Ekthyma L08

Stokes 1807

Circumscribed, as if punched out (sharp-edged) ulcers of the skin, which is favoured by external circumstances, e.g. by (sub-)tropical climate. While the disease was frequently observed in Central Europe in the years of shortage during the Second World War, it is rather rare today. Increasingly it is found in travelers returning from tropical or subtropical regions as well as in immunocompetent persons (see below Ecthyma gangrenosum).

Remark: The term ecthyma or ecthyma is not clearly defined etiologically.

Mostly beta-hemolytic streptococci, Streptococcus pyogenes or more rarely Staphylococcus aureus.

In general, the following forms are distinguished:

I. Ecthyma simplex: Streptococcal infection (Streptodermia ecthymatosa, Ecthyma simplex streptogenes) or Staphylococcal infection (Staphylodermia ecthymatosa).

II. ecthyma gangraenosum: caused by Pseudomonas aeruginosa; this form plays an increasing role especially in immunocompetent patients as well as in Pseudomonas aeruginosa sepsis.

Rare

The starting points for the development of ecthymata are small injuries, folliculitis, insect bites, scabies or prurigo simplex subacuta. The foci begin similarly to impetigo contagiosa, but then develop necrosis at the base of the blister. The disease is favored by poor hygiene, warm and humid climate, chronic venous insufficiency, weakened general condition, acrocyanosis, immunosuppression, HIV infection and diabetes mellitus.

Especially lower leg.

Initial stage of vesiculopustular disease, rapid tissue decay with formation of deep, sharply cut ulcers, with greasy purulent coatings and halo-like erythematous fringe. Spreading to the subcutaneous fatty tissue. Drying, dirty grey-yellow crusts. Lymphangitis and -adenitis possible. Healing with scarring.

Syphilide (ulcerous) - rare

Syphilis maligna- rare

ulcerated gums - rare

Erythema induratum

Artifacts - Questioning anamesis, personality profile

Antibiosis with Penicillin V (e.g. Megacillin) 3 times/day 1 Mega IE p.o. for 10 days. For penicillin allergy erythromycin (e.g. Erythrocin Filmtbl.) 4 times/day 500 mg p.o. For V.a. mixed infection Flucloxacillin (e.g. Staphylex) 3-4 times/day 0.5-1.0 g p.o. or i.m.

Alternatively cephalosporins such as cefazolin (e.g. Elzogram) 2 times/day 1-2 g i.v. or cefixim (Cephoral) 400 mg/day p.o. Conversion after antibiogram as soon as possible.

Without therapy, chronic course, usually lasting weeks, with no tendency to heal. Healing under systemic antibiosis and change of the favouring hygiene deficits. Scarring.

• The most common finding, the ecthyma simplex, is in most cases a cutaneous streptococcal infection (beta-hemolytic S.) with deep ulcerations that look like "punched out". E. simplex preferentially occurs at higher temperatures and high humidity on the legs and develops after insect bites or minor traumas (see the clinical picture described here).
• The Ecthyma gangraenosum is an infection caused by P. aeruginosa. The rather extensive, flat ulcerations of the intertriginous tissue with strong environmental erythema occur mainly in patients with Pseudomonas sepsis, but also as a pure local infection.
• The cause of Ecthyma contagiosum (Orf) is an infection with the parapoxvirus ovis (group parapoxviruses) transmitted from animals (foot or mouth cattle in sheep, goats, etc.) to humans.

1. Gucluer H et al (1999) Ecthyma gangrenosum. Int J Dermatol 38: 299-302
2. Inamadar AC et al (2003) Periocular ecthyma gangrenosum in a diabetic patient. Br J Dermatol 148: 821
3. Kim EJ et al (1999) Ecthyma gangrenosum in an AIDS patient with normal neutrophil count. J Am Acad Dermatol 41: 840-841
4. Kimyai-Asadi A et al (1999) Ecthyma secondary to herpes simplex virus infection. Clin Infect Dis 29: 454-55
5. Mempel M et al (2015) Selected bacterial infections of the skin. dermatologist 66: 252-257
6. Ramar K et al (2003) Ecthyma gangrenosum and chronic lymphocytic leukaemia. Lancet Infect Dis 3: 113
7. Rieger H et al (2003) Ecthyma contagiosum (Orf) as an uncommon differential diagnosis of infections of the hand. Trauma surgeon 106: 204-206
8. Vaiman M et al(2015) Ecthyma gangrenosum and ecthyma-like lesions: review article. Eur J Clin Microbiol Infect Dis 34:633-639.