very
little children under the age of two.
It's non-scarring, which is good news,and it usually resolves quite quickly,
(09:26):
just within a few days or at most a coupleof weeks, back to normal looking skin.
Yeah.
I don't normally, I don't know aboutyou Roger, but I don't normally
recommend an antibiotic unlessthe child is particularly ill.
I have a lower threshold for usingan antiseptic lotion, so I'd probably
simply use something like Dermol®Lotion, and that I think is ideal.
(09:47):
I know the PCDS recommend using thatwhen there's recurrent impetigo, but they
have a lower threshold for recommendingtopical or oral antibiotics than me.
Yeah, completely agree.
Although we both probablyexperience pressure from parents
to prescribe antibiotics.
Yeah, indeed.
Unless the child is ill, I tend toexplain why I'm not prescribing.
(10:08):
If we then look at the other commontype, you know, the simple or crusted
impetigo, and you've got preschool toprimary school, but I have seen this
in adults, I suspect you have as well.
Yes I have too.
Absolutely.
I find it much more common, probably aratio of about 70:30, than the bullous
type, but then you get the vesicles withthe erythema that rapidly breaks down, and
(10:29):
then you get that honey-coloured crust,and it's the honey-coloured crust that
you teach medical students about, and it'sthat that's really highly contagious, and
if you take scrapings of that and lookat it, then it's usually a combination
of Staph aureus or a beta-haemolyticstrep, or a combination of both.
But again, you know, even with thecrusting going on, the patient is rarely,
(10:53):
really very unwell in my experience.
They're normally not too bad at all.
No, it doesn't make people ill.
It's a relatively painless condition,like bullous impetigo, rarely ill.
Going on from how do we manage it,you may not be surprised, as you
know me well, to hear that I disagreewith NICE regarding its management.
Hold the front page.
(11:15):
[Laughing]
Yeah.
They recommend fusidic acid, and do youknow, I just think there's absolutely no
point, any longer, using fusidic acid.
It was a lovely antibiotic butit virtually only covers staph
and resistance rates are so highnow that I think it's pointless.
They also suggest mupirocin, other nameis Bactroban™, but I really do feel
(11:39):
that we should be responsible with that.
I wouldn't use it except in extremecircumstances, as this antibiotic
nicely covers MRSA, and I thinkmupirocin is far too important an
antibiotic to be using on impetigo.
They also recommend oral flucloxacillin,which has good activity against
strep as well as against staph.
But you know, I think it just doesn'twork, because, have you ever tried it?
(12:02):
It is foul.
It is foul.
It is disgusting, and besides notbeing that great an antibiotic
generally, it needs to be takenaround the clock, four times a day.
I think trying to persuade a smallchild, a sort of preschool child, to take
flucloxacillin solution four times a day,it's just going to be a nightmare for
the parents, and it's not going to work.
(12:24):
No, the parents really don't like you,as they're battling to try and get
fluclox down their very resistant child.
I mean, I would almost dialit up to 11 here and say, "do
we need an antibiotic at all?"
I mean, most members of the publicwould automatically by default think,
"oh yes, we should have an antibiotic."
Obviously, some of our colleaguesare happy to, sort of, prescribe
antibiotics almost by default, butyou know, we could be saying here,
(12:48):
just do not prescribe unless thereare some serious red flags going.
Yeah, I agree.
My views are at odds with NICE here.
I think the only advantage of prescribingan antibiotic, either topically, which
I prefer, or systemically, is that itwould shorten the period of contagiousness
and thereby enable a child to return toschool or somebody to return to work, or
(13:09):
if they're in the military, for example,they can get back to work quicker.
So I think that's the main advantage.
When the impetigo is caused by a group Astrep, a swab can be very useful because
if it shows a group A strep, then Iwould be much more inclined to treat
that with an antibiotic for that reason.
(13:29):
Yes.
I'd also consider treating higher riskindividuals, for example in pregnancy, or
somebody who's immune compromised, or inthe elderly with impetiginized lesions.
But there, I'd probably consider a topicalantibiotic, for example, clindamycin.
You could use Dalacin® lotion, butI'd probably prefer the vaginal
cream 'cause that's less stingyand will be better tolerated.
(13:52):
So I'd probably try thevaginal clindamycin cream
The only caveat I'd have is that Iwouldn't recommend clindamycin vaginal
cream in the first trimester of pregnancy.
I don't think it does any great harm,but it's not licensed in that group.
But besides, impetigo in thatgroup of people is uncommon.
(14:13):
Right.
However, I passionately believe we mustreserve antibiotics for our sick patients.
Yeah.
Or for conditions like Lyme disease, whichwe'll be coming onto in a later podcast
in this series, where there are seriouscomplications if it's left untreated.
The rise in antimicrobial resistance, Ithink is really alarming and furthermore,
(14:38):
antibiotics do untold damage to boththat gut and the skin microbiomes,
which I'm really keen to look after.
So if I were to prescribe an antibiotic,I'd probably go in with Dalacin® lotion
topically, or if I was going to give oneorally, I'd probably use clarithromycin,
which I think is a great antibioticand that can just be used twice a day.
(14:58):
Twice a day, yeah.
I appreciate that the clindamycinor in fact Dalacin® vaginal cream
is not licensed under three years,but I'm sure that's more to do
with the fact that the hymen in achild that age may not be intact.
So not really appropriate as a vaginalcream, but I can't see any harm from it.
However, it is anoff-licence product here.
(15:19):
I just think it's a nicer productto use than the Dalacin® T lotion.
I massively prefer using anantiseptic though, and NICE
recommend 1% hydrogen peroxide.
That's Crystacide®, which I'vealready mentioned, and that's
all right, but the one I reallylike nowadays is hypochlorous.
(15:41):
Patients can buy this, they can get itfrom a chemist or you can buy it from
Amazon, and the product is called, theone I like, is called Clinisoothe+.
I accept that impetigo is most common inchildren under three, and Clinisoothe+ is
not recommended for children below three.
(16:04):
However, I cannot see any harm fromit, topically, and I would be more than
happy, for example, to put it onto myown grandchild's skin, aged under three.
Can I just digress and saywhy I like hypochlorous?
Yeah, crack on.
Yep.
It's a bit like hypochlorite,which is Milton® or bleach,
but it's very different.
(16:24):
Yeah.
It's not just dilute hypochlorite.
Hypochlorous was actually discoveredabout 200 years ago, but was very
unstable and only lasted for a coupleof days before becoming inactive.
But there's been intensive researchover the last 20 years or so, and
they've now managed to stabilise itin a solution, an aqueous solution,
which has over 90% hypochlorous in it.
(16:48):
That's about the highest concentrationof hypochlorous in any of the
competitor products as well.
That is, um, stable.
On the, uh, on the packaging it saysfor two years, but they say it's
at least two to three years, andthey're almost certainly going to be
providing data shortly, confirmingthat it's stable for up to four years.
It destroys pretty well all skinpathogens, including bacteria, viruses,
(17:11):
including COVID-19, and fungi, andimportantly, fungal spores, and it
does this remarkably rapidly, muchmore rapidly than bleach, and it's many
fold more potent than hypochlorite.
I know a lot of surgeons, aestheticsurgeons and plastic surgeons, who
are now using it to sterilise theskin prior to starting surgery.
They're not using iodine-basedpreparations, they're using hypochlorous.
(17:33):
Wow.
And it's working really well for that.
Hypochlorite is a very, very strongalkaline, which, even diluted,
one capful in a bath, stillrenders the bathwater alkaline.
So it's caustic and it's damagingto the skin and the skin barrier.
Critically, hypochlorous, thesolution, is not a potent alkaline.
(17:57):
Indeed, it's mildly acidic, mimickingthe normal acid mantle on the skin's
surface, and that acid mantle is soimportant as it helps to maintain,
not only the healthy skin barrier,but also the normal skin microbiome.
And this is the interesting bit.
Hypochlorous is produced naturally by ourneutrophils as part of our innate immune
(18:21):
system, and therefore it's no surpriseit's non-toxic to mammalian cells.
There've been no cases of allergyto it, it rarely causes much
irritation, and even on inflamed anddamaged skin, it's well tolerated.
Indeed, I've used hypochlorousfor its anti-inflammatory
properties on things like sunburn.
So it has powerful anti-inflammatoryeffects as well as antimicrobial, and
(18:44):
although it can sometimes have a slightsort of swimming pool type smell,
it doesn't have the nasty smell ofbleach, and it doesn't bleach clothes.
Or in fact, what the company says thatafter the several million canisters that
they have now dispensed and sold, they'veonly had half a dozen people who've
(19:06):
complained of any bleaching of clothes.
For me, it's the perfect antiseptic,and I'm mentioning it now more
and more and more to my patients.
There are various preparations ofhypochlorous, but I honestly think
that the Clinisoothe+, or the one thatdoctors tend to use, which is identical,
called Clinisept+, is absolutelythe best for a variety of reasons.
(19:28):
Firstly, it has the minimal amount ofhypochlorite, less than the competitors.
It is not actually possible to producehypochlorous without producing some
hypochlorite, but also it's made by aunique chemical process which guarantees
a consistently high purity and a stablehypochlorous solution, which has this
(19:49):
fantastic efficacy and a long shelf life.
So that's what I'll beusing nowadays for impetigo.
Oh, that is a fantasticmasterclass, George.
I'm going to have to pick someof that up for my, for my shelf.
I would actually, yep.
I'd have it there for when you'vegot any grandchildren coming to stay.
It's great for stinging nettles.
Oooh, [laughing] that'ssomething that they don't like.
(20:11):
We mustn't also forget, tomention to our patients just how
highly contagious impetigo is.
So personal hygiene is essential.
So I'll tell you what I recommendto my patients, George, I always
advise them that towels andflannels shouldn't be shared.
I mean, that's a given really, but it'samazing the number of times that they are.
Use a clean cloth each time youdry the affected area, and you wash
(20:34):
your hands regularly, and definitelyevery time you touch the impetigo.
Also don't forget, sort of things likehard surfaces, countertops, mobile
phones, door handles, that sort of thing.
They're absolute breeding groundsif they're not sterilised, and,
you know, as often as you canremember, you know, warm water and
a little bit of antiseptic is fine.
(20:55):
Wash the towels and pillowcases andsheets every day, which is a bit of
a pain, but wash them every day forthe first couple of days, you know.
Probably in a hot wash, I mean, I thinkwe're looking at 60 rather than 30 here.
There's often a big debate aboutkeeping children off school, and I'm
sure you've been asked this question.
Keep them off school until the areashave healed, in my view, or until 48
(21:17):
hours after they've started antibiotics.
Those are my two sort of guidelines, andI always mention this right at the top
of my conversations with patients andparents of kids with impetigo, to make
sure I don't forget to mention them.
So I think that's a nice sort of overviewof where we both are with impetigo
(21:37):
and I hope that sort of raised someinteresting points for our listeners,
and made them think about, well, maybewe should try this or, or try that.
I saw a case of something completelydifferent last week that made me
think we've got to talk about this,because I had to admit this patient
to hospital, and it's StaphylococcalScalded Skin Syndrome, and I think
(21:58):
we've really got to touch on it.
Even though people are not goingto see it very commonly, I do
think it's worth a mention.
I agree.
I haven't seen a case for years.
That's amazing.
This is typically seen in newborn babies.
So, often before they even get out ofhospital, they go down with this, and
essentially, it's a widespread, dramaticbullous impetigo, where the gram-positive
(22:20):
cocci can produce these nasty exotoxins.
These are different to the endotoxinsthat are found in the cell wall of
gram-negative bacteria, but theseexotoxins, A and B, are produced by
Staph aureus, and they destroy thebonds that hold the skin cells together
in the epidermis, causing huge sheetsof skin to cleave on gentle pressure.
(22:41):
You just stroke the skin and the skincomes away, the so-called Nikolsky's
sign, and this, as you rightly did,needs urgent admission if they're
not already in hospital, and thisdoes need systemic antibiotics.
There is a rare, deeper form ofimpetigo called ecthyma, and here
the infection is deep down in thedermis, and it typically presents with
(23:03):
large, coin-shaped, crusty craterswith a bit of surrounding erythema.
It's usually caused by the same bacteriathat cause simple impetigo, but it does
occur if there's a less vigorous immuneresponse, so, allowing that bacteria
to get in and go down a bit deeper.
So we typically see in individualswith a compromised immune system
(23:23):
or homeless people, or perhaps inthose with just general poor hygiene.
Very rarely, there's a much moreaggressive form, which is quite
necrotic, and this is called ecthymagangrenosum, and that's usually caused
by pseudomonas, though it can be causedby staph, and I've even heard of it
being caused by aspergillus, but,it's a particularly nasty pattern.
(23:47):
Ecthyma, I think again, should be treatedwith an oral antibiotic, and again,
I'd probably recommend clarithromycin.
In my experience, it typicallyclears quite rapidly and there's
no scarring and it heals reallyquite well in a couple of weeks.
However, I'm intrigued to note that bothDermNet NZ and the PCDS say that treatment
varies and it can take several weeksto clear and there's often scarring.
(24:10):
That's not been my experience.
Oh, that's so reassuring, George.
That's the one I always go for, soI'm really pleased to hear that.
So again, I tend to advise in thissituation with my patients about,
in the short-term, use separatetowels and flannels and in the
longer-term, obviously good hygieneadvice that we'd all normally give.
Now, you and I have both been in themedical game a long time, George, and over
(24:34):
that time, one interesting observationI've thought of and seen, over the last
sort of 40 years or so, is the absoluterise and rise in body shaving, pretty much
from top to toe, and with it, more casesof folliculitis than I used to see, and
there are a number of causes for this.
Well, yes there are, including bacteria,which is the usual one that shaving
(24:55):
triggers, but you can get a yeastfolliculitis caused by pityrosporum,
so, pityrosporum folliculitis.
Even mites, Demodex mites can causea folliculitis, and there's a rare
form, which isn't due to a pathogen,as far as I know, called eosinophilic
folliculitis, which we see, sometimesin Eastern Asian people, for example,
(25:15):
Japanese ethnic backgrounds, or in HIV.
It's a funny condition,but very rare, mercifully.
The commonest bacterial cause isStaphylococcus aureus again, and here
it's just involving a single hairfollicle, often with just a small
bead of pus around the infundibularopening, with some surrounding erythema,
(25:36):
can become a bit scaly actually.
They can occur anywhere on the bodywhere we have hairs, so you don't, for
example, see it on the palms or the soles.
Yep.
But often occurs as a result offriction or more commonly shaving.
The proper name for it isBockharts, B-O-C-K-harts impetigo.
So you see it, for example, under the chinin men or sometimes down the lower legs,
(25:57):
or if people shave in the genital area.
So I'd recommend stoppingshaving if possible.
That's the most important thing.
Or, if they can't, use a fresh,ideally disposable razor every time.
Perhaps they could shave through anantiseptic, such as Dermol® Lotion,
and I certainly did that for a while.
Use that as your shaving gel, far betterthan putting a detergent on your face.
(26:19):
If it's particularly bad, I might suggestafter shaving, they could put some
Clinisoothe+ on, perhaps just apply iton a dressing and hold it against the
skin for, say, ten minutes, twice a day.
Very rarely I have seen a widespreadgram-negative folliculitis, and
I've seen this mostly in my patientswho've been started on isotretinoin,
(26:40):
Roaccutane®, for their acne, typicallytowards the start of their course.
That needs, usually, to cut backon the dose of isotretinoin,
occasionally needs a short courseof steroids, which is the last thing
you want to do if you can help it.
I've been advised to use, by theconsultants, and therefore prescribe
it, high dose trimethoprim,300 milligrams, twice a day.
(27:02):
I'm intrigued by some reports I'vecome across though, showing that
isotretinoin can be used as a treatmentfor gram-negative folliculitis.
So that's an area I'm quite keen tolook into, what's going on there,
but in my experience, it's mostlycaused by starting a course of
isotretinoin in someone with acne.
That's really, really interesting.
We're just finishing off then, George.
Let's quickly mention, because I thinkit's helpful, the difference between a
(27:24):
furuncle and a carbuncle, as these cansometimes cause confusion, can't they?
Yeah, and I don't think it really greatlymatters, to be honest, but a furuncle,
or boil, is a noncommunicating infectionof just one individual hair, whereas a
carbuncle is a more serious infection.
It's an abscess around severalhair follicles, with quite
marked induration and erythema.
(27:45):
Abscesses can occur anywhere on the body,including the skin, not in relation to
hair follicles, but a carbuncle is whereit's associated with hair follicles,
and these, as we all know, are painful.
The patient is usually ill with a fever,and it needs, the most important thing
it needs, is incision and drainage, butalmost certainly one would recommend
(28:06):
a systemic antibiotic for that.
And finally, with all these skininfections from folliculitis, and
even impetigo, I think it's a goodidea to exclude any underlying
or poorly managed diabetes.
Yeah, it's a great pointto finish on George.
Always check the blood sugarof someone with unexplained
or persistent skin infections.
That's one of my messages from thewayside pulpit to medical students.
(28:31):
So I do hope that people havefound this overview of the simple
bacterial skin infections wesee in our surgeries helpful.
And we also look forward to you joiningus in a couple of weeks time, when
we'll be talking about more deeper skininfections and how to manage these.
We'd also like to thank our sponsor,AproDerm®, for all the help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
(28:51):
Absolutely, and if you do like whatyou hear, take a moment to rate and
review us wherever you get your podcast.
It really does help us put together thecontent that you want to hear, and let us
know what facts surprised you the most.
That would be fun.
But until the next time,it's goodbye from George.
Goodbye.
And as always, it's goodbye from me.
Goodbye.
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