Pustular skin diseases - pyoderma, how to treat? Clinical signs and symptoms of pyoderma. Staphylococcal skin infections

Purulent diseases and their development depend on the following conditions: penetration of pyogenic microbes into the tissues of the body, the state of the body and environmental conditions. Therefore, all measures to prevent acute purulent diseases should take into account the listed reasons on which the appearance and development of these diseases depends.

Purulent diseases causes. One of the main causes of purulent diseases is, as mentioned, the penetration from the outside into the tissues or blood of the body of certain pyogenic microbes through various lesions of the skin or mucous membranes. Therefore, one of the important ways to prevent many purulent diseases is to prevent injuries both at work and at home.

Any open damage special meaning acquires the timely provision of rational first aid in compliance with general rules asepsis and antiseptics, as well as the immediate treatment of minor injuries by trained persons or in self-help and mutual assistance.

With any damage to tissues and organs, no matter what they arise from (wounds, operations), it is very great importance has the prevention of purulent complications. It consists of a number of measures aimed at preventing the entry of purulent microbes into the wounds and the further development of infection. In this regard, the organization and quality of first and emergency care for all persons who have received an accidental injury plays an exceptional role.

Purulent diseases prophylaxis a. Prevention of wound infection (and, consequently, possible purulent complications) consists primarily in the careful observance of all modern rules surgical asepsis in the provision of medical care (when applying dressings, with injections, dressings, etc.).

To prevent the penetration of pyogenic microbes into the wound, many methods have been proposed. The simplest of them is the lubrication of minor damage to the skin with iodine tincture or an alcohol solution of brilliant green. More top scores gives the use of liquid N. N. Novikov, which has the following composition: tannin-1.0, brilliant green - 0.2, 96 ° alcohol - 0.2, castor oil - 0.5 and collodion - 20.0. Using a pipette or a glass rod, this liquid or BF-6 glue is applied directly to the damaged area of ​​the skin and the surrounding skin surface. After 1-2 minutes, a dense elastic film is formed over the damaged area of ​​the skin. For minor injuries, you can also use another method: the wound and its circumference are wiped (washed) with a 3-5% soap solution or 0.25 - 0.5% ammonia solution using gauze or cotton balls, dried, lubricated with iodine tincture, sprinkled a mixture of penicillin with streptocide and carefully sealed with a sticky plaster. To prevent infection with microtrauma, a colloidal solution of furacilin or brilliant green can also be used.

In the prevention of purulent diseases in wounds and operations, the prophylactic use of antibiotics or sulfa drugs. Paramedics and nurses should make extensive use of them when providing first aid for injuries. To do this, apply, for example, sprinkling the wound with penicillin, streptocide, or even better - a mixture of them.

For major injuries open fractures or burns, penicillin or bicillin should be administered intramuscularly. If injections are not possible, antibiotics are given orally in the form of tablets. After that, patients who have wounds that are subject to primary surgical treatment are sent to the doctor. When treating fresh wounds by a doctor, as well as during various operations (in the pre- and postoperative period), general and local application antibiotics.

The prophylactic use of antibiotics in various open injuries and operations contributes to better wound healing, a significant reduction in purulent complications and their severity, and faster recovery and rehabilitation of patients.

In the prevention of the further spread of acute purulent processes and the appearance of various complications, timely and rational treatment primary inflammatory diseases especially in the early stages of their development. Thus, the timely use of antibiotics and surgical intervention with a limited abscess can prevent its transition to a more common and serious disease- phlegmon, as well as the appearance of complications such as lymphangitis, lymphadenitis. Timely and rational treatment of one boil can prevent its transition to furunculosis, timely surgery for acute appendicitis or other acute purulent process in the abdominal cavity prevents the development of general peritonitis, etc. The fight against pustular diseases (pyodermatitis) at work and at home is also of great importance .

Speaking about the prevention of purulent diseases, it should be emphasized that all medical personnel must meticulously observe the rules of personal hygiene (frequent washing of hands, changing gloves and gowns), since dirty hands, dirty clothes contribute to the spread of pyogenic infection. In this regard, purulent diseases in medical personnel (boils, abscesses), as well as diseases such as tonsillitis and influenza are of particular danger to surgical patients. The presence of these diseases among personnel can lead to infection of patients and their wounds and to possible emergence they have certain purulent diseases.

In addition to pyogenic infection, the occurrence and development of various purulent diseases largely depend on the body's defenses. Therefore, in the prevention of any, including purulent diseases, measures that strengthen the human body are of great importance: regular physical education and sports, the correct mode of work and rest, wet rubdowns, air baths, etc. General strengthening and hardening of the body increases its resistance to various infections and, to one degree or another, causes a more favorable course and outcome in the event of a purulent disease.

In the prevention of many purulent diseases, the improvement of the external environment in which a person lives and works, that is, the improvement of working and living conditions, is of great importance. So, for example, in the prevention of a number of purulent diseases (furunculosis, pyoderma, etc.), general hygienic measures and skin care (especially of the hands) play an important role.

This includes proper sanitary and hygienic and sanitary working conditions in industrial enterprises and agricultural work, the fight against dust and pollution, rational and clean overalls, the organization of showers, baths, laundries, measures to combat skin contamination (various oils and liquids ), as well as the struggle for the improvement of life (regular washing in the shower or in the bath, change of linen). To prevent diseases of the skin of the hands in some industries, it is advisable to use various protective ointments and methods of rehabilitation (improvement) of the hands.

It should be remembered that the continuous improvement of the culture of work and life is the main way to reduce the incidence in general and various purulent processes in particular.

Finally, in the prevention of many purulent diseases, sanitary and educational work among the population is of great importance. Especially great is the role of sanitary and educational work among the population (conversations, lectures, the use of print, radio, television) in preventing various microtraumas and pustular diseases (often causing more dangerous acute purulent processes), as well as complications of acute diseases of the abdominal organs (appendicitis, cholecystitis, peritonitis). Purulent diseases, as a rule, require urgent hospitalization of patients and immediate surgical intervention.

Reasonable propaganda of the initial signs of purulent diseases and advice on the need for early medical attention lead to a significant improvement in outcomes and a decrease in the number of various complications.

Pyoderma - pustular diseases skin, arising from the penetration of pathogens of pyogenic infection and the weakening of the overall resistance of the body. Currently, pustular skin diseases are the most common dermatoses. The occurrence and course of these diseases depend on the relationship of the microorganism and the infected macroorganism. Most often, pyoderma (pyon - pus, derma - skin) are caused by staphylococci, streptococci, less often - Proteus vulgaris, Pseudomonas aeruginosa, mycoplasmas, coli and others. In the study of the normal microflora of the skin, the greatest contamination with staphylococci was revealed. In this case, the skin of the folds, subungual spaces, mucous membranes of the nose and throat is most contaminated, which can serve as a source of endogenous infection. Due to the fact that the surface of the skin contains a lot of fat and protein ingredients, it creates favorable conditions for life. various kinds microorganisms, the skin is never sterile. The composition and quantity of the abundant bacterial flora of the skin is very variable. Permanent representatives of the bacterial flora include white staphylococcus aureus and epidermal staphylococcus aureus. The ability to form one or another pigment and other properties of microorganisms, including pathogenic ones, are changeable and can vary over a wide range. At the same time, as a result of bacteriological studies on the surface of the skin, the presence of various microorganisms that do not belong to the permanent bacterial flora is often detected. The most common non-permanent representatives of the bacterial flora of the skin surface include various varieties of staphylococci and streptococci, pseudodiphtheria bacilli.

In patients with pustular skin diseases, the composition of the bacterial flora changes not only within the pathological foci (and in their immediate vicinity), but also in areas of the body remote from them. Autoinfection often develops and can cause the appearance of new pathological foci, as well as infection of others.

Currently, staphylococci are well studied. They are cells of the correct spherical shape with a diameter of 0.5-1.5 microns. Staphylococci are Gram-positive and do not form spores. In the process of life, staphylococci secrete an exotoxin that has the ability to lyse human erythrocytes. The pathogenicity of staphylococcal cultures is always associated with coagulase activity. Coagulase is an exoenzyme that is easily destroyed by proteolytic enzymes, inactivated ascorbic acid. Cogulase-positive and coagulase-negative pathogens can be found in pyoderma. Coagulase-negative pathogens, in addition, are currently considered as likely pathogens of gram-positive sepsis. It should be noted that the change in the etiology of sepsis is associated with the selection of resistant gram-positive pathogens as a result of the widespread use of antibiotic therapy. As a result of transformation into L-forms, the function of their reproduction is inhibited while maintaining growth. Cells in the L-form state have reduced virulence and may not cause inflammation for a long time, which creates a misleading impression of recovery. Probably the formation of bacillus carriers and chronically current forms of pyoderma, the appearance of typical forms of bacteria, the formation of drug resistance are due to the transformation of staphylococci into L-forms. When developing therapeutic and preventive measures, it is necessary to take into account that staphylococci have a high degree of survival in the external environment. They tolerate drying well, are preserved in dust, and spread with air flow. Ways of transmission of staphylococci are very diverse: it is possible to transmit by airborne droplets and household contact, etc.

Carriage of streptococci is much less common. Facultative anaerobes form endo- and exotoxins, enzymes. Exotoxins have cytotoxic, immunosuppressive and pyogenic effects, erythrogenic activity. Suppress the functions of the reticulohistiocytic system. Streptococci produce deoxyribonuclease, hyaluronidase, streptokinase and other enzymes that provide optimal conditions for the nutrition, growth and reproduction of microorganisms.

In the pathogenesis of pyoderma, a decisive role is played by a decrease in local and general antibacterial resistance of the organism. The integrity of the stratum corneum, the presence of a positive electrical charge between bacterial cells and the skin provide a mechanical barrier to the introduction of pyococci. Detachable sweat and sebaceous glands with a high concentration of hydrogen ions (pH 3.5-6.7) has bactericidal and bacteriostatic properties. Such a "chemical mantle" is regulated by the vegetative nervous system and endocrine glands.

The most significant exogenous factors provoking the development of pyoderma are: skin pollution, especially when in contact with grass, dry skin, aggressive chemical agents, temperature irritants, etc.

To endogenous factors include fatigue, unbalanced diet, especially leading to hypovitaminosis, chronic intoxication, diseases of the gastrointestinal tract, foci of chronic purulent infection, immune imbalance, endocrine diseases. In particular, it is known that pyoderma occurs most severely and torpidly in patients with diabetes mellitus.

Other factors that weaken the protective, antibacterial function of the skin include metabolic disorders that reduce resistance to bacterial agents, diabetic changes blood vessels, trophic disorders associated with diabetic polyneuritis, as well as dry skin, itching and other subjective sensations.

There is no single generally accepted classification of pyoderma. In this work, we have used the most common working classification. It should be noted that the proposed division into superficial and deep pyoderma is conditional, since superficial foci can spread in depth. At the same time, streptococcus can be sown from the surface of a staphylococcal pustule and, conversely, staphylococci are sometimes isolated from the surface of a streptococcal lesion.

Classical subdivision into staphylococcal and streptococcal lesions takes into account a number of typical properties. Thus, a staphylococcal lesion is characterized by a connection with a hair follicle, a sweat or sebaceous gland, a deep spread, a predominantly conical shape, a local (sometimes in combination with a general) temperature reaction, and a thick creamy yellow-green purulent content. Streptococcal pustule is located on smooth skin, lies superficially, has a round or oval shape, transparent or translucent purulent contents.

most surface form staphyloderma is ostiofolliculitis.

A pustule appears at the mouth of the follicles, the size of which ranges from a pinhead to the size of a lentil. It has a hemispherical shape, penetrated by hair. The lid of the pustule is dense, its contents are purulent. On the periphery there is a small hyperemic corolla. The bottom of the pustule is located in the upper sections of the outer root sheath of the hair follicle. Purulent exudate shrinks into a crust. After 3-4 days, the element is resolved without scarring.

Folliculitis - acute purulent inflammation hair follicle. Unlike ostiofolliculitis, it is accompanied by infiltration, severe pain. The pustule opens with the release of pus and the formation of erosion or shrinks into a crust. The element is resolved either by resorption of the infiltrate, or with the formation of a scar. The duration of the course of folliculitis is 5-7 days.

Deep folliculitis differs from folliculitis in that it extends significantly into the dermis. It is allowed only with the formation of a scar, the duration of the course is 7-10 days.

Furuncle is an acute purulent-necrotic lesion of the follicle, sebaceous gland and surrounding subcutaneous fatty tissue. Often there is a development of a boil from ostiofolliculitis or folliculitis. The growth of the pustule is accompanied by the spread of sharply painful infiltration. After opening the pustule and separating the pus, a necrotic rod is clearly visible, which is gradually separated along with the pus. An ulcer is formed in place of the detached necrotic rod. As the necrotic rod is opened and separated, soreness decreases, the phenomena of general inflammation subside, infiltration resolves, the ulcer fills with granulations and scars. The duration of the evolution of a boil depends on the reactivity of tissues, localization, the state of the macroorganism, etc. When localized on the face, scalp, there is a risk of developing sepsis or thrombosis of superficial and deep veins that have direct anastomoses with the sinuses of the brain.

Carbuncle is characterized by purulent-necrotic lesions of several hair follicles. The inflammatory infiltrate increases not only due to peripheral growth and the possible involvement of new follicles in the process, but also as a result of its spread into the depths of the underlying tissues. On palpation, sharp pain is noted. Gradually, in several places around the follicles located in the central part of the lesion, deep skin necrosis occurs. The focus acquires a slate-blue, black color, melts in one or more places (the name "carbuncle" comes from carbo- coal). At the next stage, multiple holes appear, from which a purulent-bloody fluid flows. The resulting ulcer with uneven edges is initially shallow, at the bottom of it greenish-yellow necrotic rods are visible, which are rejected much more slowly than with single boils. After rejection of necrotic masses, a deep, irregularly shaped ulcer with bluish, flaccid, undermined edges is formed. The ulcer is gradually cleared of plaque, performed by granulations and scarred within 2-3 weeks.

Furunculosis is a recurrent form of a boil. Conventionally, local furunculosis is distinguished, when rashes are observed in limited areas, and disseminated, in which elements appear on different parts of the skin. As a rule, the process develops against the background of a pronounced immune imbalance, for example, in HIV-infected, diabetic patients, etc.

Sycosis vulgaris is a chronic recurrent inflammation of the follicles in the growth zone of short thick hair. Most often, the disease occurs in men with signs of an imbalance of sex hormones and is localized in the area of ​​beard and mustache growth. Gradually appear ostiofolliculitis and folliculitis, their number is increasing. The infiltration of the centers is expressed. After the resolution of the elements, scars are not formed, but scarring is possible when trying to forcibly open folliculitis.

Hidradenitis is a purulent inflammation of the apocrine sweat glands observed in young and adulthood. In children before puberty and the elderly, the disease is not observed, since the apocrine sweat glands do not function. The most common localization in this disease is the axillary regions, sometimes the process develops on the chest around the nipples, navel, genitals, and anus. The disease develops slowly, accompanied by discomfort, pain in the lesion, in some cases itching, burning, tingling in the lesion. At the beginning of the disease, the surface of the skin is of a normal color. With further development, the area increases to 1-2 cm, the surface of the skin becomes bluish-red. The formation of conglomerates protruding above the level of surrounding healthy areas is characteristic (the old name is " bitch udder"). At autopsy, one or more fistulous passages are formed, necrotic rods do not occur. With regression, retracted scars are formed. Individuals with immune imbalances often experience relapses of the disease.

Staphyloderma of early childhood differ in a number of features. Passive immunity against staphylococci is weak, the titer of antitoxins in the blood is low. Regional lymph nodes do not respond enough to the introduction of infection, the reticuloendothelial system absorbs microorganisms, but slowly destroys them. In the first months of life, the processes of synthesis of immunologically active lymphoid cells are slowed down, which is due to the insufficient corrective influence of the thymus gland in the development of the lymphoid system. It has been established that immunoglobulin (Ig) G, obtained through the placenta from the mother, completely disappears from the child's blood by 6 months of age. The subsequent production of immunoglobulins, especially IgA and IgG, is slow. Staphylococcal inflammation is most severe in newborns, since children before the 42nd day of life are not able to produce antibodies.

Infection can occur antenatal if a woman suffers any staphylococcal disease during pregnancy. In pathological childbirth (prolonged, with a long anhydrous period or complicated by endometritis), intranatal infection is possible.

In the development of staphyloderma at an early age, the pathogenicity of pathogens is important. Due to the widespread prevalence of antibiotic-resistant strains, the number of carriers of pathogenic staphylococcus aureus is increasing, especially among staff in maternity hospitals and hospitals.

Anatomical and physiological features of the skin play a significant role in the occurrence of staphyloderma of early age. Incompleteness of the morphological structure of the skin, tenderness and looseness of the stratum corneum, fragility of the connection between the epidermis and dermis due to the weakness of the basement membrane and some flattening of the papillae of the dermis, the direct location of the ducts of the eccrine sweat glands and the presence of a polysaccharide complex in them, the alkaline environment of the skin surface and the decrease in its protective properties, imperfection thermoregulation processes, increased moisture and absorption capacity of the skin, lability of the colloid-osmotic state - all these factors predispose to the development of pyoderma. Additional conditions that contribute to the development of pyoderma are exposure to moisture, especially warm (evaporation under diapers, warm clothes, etc.), skin maceration with urine, saliva, nasal discharge.

Staphyloderma is most dangerous during the neonatal period, since at this time there are:

• hypersensitivity to staphylococcal infection;
• tendency to generalize infection;
• development of staphylococcal infection both on the skin and in other organs and systems;
• the possibility of developing sepsis;
• preservation of the general reaction of the body with the disappearance of changes on the skin.

The elements do not have the typical properties of a staphylococcal pustule (there is no connection with the hair follicle, sebaceous or sweat gland, the elements are located superficially, the contents of the elements are transparent or translucent). In newborns, vesiculopustulosis is most common, which is a purulent inflammation of the mouths of the eccrine sweat glands. With adequate management of such patients, the process does not extend deep into, is not accompanied by infiltration, the duration of the disease does not exceed 7-10 days. Epidemic pemphigus of newborns is more severe. Surface elements quickly spread throughout the skin, the resulting erosions are bordered by a fringe of exfoliating epidermis. In the case of a malignant course of erosion, they merge with each other with peripheral growth of blisters and detachment of the epidermis. The severity of the condition is directly proportional to the affected area. The child's condition becomes severe, staphylococcal pneumonia, otitis media, and sepsis develop. The most severe form of epidemic pemphigus of the newborn is exfoliative dermatitis. Bubbles with a flabby tire quickly increase, open, forming erosion, bordered by exfoliated epidermis. Skin rashes accompanied by high fever, weight loss, often - diarrhea, pneumonia, otitis media, etc. Sometimes septicopyemia may develop.

In 50-70% of patients, there is an increase in temperature up to 37.5-38.0°C. A blood test reveals moderate leukocytosis, neutrophilia, and an increase in the erythrocyte sedimentation rate. The disease is very contagious for newborns.

Staphylococcus aureus can also be detected in acne, acting in association with Propionibacterium acne, sometimes with Pityrosporum ovale and orbiculare. Acne is a polymorphic multifactorial disease of the hair follicles and sebaceous glands that occurs in 80% of people. In persons older than 24 years, the incidence decreases. In the pathogenesis of acne, several of the most significant factors can be distinguished.

So, in patients with acne, excessive formation of sebum is noted. The sebum of acne sufferers contains less linoleic acid than healthy people. This factor contributes to increased desquamation of the epithelial cells of the follicle, which leads to the formation of retentional hyperkeratosis of the acrofunnel of sebaceous follicles, which is the main points in the pathogenesis of acne vulgaris. A decrease in other epidermal lipids (eg, free sterols) can also cause follicular retention hyperkeratosis.

Propionibacterium acne, Staphylococcus epidermidis, Pityrosporum ovale and orbiculare always present in comedones. They are constantly on the surface of healthy facial skin and are part of the normal microflora. Cocci are found mainly in the upper part of the funnels of the hair follicles or in the places where the ducts of the sweat glands open and do not play a significant role in the pathogenesis of acne. Propionibacterium acne, Pityrosporum ovale and orbiculare produce lipase, activate complement, increase orifice desquamation hair follicle leading to blockage.

Hyperandrogenemia predisposes to increased secretory function of the sebaceous glands. The skin contains a complex of androgen-sensitive elements (hair follicles, sweat and sebaceous glands). Under the influence of androgens, intracellular lipid synthesis increases, and mitotic activity of cells is regulated. The development of acne in puberty is associated with the active function of the gonads. In women with hyperandrogenism syndrome, the disease can occur with long-term use of contraceptives containing androgens. In the occurrence of acne vulgaris, an increase in blood testosterone, increased sensitivity of hair follicles and sebaceous glands to androgens, as well as a combination of these factors, play a significant role. In some cases, hyperandrogenemia can be hereditary.

Acne vulgaris is the most common. The disease usually begins in puberty and is characterized by the appearance on the face (less often on the chest and back) of comedones, small, up to 5 mm in diameter, bright red papules, sometimes with a pustule on the surface. Rashes, resolving, leave pigmentation, less often - superficial scars. On the face, scalp, chest and interscapular region, the skin becomes oily, shiny, uneven, rough, with enlarged mouths of hair follicles. Propionibacteria and staphylococci located on the surface of the skin produce endogenous lipase, which breaks down sebum triglycerides into free fatty acids. The latter, in turn, have an irritating effect on the skin, causing various complications.

As the number of comedones increases, the inflammatory reaction intensifies around them, an indurative form of acne develops. It is characterized by the formation of large inflammatory infiltrates.

After a few weeks, the infiltrate softens, the elements open with the formation of cavities, from which a viscous purulent exudate is released - the appearance of phlegmonous acne is noted. After healing, deep scars that disfigure the skin remain.

The most common form, characterized by a pronounced inflammatory component, is acne conglobata. The clinical picture is characterized by the appearance on the back, chest and face of large nodes located deep in the dermis, sometimes capturing the upper sections of the subcutaneous fatty tissue. The nodes can reach 1.5-2 cm in diameter. Such nodes are extremely painful, perifocal inflammation is acutely expressed. Merging, the nodes form conglomerates, abscesses may occur, after opening of which they remain for a long time non-healing ulcers, and subsequently - rough scars with bridges and fistulous passages.

With the fusion of deeply located inflamed nodes, the development of sinus acne is noted. This form is characterized by the formation of epithelial sinus tracts, "undermining" the skin of the face and trunk.

Acute transformation of typical inflammatory acne into extremely pronounced destructive inflammation distinguishes fulminant acne. Men predominate among the patients. With this form, there are multiple painful ulcerated inflammatory nodes with areas of necrosis, scattered pustules, located on an erythematous background. The process is accompanied by fever, leukocytosis, joint pain, transient glomerulonephritis. Healing occurs with the formation of rough scars.

In rare cases, young women develop an acutely inflammatory and severe form of acne. The disease is characterized by sudden onset and rapid progression. The process is localized in the central part of the face, in the forehead, temples, chin. A pronounced swelling of the face with a cyanotic skin tone is characteristic, and after 1-2 days - painful furuncle-like nodular rashes resembling acne conglobata, large (more than 5 cm) pustules. There is a lack of comedones and a sharp severity of the boundaries of inflammation.

The seborrheic background against which acne develops can be different.

The thick form of oily seborrhea is more often observed in men and is characterized by dilated orifices of the sebaceous glands; a small amount of sebaceous secret. The liquid form of oily seborrhea is more common in women, characterized by the fact that when pressed on the skin, a translucent liquid is released from the mouths of the ducts of the sebaceous glands. Mixed seborrhea is somewhat more often observed in men, while the symptoms of oily seborrhea are noted in the area of ​​​​the skin of the face, dry - on the scalp, where small-lamellar peeling is expressed, the hair is thin, dry. Acne develops in individuals suffering from oily or mixed forms of seborrhea. Among the patients, adolescents predominate (somewhat more often - boys), women with ovarian cycle disorders as a result of prolonged use of glucocorticosteroid hormones, bromine, iodine preparations, and prolonged work with chlorine-containing substances.

The most common form is acne vulgaris, localized on the skin of the face, chest, back. After the resolution of the pustules, shriveled yellowish crusts form, further pigmentation or a superficial scar. In some cases, after the resolution of acne, keloid scars (acne-keloid) occur. If the process proceeds with the formation of a pronounced infiltrate, deep scars remain at the site of acne resolution (phlegmonous acne). When the elements merge, confluent eels are formed ( acne confluens). A more severe form is acne conglobata ( acne conglobata), occurring with the formation of a dense infiltrate, nodes in the upper part of the subcutaneous adipose tissue.

Nodules may form into conglomerates, followed by abscess formation. After healing of ulcers, uneven scars with bridges and fistulas remain. Acne fulminans ( acne fulminans) is accompanied by septicemia, arthralgia, gastrointestinal symptoms.

Streptoderma is characterized by a lesion of smooth skin, a superficial location, a tendency to peripheral growth. In addition to the above factors provoking and predisposing to the development of pyoderma, it is necessary to note the role of pathological changes in the skin. With dermatosis, accompanied by the appearance of erosion and oozing changes, edema of the epidermis creates favorable conditions for the development of streptoderma. In clinical practice, the most common phlyctena is a superficial streptococcal pustule. Let's look at a few examples.

Streptococcal pustules are highly contagious, observed mainly in children, sometimes in women. Conflicts appear on a hyperemic background, do not exceed 1 cm in diameter, have a transparent content and a thin flabby tire. Gradually, the exudate becomes cloudy, shrinks into a straw-yellow and loose crust. After the crust falls off and the epithelium recovers, slight hyperemia, peeling or hemosiderin pigmentation temporarily persist. The number of conflicts is gradually increasing. Process dissemination is possible. Complications in the form of lymphangitis and lymphadenitis are not uncommon. In weakened individuals, the process may spread to the mucous membranes of the cavities of the nose, mouth, upper respiratory tract, etc.

In typical cases, streptococcal impetigo looks like a conflict, which is a superficial epidermal pustule with a thin, flabby tire, lying almost at the level of the skin, filled with serous or serous-purulent contents. The disease begins with the appearance of an element that has a tendency to peripheral growth. The conflict is surrounded by a hyperemic zone in the form of a corolla. The contents of the pustule quickly shrink into a straw-yellow crust, upon removal of which a moist erosive surface is revealed. Small initial elements of the rash due to peripheral growth rapidly increase; as a result, a new pustule in the form of a ring or horseshoe appears around the periphery, while healing occurs in the center under the crust. Bullous streptococcal impetigo is localized on the hands, feet, legs. The size of conflict exceeds 1 cm in diameter. The cover of the elements is tense. Sometimes elements appear on a hyperemic background. The process is characterized by slow peripheral growth.

Zayeda (slit-like impetigo, perlesh, angular stomatitis) is characterized by damage to the corners of the mouth. Painful slit-like erosion appears on the edematous hyperemic background. Along the periphery, a whitish corolla of exfoliated epithelium, sometimes a hyperemic rim, and infiltration phenomena can be found. Often, the process develops in people suffering from caries, hypovitaminosis, atopic dermatitis, etc.

Lichen simplex occurs more often in children preschool age. In springtime, on the skin of the face, the upper half of the body, rounded pink spots appear, covered with whitish scales. At in large numbers scales spot is perceived as white.

Superficial paronychia can be observed both in people working in fruit and vegetable processing plants, in confectioneries, etc., and in children who have the habit of biting their nails. The skin of the periungual roller turns red, swelling and pain appear, then a bubble with transparent contents forms. Gradually, the contents of the bubble becomes cloudy, the bubble turns into a pustule with a tense tire. If the process becomes chronic, deformation of the nail plate is possible.

Intertriginous streptoderma (streptococcal diaper rash) occurs in large folds, axillary areas. Conflicts appear in large numbers, then merge. When opened, continuous eroded weeping surfaces of a bright pink color are formed, with scalloped borders and a border of exfoliating epidermis along the periphery. Painful cracks can be found in the depth of the folds. Often there are foci of dropouts in the form of separately located pustular elements that are in various stages of development.

Syphilis-like papular impetigo occurs predominantly in children. infancy. Favorite localization - the skin of the buttocks, genitals, thighs. Characteristic is the appearance of quickly opening conflicts with the formation of erosions and a slight infiltrate at their base, which gave rise to the name "syphilis-like" because of the similarity with erosive papular syphilides. Unlike syphilis, there is an acute inflammatory reaction here.

Chronic superficial diffuse streptoderma is characterized by diffuse lesions of significant areas of the skin, lower legs, and less often, the hands. The foci have large scalloped outlines due to growth along the periphery, they are hyperemic, sometimes with a slight bluish tinge, somewhat infiltrated and covered with large-lamellar crusts. Under the crusts there is a continuous weeping surface. Sometimes at the beginning of the disease it is possible to observe an acute stage (acute diffuse streptoderma), when an acute diffuse skin lesion occurs around infected wounds, fistulas, burns, etc.

A deep streptococcal pustule is an ecthyma. The element is deep, non-follicular. The disease begins with a small vesicle or perifollicular pustule with serous or serous-purulent contents, quickly shrinking into a soft, golden-yellow convex crust. The latter consists of several layers, which served as the basis for the textbook comparison with the Napoleon cake. After falling off or removing the crust, a round or oval ulcer with a bleeding bottom is found. There is a dirty gray coating on the surface of the ulcer. The edges of the ulcer are soft, inflamed, as a result of which they rise slightly above the surrounding skin. The ulcer heals slowly, within 2-3 weeks, with the formation of a scar, a zone of pigmentation along the periphery. At severe course ecthyma vulgaris may form a deep ulcer ( ecthyma terebran- penetrating ecthyma) with the phenomena of gangrenization, high probability sepsis.

Mixed pyoderma is characterized by the absence of both staphylococcal and streptococcal pustules (in fact, in addition to staphylococci and streptococci, other pathogens can be detected). Let's look at a few examples.

Vulgar impetigo is the most common. Children and women are predominantly affected. Favorite localization is the skin of the face around the eyes, nose, mouth, sometimes the process extends to the upper half of the body, arms. A vesicle with serous contents appears on a hyperemic background. The lid of the bubble is thin, sluggish. Within a few hours, the contents of the vesicle become purulent at the base of the pustule, infiltrate, and the corolla of hyperemia increases. After a few hours, the lid opens, forming erosion, the discharge of which shrinks into “honey crusts”. On the 5-7th day, the crusts are torn off, for some time a slightly flaky spot remains in their place, which later disappears without a trace.

Chronic deep ulcerative-vegetative pyoderma has a predominant localization on the scalp, shoulders, forearms, axillary regions, legs. On the infiltrated bluish-red background, sharply demarcated from the surrounding healthy skin, irregularly shaped ulcerations appear in place of the pustules. On the surface, papillomatous growths with verrucous cortical layers can be found. When squeezed, purulent or purulent-hemorrhagic contents are released from the openings of the fistulous passages. With regression, the vegetation gradually flattens, the separation of pus stops. Healing occurs with the formation of uneven scars.

Pyoderma gangrenosum often develops in patients with chronic inflammatory infectious foci. Changes in the skin occur against the background of chronic inflammatory infectious foci, connective tissue diseases, oncological processes. Bubbles with transparent and hemorrhagic contents, deep folliculitis quickly disintegrate or open with the formation of ulcers that expand along the periphery. In the future, a focus is formed with an extensive ulcerative surface with uneven undermined edges. Along the periphery, uneven undermined edges are raised in the form of a roller surrounded by a zone of hyperemia. At the bottom of the ulcers, bleeding granulations are found. Ulcers gradually increase in size, sharply painful. Scarring of different areas does not occur simultaneously, i.e., with scarring of one area, further growth of another can be observed.

Chancriform pyoderma begins with the formation of a vesicle, after opening which remains erosion or an ulcer of round or oval outlines, the base of which is always compacted. As the name implies, in the future, an ulcerative surface is formed, pinkish-red in color with clear boundaries, along appearance reminiscent chancre. Certain difficulties in differential diagnosis may also be due to similar localization in these diseases: genitals, red border of the lips. In contrast to syphilis, a pronounced infiltrate is palpated at the base of the focus, sometimes painful on palpation. Negative multiple studies for the presence of pale treponema, negative serological tests for syphilis confirm the diagnosis.

For the treatment of superficial pyoderma, alcohol solutions are used (1% salicylic alcohol, camphor alcohol), aniline dyes (fucorcin, 1% brilliant green). If necessary, taking aseptic measures, open the cover of conflict and pustules, followed by washing with a 3% solution of hydrogen peroxide and lubricating with disinfectant solutions (furacillin 1: 1000 3% alcohol solution of iodine). Ointments containing antibiotics (fucidin, baktroban, heliomycin) are applied to common multiple foci.

In the absence of the effect of external therapy, deep lesions on the face, neck (furuncle, carbuncle), pyoderma complicated by lymphangitis or lymphadenitis, parenteral or oral use of broad-spectrum antibiotics is indicated. For successful antibiotic therapy of an infectious process, an antibacterial drug must be selected that satisfies the following basic conditions:

• high activity (optimally - in relation to bactericidal properties) against all probable pathogens (if a microbiological study has not yet been carried out and the pathogen is unknown for a particular patient, i.e. empirical antibiotic therapy is being carried out) or against an isolated pathogen (if a bacteriological study has already been carried out and we are talking about about targeted antibiotic therapy);
• the ability to penetrate into the infectious focus, creating concentrations there that significantly exceed the minimum inhibitory concentration of the antibiotic for this pathogen;
• a high degree of safety, i.e. exceeding the antibiotic dose even several times should not lead to the creation of toxic concentrations for the macroorganism in the blood, in various organs and environments, including the infectious focus;
• good tolerance, i.e., the absence of adverse effects of therapeutic concentrations of the antibiotic on the body.

In outpatient practice, it is advisable to use only oral antibiotics with high bioavailability, as well as a long half-life (which allows you to reduce the number of doses per day), while the impact on the intestinal microflora should be minimal.

When treating in a hospital, the most rational choice of antibiotics is available in forms for parenteral and oral administration. At step therapy at the beginning of the course, the antibiotic is prescribed parenterally, and with a positive dynamics of the patient's condition (after 3-7 days), they switch to its oral administration.

Macrolides are currently widely used (clarithromycin - 250 mg 2 times a day for 7-10 days, azithromycin - 1 g 1 time per day for 5-10 days, depending on the severity of the process, josamycin - 0.5 g 2 once a day for 10 days, if necessary, for children under 14 years of age, the daily dose is 30-50 mg / kg of body weight, preferably in three doses; for acne, the drug is used for 2-8 weeks), tetracyclines - unidox-solutab (adults and children weighing more than 50 kg on the first day of treatment are prescribed 200 mg / day in one or two doses, on subsequent days of treatment - 100 mg / day in one dose, children over 8 years old weighing less than 50 kg in the first day of treatment, a daily dose is prescribed at the rate of 4 mg / kg per dose, on the following days, 2 mg / kg 1 time per day, the course of treatment is 5-10 days; in the most severe cases, treatment can be started with intramuscular injections of doxycycline hydrochloride 100 mg 2-3 times a day), cephalosporins (zinnat 250 mg 2 times a day) ducks for 7 days, lincomycin 300 mg intramuscularly 3-4 times a day, 3-7 days, then orally in capsules of 250 mg 3-4 times a day, 5 days).

In chronic and recurrent forms of pyoderma, specific immunotherapy is used: staphylococcal toxoid (native is administered in increasing doses from 0.1 to 2.0 ml in adults and from 0.1 to 1.0 ml in children under the skin of the lower angle of the scapula with an interval of 3 -5 days, the next dose is administered after the reaction has faded from the previous injection; adsorbed is administered subcutaneously at a dose of 0.2-0.5 ml with an interval of 30-54 days in the amount of three injections), staphylococcal bacteriophage(intradermally, subcutaneously or intramuscularly at a dose of 0.1-2.0 ml after 1-3 days, depending on the reaction to the previous injection), staphylococcal antiphagin (injected under the skin at a dose of 0.2 to 1.0 ml also after 1 -3 days after the disappearance of the reaction from the previous injection), anti-staphylococcal immunoglobulin (injected intramuscularly 120 IU at a time with an interval of 3-5 days, for a course of 3-5 injections), streptococcal vaccine (administered intradermally or subcutaneously, starting with a dose of 100-200 million microbial bodies (0.1-0.2) and up to 2 billion microbial bodies (2.0), taking into account tolerance and the nature of the local reaction), streptococcal bacteriophage liquid (administered subcutaneously or intramuscularly in doses of 0.5; 1.0 ; 1.5 and 2.0 ml after 3-4 days, the subsequent injection is carried out no earlier than the local reaction subsides).

In severe cases, especially in debilitated patients, the use of immunomodulating agents is indicated (isoprinosine 50 mg/kg of body weight in three to four doses, T-activin subcutaneously at 1.0 ml every other day in the amount of 3-4 injections, and then 1 0 ml once a week, 10-15 injections per course).

In the case of chronic ulcerative pyoderma, courses of antibiotics can be supplemented with the appointment of glucocorticosteroids at a dose equivalent to 20-50 mg of prednisolone per day for 3-6 weeks. In the most severe course, cytostatics are used.

For the treatment of severe forms of acne, such system tools like estrogens, androgens, spironolactone, aromatic retinoids.

Women with long-term acne with the ineffectiveness of antibiotic therapy and external use of tretinoin are prescribed estrogens or androgens, depending on the profile of endocrine disorders.

Cyproterone (androgen antagonist) has antigonadotropic and progestogenic effects. Women are prescribed it at 10 mg from the 1st to the 15th day of the cycle, in courses, it is possible to use it in combination with taking oral contraceptives like ethinyl estradiol.

Spironolactone is used as an antiandrogenic agent. The drug is prescribed for 25-200 mg in 2-4 doses. The course of treatment is carried out for several months, the drug is used only in women.

Combined estrogen-progestin contraceptives are most effective when taken at high doses.

Systemic corticosteroids are used for adrenal hyperandrogenism.

The biological action of retinoids is carried out by binding them to receptors on the nuclear membrane of keratinocytes, which leads to a change in the activity of certain genes and further to the normalization of desquamation of the follicular epithelium and the prevention of the formation of comedones. Under the influence of retinoids, the renewal of the epidermis is accelerated, the stratum corneum is thinned, and the dermal matrix is ​​reorganized. In addition to affecting the growth and differentiation of skin cells, retinoids reduce the activity of the sebaceous glands, exhibit immunomodulatory and anti-inflammatory effects. Retinoids inhibit melanogenesis, which reduces the risk of hyperpigmentation. Isotretinoin is prescribed depending on the body weight of the patient. The initial dose is 0.5 mg / kg per day; the maintenance dose prescribed after 4 weeks varies between 0.1-1.0 mg / kg per day, depending on the effectiveness and tolerability of the drug. For optimal results, treatment is continued, as a rule, for 16 weeks. At high therapeutic effect their use is limited by a number of contraindications. Retinoids have an absolute teratogenic effect, are contraindicated in violations of the liver, kidneys, hyperlipidemia, neoplasms, hypervitaminosis A. When using these drugs, side effects and adverse reactions from various organs and systems are possible. Dermatological changes include dry mucous membranes, rash, itching, cheilitis, erythema, sweating, peeling of the palms and soles, paronychia, nail dystrophy, increased growth of granulation tissue in the affected area, in rare cases thinning hair, vasculitis, photosensitivity. On the part of the sense organs, conjunctivitis, photophobia, decreased night vision, corneal clouding, hearing loss, nosebleeds are possible. Among neurological disorders known headaches, in rare cases - depression, convulsive seizures. On the part of the digestive system, nausea is possible, rarely - colitis, bleeding, transient increase in liver transaminase activity. Among hematological disorders, anemia, neutropenia, a change in the number of platelets, and an increase in the erythrocyte sedimentation rate are described. Possible metabolic disorders such as an increase in the concentration of thyroglobulin, glucose. On the part of the musculoskeletal system, pain in the muscles and joints is likely, rarely - hyperostosis.

Lately on Russian market there are new lines of medical cosmetics for the treatment of acne. The line "Cleanance" of medical cosmetics "Aven" is represented by non-comedogenic preparations and contains three active components: thermal water "Aven", pumpkin seed extract, zinc gluconate. Thermal water "Aven" has a powerful anti-inflammatory, softening, soothing effect. Pumpkin seed extract blocks dihydrotestosterone (DHT) receptors and 5-alpha reductase. DHT and pumpkin extract have a similar structure: pumpkin extract takes the place of DHT on the receptors without provoking hyperseborrhea.

Zinc gluconate inhibits the production of lipases, thereby preventing the formation of free fatty acids, providing an anti-lipase effect. Zinc gluconate also inhibits polynuclear chemotaxis, providing anti-seborrheic and anti-inflammatory effects.

Some cosmetic lines offer acne treatments that can be used for sensitive skin. So, thermal water"La Roche Posay" is the only thermal water with natural high content selenium, which neutralizes the action of free radicals. For sensitive skin prone to oily seborrhea, you can apply the Toleran Fluid soothing moisturizing protective emulsion 1-2 times a day. For sensitive skin prone to redness, preparations of the Rozaliak range are indicated. If necessary, the arsenal of products can be supplemented with Efaclar products, created specifically for oily skin prone to acne.

The treatment series "Clerasil Ultra" also includes a 3 in 1 gel, a lotion for sensitive skin. The active ingredients of the series are allantoin, aloe, tartaric acid, hydrolyzed milk protein, glycerin, menthol, 1% oxidized polyethylene microgranules, 2% salicylic acid, sulfur, triclosan, 0.05% chlorhexidine digluconate, 1.5% hydrogen peroxide.

There is a large selection of drugs for the treatment of cicatricial changes on the market. These include Curiosin gel, Mederma gel, etc.

Prevention of pustular skin diseases should include not only compliance with hygiene rules, timely appeal about intercurrent diseases, adherence to diet, etc. Preventive measures should also be carried out at the national level: improving the standard of living of the population, introducing methods of protection against microtraumatism and contact with chemicals at work, solving environmental problems, etc.

I. V. Khamaganova, doctor of medical sciences, professor
RSMU, Moscow

The lion's share of acne falls on the formations of an infectious nature. In the article you will learn about primary lesions and pustular skin diseases and their treatment with folk remedies.

Folliculitis and ostiofolliculitis. Pustules appear in the mouths of hair follicles with ostiofolliculitis.

The process begins around the base of the hair with a slight reddening of the skin, then a yellowish-white cone-shaped abscess forms, shrinking after 3-5 days or opening with the expiration of thick pus, then a crust forms. Purulent inflammation occurs throughout the entire hairline with folliculitis, which occurs with a decrease in immunity or non-compliance with hygiene standards. Chronic folliculitis is caused by a multitude of red to bluish pustules, most often located on the buttocks, limbs, and armpits.

When a staphylococcal infection penetrates deeper, a furuncle is formed. This abscess is sharply painful, it takes a conical shape in 3-4 days. There is an expiration of pus several days after its opening. There is a deficit of tissues, an ulcer is formed, healing most often with the formation of a distinct scar. May be accompanied by bright severe symptoms general intoxication - drowsiness, headache, fatigue, fever up to 39-40 degrees.

Streptococcal impetigo. Superficial streptoderma, which develops mainly in children and women with more delicate skin. It is localized usually on the face. It is one or more flat blisters filled with cloudy contents. These bubbles open after a few days and shrink into yellowish crusts.

Molluscum contagiosum. In addition to the bacterial flora, a viral infection can cause a pustular rash. This is a viral pustular skin disease that occurs mainly in adolescence and childhood. The causative agent is a virus similar to the smallpox virus. It is transmitted by contact with the patient or through objects, things that the patient used.

It appears as pink or pearly white shiny nodules. The skin of the face is most often affected in children, in adults the perineum, genitals, abdomen, pubis, inner thighs are affected.

In the treatment of boils and folliculitis, antibacterial agents, lotions and creams with an antiseptic effect are used. Dietary recommendations in the treatment of these pustular skin diseases are given special attention. Flour, fatty, spicy, sweet dishes, alcohol, spices, strong tea, coffee are excluded from the diet. Washing with hot water is not recommended because it stimulates the production of sebum.

Treatment of superficial streptoderma consists in the treatment of damaged skin areas with antibacterial ointments and antiseptics. Ultraviolet light may be used.

Treatment molluscum contagiosum usually consists in squeezing out nodules with tweezers or scraping them with a special spoon, followed by cauterization with a solution of alcohol iodine. Laser therapy may be used. It is better to entrust the treatment to a specialist.

Pustular skin diseases - treatment with folk remedies:

• Wipe face for acne fresh juice plantain. Familiarize yourself with the causes and types of seborrhea: dry, oily, mixed -.
• Use for lotions, washing infusion of white birch. In 800 milliliters of water, insist 4 tablespoons for an hour. birch buds and leaves.
• Drink 2-3 times a day an infusion of black elderberry, tbsp. st.l. black elderberry pour a glass of boiling water.
• Lubricate the pustular rash with calendula tincture twice a day. Pour 50 milliliters of alcohol 2 tbsp. marigold flowers, add 30 ml of cologne and 50 ml of water. Keep 2 weeks in a dark place.
• Lubricate the face with fresh parsley juice twice a day for 20-25 days. Whitening face masks at home -.

You have read the information

Pustular skin diseases are a group of diseases that are caused by streptococci and staphylococci. These states develop under the influence internal violations. These include diabetes mellitus, blood diseases, disorders of the stomach and intestines, obesity, neuropathy, liver disease. Pustular diseases can also be caused external influences: microtraumas, cooling, overheating, abrasions, skin pollution, malnutrition. Long-term therapy with cytostatics and corticosteroids also plays a significant role in the development of diseases.

Classification of pustular diseases is carried out on the basis of pathogens. Allocate streptoderma and staphyloderma. They are divided into deep and superficial.

Superficial pustular skin diseases are divided into osteofolliculitis, folliculitis, sycosis, epidemic. Deep pustular diseases include boils, carbuncles, hydradenitis.

Osteofolliculitis is a disease that is characterized by the formation of an abscess at the mouth of the hair follicles. Along the edge of this formation there is a narrow rim of bright color. A hair protrudes from the center of the abscess. With the direct spread of the purulent process inward, the disease can transform into folliculitis. It is distinguished from the first disease by its large size. inflammatory infiltrate, which is located around the hair. There are single and multiple forms of folliculitis and osteofolliculitis.

Sycosis is a pustular skin disease characterized by the formation of multiple folliculitis and osteofolliculitis. The skin is infiltrated and has a bluish-red color. A feature of this disease is the presence of all elements at various stages of development. Sycosis develops on the skin upper lip and chin.

Epidemic pemphigus occurs in the first ten days of a baby's life. It is characterized by high contagiousness, the formation of numerous blisters that have a transparent or cloudy content, a thin, flabby surface. These formations are usually located all over the skin, except for the soles and palms. The bubbles shrink, resulting in thin crusts. They can also merge, then open, resulting in massive erosive surfaces that can capture the entire skin. Sometimes other diseases can join, which often leads to death.

Pustular diseases of the skin. Treatment

For the treatment of such diseases, alcohol solutions are also used externally. If necessary, the pustule covers are opened and washed with a 3% hydrogen peroxide solution, then lubricated with disinfectant solutions. Sycosis is usually treated with ointments that contain antibacterial agents.

In the absence of effects from surface therapy, oral or intravenous antibiotics are prescribed. Chronic and recurrent forms require the use of specific immunotherapy.

In order for purulent skin diseases to occur as rarely as possible, it is necessary to follow preventive measures, which include strict adherence to hygiene rules, a strict diet, timely treatment of internal diseases that can provoke these conditions.

Superficial pustular diseases are not life-threatening. But they require timely treatment. Otherwise, complications may develop that will negatively affect the state of the whole organism.

Section 2. PRIVATE DERMATOLOGY. Chapter 7

Definition. Pustular skin diseases (pyoderma) are infectious skin diseases that develop as a result of the introduction of pathogens into it - pathogenic pyococci, the most common of which are staphylococci and streptococci.

Etiology and pathogenesis. Piococci are very common in our environment: in the air (in the form of aerosols), in the dust of rooms, in clothes, in underwear; they are also found on the surface of the body of a healthy person. There are three types of human skin microflora:

1) resident flora(microorganisms that constantly colonize the skin);

2) temporary resident flora(microorganisms that infect the skin and multiply on it, but persist for a certain period of time);

3) transient (air) flora(bacteria that infect the skin, but rarely multiply on it and gradually disappear).

Gram-positive microorganisms belong to the first and second groups: Propionibacterium acnes, Propionibacterium gra-nulosum, Corynebacterium minutissimum, Corynebacterium tenuis, Staphylococcus epidermidis and Gram-negative bacteria: Esheri-hia coli, Proteus, Enterobacter, Pseudomonas, Acinetobacter. The transient flora includes mainly staphylococci and streptococci. They then in most cases are the causative agents of pyoderma. However, due to the fact that the skin has protective properties in relation to infectious agents, predisposing causes are necessary for the development of pyoderma. Under the conditions of a healthy body, normal fat and sweating, the resident microflora prevents the reproduction of transient microflora, gradually displacing

it from the microbial population. The causes predisposing to the development of pyoderma are both exogenous and endogenous factors.

1. Factors that reduce or neutralize the bactericidal properties of sebum and sweat: skin contamination, especially lubricating oils, flammable liquids, coarse dust particles; local circulatory disorders (acrocyanosis, varicose veins, chills); local hypothermia and overheating.

2. Factors that violate the permeability of the skin and create an "entrance gate" of infection. These include microtrauma (abrasions, cuts, injections, bites, scratches, abrasions, splinters); maceration of the stratum corneum of the epidermis (hyperhidrosis, prolonged exogenous exposure to water); hypovitaminosis (A, C).

3. Factors that suppress immune reactivity and reduce nonspecific resistance of the organism. These include factors initiating the development of secondary immunodeficiencies, causing the development of immune tolerance and sensitization to pyococci: foci of chronic infection (chronic tonsillitis, dental granuloma, chronic sinusitis and sinusitis, chronic cholecystitis); general hypothermia and overheating; metabolic disorders, especially carbohydrate (diabetes mellitus); lack of nutrition; anemia; intestinal intoxication; physical fatigue; stress and nervous strain; endocrine disorders; hypovitaminosis (A, B, C, E); previous treatment of intercurrent diseases with the use of glucocorticosteroid or immunosuppressive therapy.

4. Factors that suppress the resident flora and reduce the microbiological protection of the skin. This is excessively frequent washing, especially with the use of antibacterial agents, leading to skin dysbacteriosis and allowing transient pathogenic microflora to “fix” on it (abuse of perfumery and cosmetic products containing triclosan and other antiseptics).

According to the etiological basis, pyoderma is divided into staphylococcal (staphyloderma) and streptococcal (streptoderma). The causative agents of staphyloderma are Staphylococcus aureus, and in some cases - epidermal and even saprophytic. The causative agents of streptoderma are most often β-hemolytic streptococci of serogroup A. In addition, there are atypical pyoderma, pathogens

which can be various microorganisms. Infection of the skin with pyococci occurs not only due to contact with a patient with pyoderma, but may be due to the transmission of microorganisms by airborne droplets, for example, from patients or carriers of the infection containing bacteria in the nasopharynx. It is known that up to 40% of adolescents are carriers of group A streptococci in the nasopharynx, and carriers of nasopharyngeal staphylococci often cannot get rid of them due to the pronounced resistance of these nasopharyngeal pyococci to antibiotics.

Getting on the skin, staphylococci penetrate into its natural openings, and therefore affect mainly the appendages (hair follicles, sebaceous and sweat glands). They cause a purulent-exudative inflammatory reaction. Depending on the depth of penetration of staphylococci into the skin and the severity of this reaction, staphyloderma begins with an abscess, nodule or node. The exceptions are epidemic pemphigoid and staphylococcal scalded skin syndrome, the causative agent of which is coagulase-positive. Staphylococcus aureus II phage group, 71 phage types. This type of pathogen has the ability to secrete a special exotoxin - exfoliatin (epidermolysin), which causes diffuse skin lesions with the formation of a bubble in the epidermis.

Streptococci affect the epidermis diffusely, without penetrating into the appendages of the skin, and cause a serous-exudative inflammatory reaction with the formation of one primary element. skin rash- flabby bladder (conflicts).

To staphylococcal pyoderma include: ostiofol-liculitis, sycosis, folliculitis, furuncle, carbuncle, hydradenitis, as well as staphyloderma of newborns, infants and early childhood - ostioporitis (periporitis, vesiculo-pustules), multiple skin abscesses, epidemic pemphigoid (pemphigus of the newborn), staphylococcal scalded skin syndrome (exfoliative dermatitis of newborns by Ritter von Rittershain).

To streptococcal pyoderma include: impetigo, intertriginous and chronic diffuse streptoderma, ecthyma.

Atypical pyoderma manifest themselves mainly in chronic ulcerative, vegetative and abscessing forms, very reminiscent of focal tuberculosis of the skin and some mycoses (deep, candidal, moldy).

7.1. STAPHILODERMA

Ostiofolliculitis

Definition. Ostiofolliculitis (folliculitis superficial, osteofolliculitis)- acute purulent inflammation of the mouth of the hair follicle (Fig. 5).

Etiology and pathogenesis. The causative agent of the disease is coagulase-positive Staphylococcus aureus. The main predisposing cause of the development of the disease is excessive contamination of the skin, especially in conditions of excessive sweating, damp clothing and skin maceration.

clinical picture. Characterized by formation at the mouth (ostium) hair follicle pustules the size of a pinhead, permeated with hair and fringed with a halo of hyperemia. After 2-4 days, the pustule shrinks into a crust, which disappears without leaving a trace. Some pustules may grow peripherally, increasing in size to the size of a large pea (Bockhard's staphylococcal impetigo). Ostiofolliculitis can be either single or multiple. Rashes of pustules can be observed on any part of the skin covered with hair, but their most common localization is the skin of the face, neck and extremities. Sometimes the disease can take on a relapsing character.

Diagnostics ostiofolliculitis is based on a characteristic clinical picture: small, short-lived follicular pustules with mild inflammation around them, located on different parts of the skin.

differential diagnosis. Ostiofolliculitis should be differentiated with vulgar sycosis, pustular form of acne vulgaris, bromine and iodine acne, acne syphilide.

Treatment.General therapy not required. It is carried out in exceptional cases, when the disease is persistent chronically relapsing. Incentives are given

Rice. 5. Ostiofolliculitis. The arrow indicates the route of penetration of staphylococci

agents (autohemotherapy, methyluracil, aloe extract).

Physiotherapy. With a widespread process, UVI is prescribed - total suberythemal doses.

External Therapy limited to the treatment of pustules with a 1% solution of brilliant green or 2% tincture of iodine. Other disinfectants in the form of an ointment or powder are also used. The skin around the lesions is treated with a 2% alcohol solution of salicylic or boric acid.

Sycosis

Definition. Sycosis (perifolliculitis of the beard, sycosis staphylogenes)- chronic recurrent purulent-inflammatory folliculitis of a limited area of ​​the skin, mainly the area of ​​the beard and mustache (Fig. 6).

Etiology and pathogenesis. The reasons for the development of the disease lie mainly in skin sensitization to staphylococci and suppression of the sterilizing properties of sebum due to neuroendocrine disorders. Patients often suffer from hypofunction of the gonads.

clinical picture. The disease occurs almost exclusively in men. It is localized in the area of ​​growth of the beard, mustache, eyebrows, sometimes on the pubis, scalp, in the armpits. The lesion begins with the appearance of follicular pustules, similar to ostiofolliculitis, which continuously recur in a limited area of ​​\u200b\u200bthe skin. Gradually, reactive inflammation develops around the affected follicles with the formation of a diffuse dermal infiltrate. Purulent crusts form on its surface. Pulled out hairs are surrounded by a vitreous muff at the root. The disease proceeds torpidno.

Diagnostics sycosis is based on a characteristic clinical picture: many constantly recurring follicular pustules in a limited area of ​​\u200b\u200bthe skin (more often

Rice. 6. Sycosis. The arrow indicates the route of penetration of staphylococci

area of ​​the beard and mustache), accompanied by the development of a chronic inflammatory reaction.

Treatment.General therapy includes the appointment of antibiotics (oxacillin, cephalexin, rifampicin, augmentin) and stimulants (autohemotherapy, pyrogenal, immunonal, taktivin), if necessary, correction of hormonal disorders.

Physiotherapy - UVI erythemal doses.

Outdoor therapy. AT acute period pustules are treated with an alcohol solution of aniline dyes, pastes or creams with anti-inflammatory, disinfectant and resolving agents (boron-tar, sulfur-tar), creams or ointments containing glucocorticosteroid and antibacterial drugs("oxycort", "celestoderm-B with garamycin", "fucicort", etc.). To prevent recurrence, careful skin care is necessary (rubbing with a 2% alcohol solution of salicylic or boric acid).

Folliculitis

Definition. Folliculitis (deep folliculitis, folliculitis)- acute purulent inflammation of the middle and lower segments of the hair follicle (Fig. 7).

Etiology and pathogenesis. The causative agents of folliculitis are various types of staphylococci, among which the most common is coagulase-positive staphylococcus aureus. Microorganisms, having penetrated into the mouth of the hair follicle, sequentially penetrate into the middle and lower parts of the follicular epithelium, causing purulent fusion of the latter. The process is limited to perifollicular tissue.

Rice. 7. Folliculitis. The arrow indicates the route of penetration of staphylococci

clinical picture. Folliculitis differs from osteofolliculitis by a deeper location of the inflammatory process in the hair follicle. It is a pink papule the size of a pea. In the center of it, a pustule, penetrated by hair, often develops. After a few days, the papule either resolves or, suppurating, opens with the formation of a pinpoint ulcer, which subsequently heals and leaves a scar. Predisposing causes for the development of folliculitis are most often exogenous factors.

Diagnostics folliculitis is based on a characteristic clinical picture, manifested by rashes of inflammatory lenticular nodules that open with the release of creamy pus, or spontaneously resolve.

differential diagnosis. Folliculitis should be differentiated with the papular form of acne vulgaris, bromine and iodine acne, acne syphilis.

Treatment similar to the treatment of ostiofolliculitis.

Furuncle

Definition. Furuncle (furunculus)- acute purulent-necrotic inflammation of the hair follicle and its surrounding tissues (Fig. 8) (see color inc., Fig. 1).

Etiology and pathogenesis. The causative agent of the disease is coa-gulase-positive Staphylococcus aureus. Due to the high pathogenicity of the pathogen, which ensures the release of a significant amount of enzymes (esterases, proteinases, collagenases, etc.), the initial infectious process (folliculitis) turns into perifolliculitis, causing extensive necrosis of surrounding tissues. Infection often occurs by airborne droplets from nasopharyngeal carriers, as well as due to microtraumatism and wearing contaminated clothing.

clinical picture. Furuncle develops as a result of acute purulent necro-

Rice. eight. Furuncle. The arrows indicate the routes of penetration of staphylococci.

tic inflammation of the hair follicle and surrounding tissues. The initial manifestations of a furuncle look like ostiofolliculitis or folliculitis, but they are painful. After 1-2 days, an inflammatory node is formed, rapidly increasing to the size of a hazelnut or walnut, while pain intensifies. After a few days, the node is opened with the release of pus. At the same time, dead tissue of a greenish color is found - a "necrotic rod". After its demarcation and rejection, an ulcer remains with pus, which quickly heals by scarring.

In some cases, purulent fusion of almost the entire infiltrate occurs along with a necrotic rod and an abscess (abscessing boil) is formed. In other cases, on the contrary, suppuration is expressed very slightly - this is the so-called dry boil.

Sometimes there are different furuncle complications. Due to the penetration of staphylococci into the lymphatic vessels, lymphangitis and regional lymphadenitis develop. The spread of infection to neighboring tissues leads to the development of phlegmon, osteomyelitis. The close connection of the skin of the chin with the periosteum (due to dense connective tissue strands) contributes to the development of osteomyelitis of the lower jaw. In debilitated patients, a furuncle on the lower leg can transform into chronic ulcerative pyoderma. The entry of staphylococci into the blood causes the formation of metastatic abscesses in the bones, muscles, perirenal tissue, kidneys and other organs. This may be predisposed by an injury to the corresponding organ with hemorrhage (even a small one), which creates favorable conditions for the sedimentation of microorganisms. Finally, the course of the boil can become malignant: the infiltrate increases in size, the edema increases, due to which the tissues become tense and dense, thrombophlebitis develops around the boil, as well as lymphangitis and regional lymphadenitis, pain increases sharply, body temperature rises (up to 40 ° C) , the number of leukocytes in the peripheral blood increases, the ESR rises, a headache appears, consciousness is darkened. The result of such development of a boil can be sepsis or septicopyemia with the formation of multiple abscesses in the internal organs, which leads to death. Most dangerous carbuncle, developing on the face and, in particular, in the region of the nasolabial triangle, nose and lips

(especially on the top). In these cases, the presence of a dense and very superficially located venous network creates favorable conditions for the penetration of infection into the vessels and the development of purulent meningitis. Dissemination is facilitated by the high mobility of mimic muscles, squeezing out the initial elements of the boil, cutting them off during shaving, and irrational local treatment.

Furunculosis. Under furunculosis understand multiple rash of boils or constant recurrence of single boils. Furunculosis can be localized (for example, on the back of the neck, in the lumbar region) or general - with dissemination of boils throughout the skin.

Localized furunculosis, like solitary boils, is due to the influence of exogenous predisposing causes, general furunculosis is due to the influence of predominantly endogenous causes. With short-term exposure to predisposing factors, acute furunculosis develops, with prolonged exposure - chronic. Recurrent boils, which are related to chronic furunculosis, are associated mainly with skin sensitization to staphylococci. Furunculosis, especially acute, is often accompanied by general malaise, fever. Sometimes these phenomena are observed with a single boil.

Diagnostics furuncle and furunculosis is carried out on the basis of a characteristic clinical picture: painful inflammatory nodes, in the central part forming necrotic rods, which are rejected with the formation of purulent crater-like ulcers.

differential diagnosis. Furuncles should be differentiated from deep folliculitis, carbuncle, hydradenitis, scrofuloderma.

Treatment.General therapy in the treatment of a single uncomplicated boil, located outside the face, is not required. General treatment is used for the localization of a boil on the face (with mandatory bed rest), complicated boils of any localization, as well as furunculosis. In these cases, antibiotics are required. Semi-synthetic preparations of penicillin, cephalosporins, rifamycins, augmentin are effective. In chronic furunculosis, immunostimulating therapy should be used (prepa-

thymus, interferon, immunal, pyrogenal) and general strengthening (vitamins A, B 1, B 2, C, E, P) therapy.

Physiotherapy used in the stage of developing infiltrate, when it is advisable to use dry heat (UHF therapy, Sollux).

Outdoor therapy. Before starting treatment, the hair around the boil should be cut (but not shaved!). In the initial stage, characterized by the development of an inflammatory infiltrate, pure ichthyol is used, which is applied 1-2 times a day to the lesion in the form of cakes covered with cotton wool. In this case, bandages or stickers are not required, since ichthyol adheres well to the skin. During dressings, previously applied ichthyol is removed with warm water. The surrounding healthy skin is wiped with a 2% alcohol solution of boric or salicylic acid in the direction from the periphery to the center. Washing in a bath, bath or shower is prohibited. After opening the boil, ichthyol is contraindicated and can only be applied to the marginal zone of the infiltrate. AT central part the opened furuncle is superimposed with a gauze napkin or turunda is introduced with a hypertonic solution of sodium chloride. The napkin is attached with adhesive tape or glue, circular bandages are not used, as they can cause autoinoculation and spread of infection. Dressings are carried out at least 2 times a day. Such local therapy is carried out up to the complete rejection of necrotic masses. After rejection of the necrotic rod, ointments containing antibacterial agents (streptocid, tetracycline, erythromycin, lincomycin, "baneocin", etc.) are used. When the boil is localized on the face, ichthyol is not used, maximum rest of the facial muscles is created, in connection with which the patient is forbidden to talk and is transferred to liquid food. Abscessing boils are treated surgically: an abscess is opened.

Carbuncle

Definition. Carbuncle (carbunculus)- extensive acute purulent-necrotic inflammation of the dermis and subcutaneous fatty tissue, involving several nearby hair follicles in the inflammatory process (Fig. 9).

Etiology and pathogenesis. The causative agent of the disease is coagulase-positive Staphylococcus aureus, sometimes in combination with streptococci. The development of the carbuncle is due to

Rice. 9. Carbuncle. The arrows indicate the routes of penetration of staphylococci.

but, on the one hand, high virulent and pathogenic properties of staphylococci, on the other hand, a pronounced influence of endogenous predisposing causes. The combination of these two factors leads to extensive purulent-necrotic inflammation with the development of deep phlegmon, reaching the fascia and muscles. clinical picture. The development of a carbuncle begins in the same way as a furuncle, however, staphylococci in this case quickly penetrate from the hair follicle into the lymphatic vessels of the deep sections of the dermis and subcutaneous tissue, which leads to the spread of a purulent-necrotic inflammatory process and an increase in the initially formed infiltrate to large sizes. Severe edema develops around the infiltrate. The patient is worried about a sharp pain.

Carbuncles are usually solitary. However, they are usually accompanied by fever, chills, headache. The further course of the carbuncle is characterized by the formation of several perforations on its surface, from which thick pus is released mixed with blood. Soon, the entire skin covering the carbuncle melts, and then a deep ulcer (sometimes reaching the fascia and even muscles) is exposed, the bottom of which is a continuous necrotic mass of a dirty green color. After demarcation and rejection of the latter, the ulcer is filled with granulations and heals with the formation of a rough scar. In some cases, the course of the carbuncle is complicated in the same way as the course of the boil.

Diagnostics carbuncle is based on a characteristic clinical picture, manifested by the development of a large, suppurating and turning into an abscess inflammatory node, located in the deep sections of the skin, accompanied by a general intoxication syndrome and opening in the form of several holes, united by a common cavity containing thick creamy pus.

differential diagnosis. Carbuncle is differentiated from furuncle, hydradenitis, scrofuloderma.

Treatment is carried out according to the same principles as the treatment of a complicated boil with the mandatory prescription of antibiotics and stimulants. A feature of external therapy is the preliminary surgical opening of the abscess.

Hydradenitis

Definition. Hydradenitis (hidradenitis)- acute purulent inflammation of the apocrine sweat gland (Fig. 10).

Etiology and pathogenesis. Hidradenitis is caused by coagulase-positive Staphylococcus aureus, sometimes in combination with other gram-negative bacteria such as Proteus, Klebsiela, E. coli. Predisposing causes for the development of staphylococcal lesions of the apocrine sweat glands are mainly increased sweating, skin contamination, friction with clothing, shaving damage to the armpits, and dysfunction of the gonads.

clinical picture. In the armpit, less often - on the labia majora or on other areas of the skin containing apocrine glands (in the anus, navel, pubis, nipple field, in the inguinal region), a node appears, often reaching the size of a chicken egg. The skin over it is purplish red. The node is painful. Sometimes the body temperature rises. Soon it softens and opens with the release of a large amount of pus. Healing occurs with the formation of a scar. In some cases, hydradenitis is resolved without purulent fusion of the infiltrate and does not leave a scar. Hidradenitis differs from a furuncle in a hemispherical shape and the absence of a necrotic rod. With the defeat of several glands, a group of nodes develops, which, turning into abscesses, can merge with each other. The course of the disease sometimes acquires a chronic, relapsing character.

Diagnostics disease is carried out on the basis of the clinical picture - pus-

Rice. ten. Hydradenitis. The arrows indicate the routes of penetration of staphylococci.

but-inflammatory node located in the anatomical areas of the skin containing apocrine sweat glands, and opened with the release of a significant amount of pus without the formation of a necrotic core.

differential diagnosis. Hidradenitis is differentiated with scrofuloderma, deep folliculitis, furuncle, carbuncle.

Treatment hidradenitis is similar to the treatment of a boil. In case of recurrent hydradenitis, general strengthening and immunocorrective agents are additionally prescribed (see "Treatment of furunculosis"). Often used surgical methods of treatment (opening nodes).

7.2. STAPHILODERMAIA OF NEWBORN,

INFANT AND EARLY CHILDHOOD

Ostioporitis

Definition. Ostioporitis (periporitis, vesiculopustulosis) is an acute purulent inflammation of the mouths of the sweat glands in newborns.

Etiology and pathogenesis. Staphylococcal lesion of the mouths of the sweat glands develops in the first days of a child's life against the background of predisposing factors, which include, first of all, skin maceration due to excessive sweating in violation of the rules for swaddling children. Common predisposing factors include premature birth, artificial feeding child.

clinical picture. In the area of ​​the inguinal and axillary folds, the skin of the trunk and the scalp, numerous pustules ranging in size from millet grain to a pea pour out. Pustules are surrounded by a hyperemic corolla, they quickly shrink into crusts, which subsequently fall off, leaving no traces of the disease. In asthenic, weakened children, the process covers vast areas and tends to merge.

Diagnostics vesiculopustulosis is carried out on the basis of anamnesis data (violation of the rules for caring for a child) and a characteristic clinical picture - a rash of multiple pustules in areas of increased sweating.

Differential Diagnosis carried out with osteofollicitis and scabies.

Treatment consists in lubricating the affected areas of the skin with 1-2% alcohol or aqueous solutions of aniline dyes. The surrounding healthy skin is treated with 2% salicylic or boric alcohol. It is not recommended to bathe the child during the treatment period.

Multiple skin abscesses

Definition. Multiple skin abscesses (Finger's pseudofurunculosis) is an acute purulent inflammation of the eccrine sweat glands in newborns, infants and young children.

Etiology and pathogenesis. The causative agent of the disease is Staphylococcus aureus, sometimes in combination with streptococci and other microorganisms. The main cause of the disease is skin maceration caused by excessive sweating of the child against the background of its untidy content (violation of the rules of swaddling and skin care). Concomitant predisposing factors are past childhood infections, rickets, diseases of the gastrointestinal tract, reduced nutrition, artificial feeding.

clinical picture. The disease begins with the appearance in the back, back of the neck, thighs and buttocks of numerous dense nodes the size of a large pea, the skin over which becomes a bluish-red hue. The nodes slowly increase, reaching the size of a cherry and gradually turning into abscesses, then a fluctuation appears and they open, releasing bloody pus. Above some of the nodes, superficial pustules may be observed at the mouths of the ducts of the eccrine sweat glands (ostioporitis).

Diagnostics the disease is carried out on the basis of anamnesis data (violation of the rules for swaddling a child) and a characteristic clinical picture - a rash of multiple compacted inflammatory nodes that form purulent abscesses and are often combined with manifestations of vesiculopustulosis.

Differential Diagnosis should be carried out with folliculitis and furunculosis.

Treatment.General therapy includes the appointment of broad-spectrum antibiotics and stimulants (maternal blood injections, gamma globulin).

External Therapy consists in imposing ichthyol cakes on developing nodes and piercing developed abscesses in combination with lubricating them with alcohol solutions of aniline dyes. Healthy skin of the trunk and extremities is wiped with colorless disinfectant solutions (2% alcohol solution of salicylic or boric acid).

epidemic pemphigoid

Definition. Epidemic pemphigoid (epidemic pemphigus of the newborn, pyococcal pemphigoid, pemphigus neonatorum)- acute highly contagious staphylococcal disease of newborns, characterized by diffuse skin lesions with the formation of blisters in the epidermis.

Etiology and pathogenesis. The causative agent of the disease is Staphylococcus aureus phage type 71, which secretes an exfoliative exotoxin (epidermolysin), which causes acantholysis of the epidermis under its stratum corneum with the formation superficial blisters. The source of infection is the medical staff of maternity hospitals and mothers of newborns, including bacteria carriers of nasopharyngeal staphylococci. The high contagiousness of the pathogen causes outbreaks and the development of epidemics in medical institutions. The occurrence of the disease is promoted by premature birth and toxicosis of pregnant women.

clinical picture. The disease begins, as a rule, at 2-3 weeks of a child's life. It is characterized by rashes in the area of ​​the trunk, neck, head, limbs on unchanged or slightly hyperemic skin of small (pea-sized) blisters filled with serous contents. The blisters gradually increase in size, their contents become cloudy, then they open up, forming moist, brightly inflammatory erosions. There is no infiltrate at the base of the erosions, and they quickly epithelialize. The disease proceeds paroxysmal with repeated outbreaks of fresh rashes, in premature or debilitated children it may be accompanied by general phenomena - fever, increased ESR, leukocytosis, eosinophilia.

Diagnostics pyococcal pemphigoid is based on a characteristic clinical picture (flash-like development of small blisters with rapidly cloudy contents) and data

nyh anamnesis (the appearance of the first rashes 1-2 weeks after the birth of the child).

differential diagnosis. Epidemic pemphigoid should be differentiated from syphilitic pemphigus of newborns (examination of the cystic fluid for the presence of pale treponema, and blood for serological reactions), chicken pox, epidermolysis bullosa.

Treatment.General therapy is carried out in severe cases, accompanied by a syndrome of general intoxication, and includes the appointment of broad-spectrum antibiotics, vitamins, parenteral administration of maternal blood.

External Therapy consists in removing the covers of the blisters and prescribing warm baths with a solution of potassium permanganate. After the cessation of weeping - creams with anti-inflammatory and disinfectants.

Staphylococcal scalded skin syndrome

Definition. Staphylococcal scalded skin syndrome (exfoliative dermatitis of newborn Ritter von Rittershein, Lyell's staphylococcal syndrome) is an acute severe staphylococcal disease characterized by diffuse skin lesions with the formation of large flabby blisters, clinically resembling second-degree burns.

Etiology and pathogenesis. The causative agent of the disease is Staphylococcus aureus of phage group II, phage type 71, which secretes a special exotoxin (exfoliatin, epidermolysin), which causes extensive subcorneal acantholysis of the epidermis with the formation of large surface blisters. infectious process develops in children in the first 3 months of life, most often in maternity hospitals, where the sources of infection are medical staff or puerperas. Older children or even immunosuppressed adults may develop the disease, which is most common in patients on long-term immunosuppressive therapy (for example, for a kidney transplant).

clinical picture. The disease begins with a bright acute inflammatory periorificial erythema, reminiscent of exanthema in scarlet fever. Starting around the mouth, navel, anus, genitals, erythema spreads rapidly, and large blisters appear on it within 1-2 days, quickly opening and exposing extensive weeping erosions.

Nikolsky's symptom is positive. Bubbles and erosions undergo peripheral growth, merging, they can capture almost the entire skin of the child. At this stage, the lesion may be accompanied by fever, elevated ESR, leukocytosis, eosinophilia, and anemia. With the appointment of adequate therapy against the background of a decrease in the intensity of hyperemia and swelling of the skin, re-epithelialization of erosions occurs within one week.

Diagnostics exfoliative dermatitis of newborns is based on a characteristic clinical picture - multiple blisters increasing in size, demonstrating extensive acantholysis of the epidermis (positive Nikolsky symptom) and often accompanied by a syndrome of general intoxication.

Differential Diagnosis spend with thermal burns, syphilitic pemphigus of newborns, bullous epidermolysis. In adults, staphylococcal scalded skin syndrome is differentiated from toxic epidermal necrolysis.

Treatment.General therapy includes the appointment of penicillinase-resistant antibiotics (amoxiclav) or other broad-spectrum antibiotics.

External Therapy begins with the appointment of warm baths with a solution of potassium permanganate on the area of ​​weeping erosion. Ointments with disinfectants are applied to the crusts.

7.3. STREPTODERMIAImpetigo

Definition. Impetigo (impetigo streptogenes)- acute diffuse serous inflammation of the skin with the formation of subcorneal or intraepidermal blisters.

Etiology and pathogenesis. The causative agent of the disease is group A β-hemolytic streptococcus. In rare cases (bullous impetigo), coagulase-positive staphylococci of phage type 71, causing intraepidermal acantholysis, are involved in the pathogenesis of the development of intraepidermal blisters. The leading predisposing cause for the development of impetigo is microtrauma (shaving, scratching, insect bites).

clinical picture. Streptococcal impetigo is characterized by a sudden onset, expressed in the formation

against the background of hyperemia of subcorneal blisters, which turn within a few hours into layered or bumpy crusts of honey-yellow color, upon removal of which erosions are exposed, bordered by a narrow collar of the stratum corneum. The primary element is a superficial (under the stratum corneum) flabby bladder up to 1 cm in size with transparent serous contents - conflict. It shrinks so quickly into a crust that, as a rule, it is visible. As a result of the addition of a staphylococcal infection, the crusts acquire a greenish-yellow color (streptostaphylococcal, or vulgar impetigo). The disease is accompanied by itching, so the crusts can be hemorrhagic. Impetiginous elements tend to grow peripherally and merge. Often regional lymphadenitis develops. Children are more often affected. Favorite localization - the face, for men - the area of ​​\u200b\u200bgrowth of the beard and mustache, for women - hairy part heads. Sometimes, especially in children, the mucous membranes of the mouth, nose, and eyes are involved in the process: conflicts arise that quickly open with the formation of painful erosions.

In some patients, after the resolution of impetigo, for a long time, flour-like or scaly scaly hyperemic spots remain on the faces. Similar elements may occur primarily, predominantly in children before puberty, as well as in adults working outdoors. In summer, under the influence of sunlight, the spots may disappear, but the skin in their place tans to a lesser extent and becomes lighter than healthy. Such a lesion of the skin of the face is considered as an erased, dry form of impetigo and is called simple, or white, deprive faces.

In some cases, the growing conflict shrinks into a crust (lamellar) only in the central part, and a cystic roller remains along the periphery (annular impetigo). In other cases, conflict persists, located in the deeper layers of the epidermis. It, without opening and shrinking into a crust, increases in volume and reaches the size of a large bubble. (bullous impetigo). Often, bullous impetigo develops in the area of ​​​​the nail ridges (usually in the presence of burrs), horseshoe-shaped surrounding the nail plate (superficial panaritium).

In persons who have a habit of licking their lips, as well as in those who sleep with their mouths open, from which saliva flows, excessive moistening of the corners of the mouth occurs, which contributes to

orgy slit-like impetigo ("jam"). The latter is an erosion surrounded by a collar of the stratum corneum left from the lid of the conflict; a crack forms in the depths of the mouth, and honey-yellow crusts appear on the skin around it. The course of the jam is very stubborn. Candidiasis of the corners of the mouth (it does not form crusts) and papular syphilis of the corresponding localization, which is characterized by infiltration at the base of erosion, have a picture similar to slit-like impetigo.

Papulo-erosive syphilis resembles another impetigo observed in infants. Conflicts appear on the buttocks and back of the thighs, which quickly open up, leaving behind erosion. A papular infiltrate soon develops at the base of the erosions. This form of streptoderma is called syphilitic posterosive papular impetigo. The predisposing cause of its development is maceration and skin irritation with feces with insufficient care for the child (hence the other name - diaper dermatitis). This explains the originality of the clinical picture: moisture prevents the formation of crusts, "washes away" the collar of the stratum corneum around erosions (remnants of the tire conflict); irritation causes reactive infiltrative inflammation at their base.

Diagnostics impetigo is based on anamnesis data (microtraumatism, skin contamination) and a characteristic clinical picture (flash-like appearance of rapidly cloudy and drying superficial blisters).

differential diagnosis. Impetigo should be differentiated from arteficial and allergic dermatitis. Slit-like impetigo is differentiated from seizures with yeast lesions. Differential diagnosis of diaper dermatitis is carried out with papular infiltration in congenital syphilis. The diagnosis of syphiloid-like posterosive papular impetigo should be confirmed by negative results of the study of discharge erosions for pale treponema and negative results of serological tests for syphilis.

Treatment.General therapy carried out with the widespread nature of the process and the presence of complications in the form of lymphangitis and lymphadenitis. In these cases, antibiotics are prescribed (semi-synthetic penicillins, rifamycins, cephalosporins).

External Therapy carried out depending on clinical form impetigo. The skin around the lesions 3-4 times a day is wiped with disinfectants (2% alcohol solution of salicylic, boric, boric-levomycetin-salicylic acid). Bubbles are opened with the removal of tires. In the stage of weeping erosion, lotions or wet-drying dressings are used with solutions of 0.25% silver nitrate, 1-2% resorcinol, 1-2% boric acid, Alibur liquid. After the cessation of weeping or the presence of dry crusts, ointments with disinfectants are applied. With severe inflammation along the periphery of the lesions, it is possible to short term(within 1-2 days) the use of ointments and creams containing glucocorticosteroids and antibacterial agents ("belogent", "diprogent", "fucicort", "lorinden-S".)

Intertriginous streptoderma

Definition. Intertriginous streptoderma (streptococcal diaper rash, streptococcal intertrigo) is a diffuse serous-purulent inflammation of the skin with the formation of blisters that develops in the inguinal-femoral and intergluteal folds, in the armpits, in the folds of the abdomen and neck in obese subjects, less often in the interdigital folds of the feet, sometimes - brushes.

Etiology and pathogenesis. The causative agent of the disease is group A β-hemolytic streptococcus. The process is a streptococcal skin lesion, the predisposing causes of which are increased sweating and sebum secretion, leucorrhea, urinary incontinence, discharge from fistulas, hemorrhoids, warming compresses, insufficient drying of skin folds after bathing, etc. Sometimes the cause is the excretion of sugar with sweat in diabetic patients.

clinical picture. Clinically, streptococcal intertrigo is a wet erosive surface formed as a result of the opening of the conflict, bordered by the collar of the stratum corneum. Its boundaries are clear, large-scalloped. In the depth of the fold, superficial, non-bleeding cracks are longitudinally located. Lesions have peripheral growth that occurs by detachment of the stratum corneum. Outside the contact areas of the skin, the clinical picture takes the form of impetigo. Subjective sensations are expressed in the form of itching (pain, burning are less often noted).

Diagnostics the disease is carried out on the basis of a characteristic clinical picture (large scalloped wet erosions located in large folds of the skin). In difficult cases, laboratory diagnostics (microscopic or cultural methods) is used.

differential diagnosis. Streptococcal diaper rash should be differentiated from intertriginous candidiasis (yeast diaper rash).

Treatment.General therapy is carried out in the presence of complications (lymphangitis, lymphadenitis) or chronically recurrent course of the disease and includes the appointment of antibiotics and stimulants.

Physiotherapy is prescribed after the removal of acute inflammatory phenomena and the cessation of weeping in the form of UV radiation with erythemal doses on the affected skin.

Outdoor therapy. When wetting - lotions and wet-drying dressings from disinfectants and anti-inflammatory drugs (2% alcohol solution of boric acid, 2% resorcinol solution, Alibur liquid, etc.). After the cessation of weeping and the removal of acute inflammatory phenomena, pastes with disinfectants and anti-inflammatory agents are used (2% gentian violet, ethacridine-boron-naftalan, 2% methylene), it is possible to use creams containing glucocorticosteroids and disinfectants ("polcortolone-TS", "oxycort", "celestoderm-B with garamycin", "fucicort", etc.). In stubborn cases, characterized by the development of chronic inflammation, ointments with resolving and disinfecting agents are used - 5-10% sulfur-tar, Wilkinson's ointment, 10% ichthyol. Since intertriginous streptoderma is not always possible to differentiate from intertriginous candidiasis, drugs that act on both streptococci and yeast-like fungi should be used.

Chronic diffuse streptoderma

Definition. Chronic diffuse streptoderma is an extensive chronic focus of serous or serous-purulent inflammation that diffusely affects the skin of the lower leg, less often the scalp.

Etiology and pathogenesis. The disease is a streptococcal or strepto-staphylococcal disease

skin, the originality of the clinical picture and the chronic course of which are due to persistent local circulatory disorders that cause hypoxia of skin tissues. Most often they are associated with constant hypothermia of the legs or head, varicose veins, daily long stay on the legs, etc.

Clinical picture characterized by hyperemia, often congestive, slight infiltration, clear large-scalloped borders formed by the collar of the stratum corneum. The surface of the focus is covered with large lamellar serous-purulent and serous-hemorrhagic crusts, between them - erosion. Upon removal of the crusts, a continuous weeping surface is exposed. The lesion is gradually "spreading" along the periphery. Around it, it is possible to detect primary elements - large conflicts. The disease is characterized by torpidity, proceeds for a long time, the inflammatory process either worsens or subsides. In the latter case, wetting stops, and the crusts are replaced by large scales. The long course of the disease contributes to its transformation into microbial eczema, which is expressed in the appearance of microerosions on an erythematous background that separate drops of serous fluid.

Diagnostics chronic diffuse streptoderma is based on the features of the clinical picture (large wet erosion, sometimes covered with purulent-hemorrhagic crusts and large-lamellar scales, which is located most often in the area of ​​\u200b\u200bthe legs and often in patients with impaired trophism of the lower extremities).

Differential Diagnosis carried out with microbial eczema.

Treatment.General therapy. From the means of general treatment are used intramuscular injections 10% solution of calcium gluconate 10 ml daily or every other day, antihistamines, vitamins (B 1, B 6, C, P, PP), immunostimulating therapy (autohemotherapy, pyrogenal, methyluracil, taktivin, reaferon), as well as broad-spectrum antibiotics actions (ampicillin, azlocillin, amoxiclav).

Physiotherapy carried out in the same way as with intertriginous streptoderma.

Outdoor therapy. When wetting, it is recommended to use lotions and wet-drying dressings from solutions with disinfectants and astringents (0.25% silver nitrate solution, 2% alcohol solution of resorcinol, boric

acids, Alibur liquid). On crusts - ointments with disinfectants. After the removal of acute inflammation and the cessation of weeping, pastes with disinfectants and anti-inflammatory drugs are used (etacridine-boron-naphthalene, 2% methylene, 3-5% ichthyol), it is possible to use creams containing glucocorticosteroids and disinfectants ("white -gent", "diprogent", "lorinden-S", "fucicort", "celesto-derm-B with garamycin"). In the stage of chronic inflammation, torpid flow, ointments with resolving and disinfecting agents are shown - sulfur-tar-naftalan, tar and naftalan in equal parts.

Ectima

Definition. Ecthyma is an acute serous-purulent-necrotic inflammation of the skin that develops as a result of microorganisms entering the depth of the skin (under the epidermis) and causing necrosis of the dermis with the formation of ulceration (see color inc., Fig. 2).

Etiology and pathogenesis. Ecthyma can be not only streptococcal, but also strepto-staphylococcal, staphylococcal, and in exceptional cases - gonococcal. The penetration of the infection into the depths of the skin is caused by microtraumas and, mainly, by scratching due to lice, scabies and other itchy dermatoses. The disease often develops against the background of a decrease in immune reactivity due to hypovitaminosis, stress, chronic intercurrent diseases.

clinical picture. Due to the peculiarities of the etiopathogenesis, the disease begins with the formation of not a conflict, but a deep, against the background of an inflammatory infiltrate, a bubble or an epidermal-dermal pustule the size of a large pea or more. A bubble or pustule quickly shrinks into a serous-hemorrhagic or purulent-hemorrhagic crust, immersed in the thickness of the skin and bordered by a zone of soft hyperemia. Upon removal of the crust, an ulcer with sheer edges is found, which fills with granulations over time. Ecthymas are usually multiple, often linear (in the course of scratching); favorite localization - lower limbs and buttocks. In unscrupulous people, in the presence of congestion in the legs, in weakened patients, the disease without treatment can become chronic.

Diagnostics ecthyma is carried out on the basis of a characteristic clinical picture (purulent hemorrhagic crusts inlaid into the skin, as well as superficial rounded ulcers located in the lower extremities).

differential diagnosis. Ecthyma vulgaris should be differentiated from chronic pyococcal ulcer, acute necrotizing type of cutaneous leishmaniasis, indurative erythema, and syphilitic gumma.

Treatment.General therapy. Of the general treatment, vitamins are prescribed (A, B 1, B 6, C, P) and stimulating therapy (autohemotherapy, methyluracil, pyrogenal, thymalin). With a common process, a complicated course, broad-spectrum antibiotics are used.

Physiotherapy carried out similarly to the treatment of streptococcal diaper rash and chronic diffuse streptoderma.

Outdoor therapy. The skin around the affected areas is wiped with disinfectant alcohols or treated with aniline dyes. The conflict tires are removed, and ointments with disinfectants are applied to the crusts. After removing the covers of the blisters or the discharge of the crusts, lotions or wet-drying dressings with disinfectants and anti-inflammatory agents (1% silver nitrate solution, 2% boric acid solution, 1% resorcinol solution) are used. The same ointments with disinfectants are applied to the dried ulcer. With a weak tendency to healing, Mikulich ointment, iruksol, levosin, 10% methyluracil ointment are used.

7.4. ATYPICAL PYODERMAS

Definition. Atypical pyoderma is a chronic sluggish ulcerative, vegetative and abscessed form of pyoderma, difficult to treat and very reminiscent of focal skin tuberculosis and deep mycoses.

Etiology and pathogenesis. The nature of the clinical manifestations of these pyodermas does not depend on the type of pathogen, which, in addition to staphylococci and streptococci, can be a wide variety of microorganisms and their combinations in the form of mixed infections. The main role in the development of clinical pictures belongs to the state of the macroorganism, which, for various reasons, changes its reactivity. Examination of patients reveals a variety of

immune disorders and a decrease in nonspecific resistance, characteristic of various types of immunodeficiencies (primary, secondary (infectious) and primary-secondary).

Chronic ulcerative pyoderma

clinical picture. Chronic ulcerative pyoderma (chronic pyogenic ulcer) is localized mainly on the shins (see color inc., Fig. 3). Most often it is preceded by a boil or ecthyma. In debilitated patients, the ulcers that form in these diseases lose their tendency to heal and acquire a long, torpid course. Their bottom is covered with flaccid granulations, the edges are slightly infiltrated, congestively hyperemic, palpation is painful. In some cases, chronic pyogenic ulcers increase in size and merge with one another. The lesion gradually grows in one direction or another, while scarring in the central part (serpiginous-ulcerative pyoderma). Sometimes a pyogenic ulcer, localized on the genitals, the red border of the lips, eyelids, is so reminiscent of a hard chancre (chancriform pyoderma) that it is possible to exclude the diagnosis of primary syphilis only after repeated laboratory examination of the patient.

Diagnostics disease is carried out on the basis of the characteristics of the clinical picture (torpid flowing chronic pyogenic ulcers, tending to deepen and peripheral growth).

Differential Diagnosis carried out with vulgar ecthyma, indurative erythema, acutely necrotizing type of cutaneous leishmaniasis and syphilitic gumma.

Chronic vegetative pyoderma

Clinical picture chronic vegetative pyoderma is a soft bluish-red plaque covered with purulent crusts, upon removal of which a juicy papillomatous (vegetative) surface of the infiltrate is exposed. When squeezing the plaque, large drops of thick green pus are released. Deep pustules are found around it. Vegetative pyoderma is localized mainly on the back surface of the hands and feet, in the ankles. The lesions have a tendency to peripheral

mu growth, heal with the formation of a scar, in which there are interspersed areas of normal skin.

Diagnostics disease is based on data from microbiological and histological studies, as well as on the features of the clinical picture (torpidly flowing papillomatous plaques covered with purulent crusts and located in the area distal departments limbs).

Differential Diagnosis should be carried out with warty tuberculosis of the skin and deep mycoses(chromomy-goats, blastomycosis, sporotrichosis).

Chronic abscess pyoderma

Clinical picture characterized by the formation of an inflammatory node, the skin over which acquires a bluish-red color. Gradually, the node softens and turns into an abscess. Over time, the abscess opens, forming one or more holes, from which liquid pus is released, often with an admixture of blood. In those cases when several nodes develop, abscesses are connected to each other by fistulous passages, and the lesion becomes very similar to colliquitative tuberculosis (scrofuloderma). This impression is intensified after the formation of uneven ("torn", "shaggy") scars. Hence the name of such a variety of abscessed pyoderma is collicative, or scrofuloderma-like, pyoderma. The most common localization of abscessed pyoderma is the buttocks, perineum, armpits, back of the neck, face.

Diagnostics chronic abscessing pyoderma is carried out on the basis of data from microbiological studies and a characteristic clinical picture (torpid flowing purulent abscesses in the deep sections of the skin, tending to slow peripheral growth, breaking through several holes and connecting with each other).

Differential Diagnosis carried out with scrofuloderma and actinomycosis.

Treatment of chronic atypical pyoderma

General therapy. Treatment is carried out in courses. At the first stage, immunotherapy is recommended to correct immune disorders caused by secondary infectious immunity.

nodeficiency. For this purpose, thymus preparations (tactivin, thymalin), interferon (reaferon), levamisole are prescribed, with the help of which the amount of total T-lymphocytes and T-helpers, the ratio of T-helpers and cytotoxic T-cells is normalized, antibody genesis is enhanced, phagocytosis is activated, and antibiotic resistance of the pathogen decreases in the foci of infection. Next, antibiotics are prescribed (taking into account changes in the sensitivity of microorganisms to them) in combination with stimulants humoral immunity and non-specific resistance (pyrogenal, prodigiosan, vaccines, immunal, methyluracil, pentoxyl, diucifon, vitamins A, C, E). Such treatment is carried out until remission is achieved, during which (under the guise of antibiotic therapy) surgical treatment of the affected skin is used.

Physiotherapy. Of the physiotherapeutic agents, UVI is used locally, electrophoresis or phonophoresis of lidase and antibiotics.

External Therapy depends on the form of atypical pyoderma. With ulcerative pyoderma - washing the foci with disinfectant solutions, followed by the use of ointments with antibacterial agents. With vegetative pyoderma, after the cessation of pus release, antibiotic ointments are applied. Treatment of abscessed pyoderma consists in washing the fistulous passages with antibiotics and ends with the excision of nodes and abscesses within healthy tissue. Fresh unopened nodes are treated with a 40% dimexide solution containing antibiotics.

7.5. PIOALLERGIDES

Definition. Pyoallergides are secondary rashes that develop in patients with pyoderma in conditions of skin sensitization to the corresponding pyococci.

Etiology and pathogenesis. The development of sensitization to pio-cocci usually occurs in chronic pyoderma, more often streptococcal etiology, which is usually associated with irrational, irritating local treatment leading to the absorption of pyococci or their decay products into the blood.

clinical picture. Suddenly, a widespread, symmetrical, monomorphic rash appears on the trunk, limbs, face, consisting of roseola, scaly in the center, or follicular papules, papulo-vesicular or papules.

lo-pustular elements. With the defeat of the palms and soles, pioallergid is manifested by dyshidrosis or blistering rashes. In some cases, the development of pioallergid is accompanied by an increase in body temperature.

Diagnostics pioallergides is based on a characteristic clinical picture (development of symmetrical monomorphic rashes on various parts of the body in patients with foci of pyogenic bacterial skin infection).

Treatment. First of all, it is necessary to cancel the previous treatment of the primary pyococcal focus. General treatment is carried out - desensitizing therapy, including calcium preparations and antihistamines (diphenhydramine, diazolin, "Kestin", "Erius", etc.), with an increase in body temperature - antibiotics; locally - corticosteroid ointments, creams "elo-com", "advantan", etc.).

7.6. PREVENTION OF PYODERMA

Preventive measures aimed at reducing the incidence of pustular skin diseases should be carried out systematically, taking into account a thorough analysis of the causes of their occurrence, living conditions, life, physical and mental stress of various contingents of the population. Therefore, the prevention of pyoderma includes a whole range of activities.

Accounting and analysis of morbidity. Accurate and systematic accounting of pustular diseases is of great importance, as it allows you to establish the true and specific causes of their occurrence and spread.

Sanitary and hygienic measures should be aimed at maintaining the cleanliness of the skin, especially among workers in various industries and agriculture, whose work is directly related to the constant excessive contamination of the skin. The most important is the creation of conditions for personal hygiene. Washbasins and showers with hot and cold water should be installed in enterprises, and employees should be regularly provided with soap and clean towels. To remove poorly washed contaminants (fuels and lubricants, paints and varnishes), special cleaning agents should be used. Of great importance is the provision of overalls, its regular change and washing, as

soiled and worn out workwear brings great harm. To prevent hypothermia of persons working outdoors in cold weather, it is necessary to provide warm clothing. It is also of great importance to maintain cleanliness in working and residential premises, compliance with the temperature regime and normal humidity in them.

Sanitary measures. In addition to the generally accepted methods for improving the sanitary condition in workshops, workshops, garages, etc., much attention should be paid to the prevention of microtraumatism and the provision of assistance with it. Persons who are constantly exposed to the risk of microtraumatism should be trained in self-help and mutual help skills. First-aid kits should be constantly equipped with means of protection against infection of microtraumas: Novikov liquid (tannin 1.0, brilliant green 0.2; alcohol 0.2; castor oil 0.5; collodion 20.0), 2% alcohol solution of iodine and other disinfectants.

strengthening physical condition of people. To improve health, it is necessary to pay attention to improving living conditions and nutrition, hardening the body through propaganda and methodically correct organization of physical exercises, sports, and water procedures. It is necessary to achieve an even distribution of the workload and the organization of good rest, preventing the development of the "chronic fatigue syndrome" and contributing to the strengthening of physical development, reducing morbidity and labor losses.

Therapeutic and preventive measures include early detection initial forms of pyoderma, timely, correct and complete treatment, prevention of recurrence of diseases, identification and sanitation of sources and chronic carriers of infection. Irrational therapy causes the spread of infection, and in addition to complications of a purulent nature (lymphadenitis, lymphangitis), it can lead to sensitization to pyococci (primarily streptococci), which contributes to the development of complications such as pioallergides, microbial eczema, erythema nodosum and acute glomerulonephritis. For this reason, training is of great importance. medical workers(especially mid-level) to the correct methods of external treatment and rehabilitation of those who have been ill. Knowledge of the principles of external therapy of pustular skin diseases helps to prevent dissemination of the process.

sa, prevent recurrence of infection and reduce the likelihood of complications. In the external treatment of patients, the following main principles must be observed:

1) treatment of the focus of skin infection is carried out with the help of disinfectants, which allows you to effectively act directly on the pathogen;

2) to prevent dissemination of infection, it is necessary to prohibit washing in the bath, as well as treat healthy skin surrounding the affected areas with disinfectants;