Bacterial Skin Infections

Basic Dermatology Curriculum

Last updated December, 2018

1
Goals and Objectives
 The purpose of this module is to help medical students
develop a clinical approach to the evaluation and initial
management of patients presenting with cutaneous bacterial
infections.
 By completing this module, the learner will be able to:
• Describe the morphology of common cutaneous bacterial
infections
• Discuss the bacterial etiologies of cellulitis and erysipelas
• Recognize clinical patterns and risk factors that suggest MRSA
• Recommend initial steps for the evaluation and treatment of
common cutaneous bacterial infections
• Recognize characteristic features of necrotizing fasciitis and the need
for emergent treatment, including surgical intervention

2
Case One
Mr. Neal Tolson

3
Case One: History
 HPI: Mr. Tolson is a 55-year-old man who presents with 5 days
of worsening right lower extremity pain and a red rash. He
reports recent fevers and chills since he returned from a
camping trip last week.
 PMH: arthritis
 Medications: occasional NSAIDs, multivitamin
 Allergies: no known drug allergies
 Family history: father with history of melanoma
 Social history: lives in the city with his wife, two grown
children
 Health-related behaviors: no alcohol, tobacco or drug use
 ROS: able to bear weight, no itching

4
Case One: Exam

 Vital signs: T 100.2, HR 80, BP

120/70, RR 18
 Skin: erythematous plaque with ill-
defined borders over the right medial
malleolus that is tender to palpation.
 Tender, slightly enlarged right inguinal
lymph node
 Laboratory data: WBC 12,000 (75%
neutrophils, 10% bands)

5
Case One, Question 1
What is the most likely diagnosis?
a. Bacterial folliculitis
b. Cellulitis
c. Necrotizing fasciitis
d. Stasis dermatitis
e. Tinea corporis

6
Case One, Question 1
Answer: b
What is the most likely diagnosis?
a. Bacterial folliculitis (Would expect pustules and papules centered on hair
follicles. Without systemic signs of infection)
b. Cellulitis
c. Necrotizing fasciitis (Would expect rapidly expanding rash, usually appears as
a dusky, edematous, red plaque. In this setting, it is always appropriate to ask
the question, “Could this be necrotizing fasciitis?”)
d. Stasis dermatitis (Although found in similar location, stasis dermatitis often
presents on both legs with itch, some pain, and scale, which may erode or
crust. There should not be fever or elevated WBC)
e. Tinea corporis (Would expect annular plaque with elevated border and
central clearing. Painless, but itchy without fever or elevated WBC)

7
Diagnosis: Cellulitis
 Cellulitis is a very common infection occurring in up to 3% of
people per year
 Results from an infection of the dermis that often begins with
some entry portal such as a wound, maceration between toes
or fungal infection (e.g., tinea pedis)
 Presents as a spreading erythematous, non-fluctuant tender plaque
 More commonly found on the lower leg
 Streaks of lymphangitis may spread from the area to lymph
nodes
 Most do not require hospitalization unless IV therapy is
required: systemically signs of toxicity, rapid progression,
inability to tolerate oral therapy, proximity to an indwelling
medical device, or immunosuppressed

8
Differential of Lower Extremity Cellulitis
Redness
Entity Unilateral/Bilater Painful Swollen Red disappears Other Findings
al with elevation
Stasis Dermatitis (acute flare Usually bilateral Erythema with Usually medial
of chronic venous chronic problem yellowish or light ankle area; assoc
insufficiency but may have No, itchy Little if any brown No with papules,
unilateral flare pigmentation; vesicles, weeping,
sharply demarcated crusting
redness
Acute Usually unilateral Yes, but develops Usually medial
Lipodermato- sclerosis but may have over weeks to No Red-purple No ankle, lower calf;
bilateral months plaque indurated and warm
Asteatotic Bilateral No, may be itchy No Reticular pattern No Lower legs; not
Eczema: dryness in net-like hot; can be oozing,
pattern crusting, fissuring

Acute Allergic Depends on No, itchy Yes Yes No Well-

Contact, as with neomycin exposure; at area demarcated;
of contact scaling, blistering,
weeping
Acute Irritant Depends on Yes, painful, burning, Yes Yes No Well-demarcated;
Contact exposure; at area stinging bullae, weeping,
of contact crusting
Gout: uric acid level may be Unilateral Yes, severe Yes Yes, violaceous; No Affects lower
normal during attack extends extremity, as great
beyond joint toe the most, instep,
involved heel, ankle, knee
Lymphedema, primary or Almost always No, but Yes, including Yes Yes, usually May be warm but
secondary as surgery, unilateral uncomfortable dorsal disappears not hot
radiation, trauma surfaces of
feet and toes

Dependent Unilateral or No, usually; may No Fiery red-dusky Yes Ischemic changes
Rubor bilateral have pain at rest with erythema causal; not hot
arterial insufficiency 9
Cellulitis: Risk Factors
 Risk factors for cellulitis include:
• Local trauma (bug bites, laceration, abrasion,
puncture wound)
• Spread of a preceding or concurrent skin lesion
(furuncle, ulcer)
• Secondary cellulitis from blood-borne infection or from direct
spread of subjacent infections (e.g. osteomyelitis) is rare
• A preexisting skin infection due to compromise of skin
barrier (intrerdigital toe web infection, tinea pedis)
• Inflammation (local dermatitis, radiation therapy)
• Edema and impaired lymphatics in the affected area

10
Cellulitis: Etiology
 80% of cases are caused by Gram positive organisms
 Group A streptococcus is most common >>> other strep
 Staphylococcus aureus is less common but occurs with open
wound or penetrating trauma as with needle injection with drug
abuse
 Think of other organisms if there have been unusual
exposures or conditions:
• Pasteurella multocida (animal bites)
• Eikenella corrodens (human bites)
• MRSA (with concurrent MRSA elsewhere/illicit drug
use/purulent drainage)

11
Case One, Question 2
Based on Mr. Tolson’s history and findings, what is
the next best step in management?
a. Apply topical antibiotics
b. Apply topical steroids, compression wraps, and
encourage leg elevation
c. Begin oral antibiotics immediately with coverage for
Gram positive bacteria and encourage leg elevation
d. Order an imaging study
e. Hospital admission for IV antibiotics

12
Case One, Question 2
Answer: c
What is the next best step in management?
a. Apply topical antibiotics (not effective)
b. Apply topical steroids, compression wraps, and encourage leg
elevation (this is the treatment for stasis dermatitis, not cellulitis)
c. Begin antibiotics immediately with coverage for Gram
positive bacteria and encourage leg elevation
d. Order an imaging study (radiographic examination is not
necessary for routine evaluation of patients with cellulitis)
e. Hospital admission for IV antibiotics (admission only with
differential including deeper/necrotizing infection; severely
immunocompromised or non-compliant patient; non-response to
oral outpatient treatment; signs of systemic toxicity)

13
Cellulitis: Treatment
 It is important to recognize and treat cellulitis early as untreated
cellulitis may lead to sepsis and death
 The following guidelines are for empiric antibiotic therapy for
outpatients with:
• Nonpurulent cellulitis: treat for β-hemolytic streptococci (group A
streptococcus)  cephalexin, amoxicillin, amoxicillin-clavulanate,
dicloxacillin, or clindamycin
• Purulent cellulitis (purulent drainage or exudate without drainable
abscess)/injection drug use/other penetrating trauma/MRSA presence
elsewhere: Treat for community-associated MRSA and strep 
clindamycin, TMP/SMX, or doxycycline + amoxicillin; work with
dermatology and infectious disease specialists
• Unusual exposures: treat for additional bacterial species based on such
exposure; work with dermatology and infectious disease specialists
14
Cellulitis: Treatment (cont.)
 Monitor patients closely and revise therapy if there is a poor response to
initial treatment; usually a 5 day course of antibiotics is sufficient
 Treat underlying dermatologic disorder/condition, if present
 Elevation of the involved area
 Treat tinea pedis, toe maceration (strep or Gram negative infection) if
present
 For hospitalized patients: empiric therapy for MRSA should be
considered
 Cultures from abscesses and other purulent skin and soft tissue infections
(SSTIs) are recommended in patients to be treated with antibiotic therapy
but if case has a typical presentation, they need not be performed

15
MRSA Risk Factors
Healthcare-associated MRSA (HA-MRSA) and community-
associated MRSA (CA-MRSA) risk factors include:

• Antibiotic use • Proximity to others with MRSA

• Prolonged colonization or infection
hospitalization • Skin trauma
• Surgical site infection • Cosmetic body shaving
• Intensive care • Group facilities
• Hemodialysis • Sharing equipment that is not
• MRSA colonization cleaned or laundered between
users/body contact as in sports
16
Antibiotics Used to Treat MRSA
Dosage (adult
Drug dosing with normal Comments
renal function)
Excellent tissue and abscess penetration.
600 mg/kg IV Q8H
Clindamycin Risk for C. difficile
300-450 mg PO QID
Inducible resistance in MRSA
Trimethoprim- Unreliable for S. pyogenes (will need to
1 or 2 double-strength
Sulfamethoxazole combine with amoxicillin/equivalent to
tablets PO BID
(TMP/SMX) cover for group A strep)
Unreliable for S. pyogenes (will need to
Doxycyline, combine with amoxicillin/equivalent to
100 mg PO BID
minocycline cover for group A strep). Do not use in
children < 8 years old.
600 mg IV Q12H Expensive. No cross-resistance with
Linezolid
600 mg PO BID other antibiotic classes
30mg/kg/d in 2
Parenteral drug of choice for treatment of
Vancomycin divided
severe infections caused by MRSA
doses IV
17
Case Two, Question 1
Does this person have
cellulitis?
18
Yes- a type of cellulitis
called Erysipelas

19
Erysipelas
 Erysipelas is a superficial cellulitis with marked dermal lymphatic
involvement (causing the skin to be edematous or raised)
• Main pathogen is group A streptococcus
• Also caused by Staph aureus, Haemophilus spp, and others
 Usually affects the lower extremities and face
 Presents with pain, bright erythema, and plaque-like edema with
a sharply defined margin to normal tissue
 Plaques may develop overlying blisters (bullae)
 May be associated with a high white count (>20,000/mcL)
 May be preceded by chills, fever, headache, vomiting, and joint
pain
20
Example of Erysipelas

Large, shiny erythematous

plaque with sharply
demarcated borders located on
the leg

21
Case Two, Question 2

What is the most appropriate

treatment?
a. Oral antibiotics
b. Oral steroids
c. Topical antibiotics
d. Topical moisturizers
e. Topical steroids

22
Case Two, Question 2
Answer: a
What is the most
appropriate treatment?
a. Oral antibiotics
b. Oral steroids
c. Topical antibiotics
d. Topical moisturizers
e. Topical steroids
Oral antibiotics are the most appropriate
therapy in uncomplicated erysipelas.

23
Erysipelas: Treatment

 Immediate empiric antibiotic therapy should be

started (cover most common pathogen -
Streptococcus)
 Such as penicillin V, amoxicillin, clindamycin,
macrolide, and others
 Monitor patients closely and revise therapy if
there is a poor response to initial treatment
 Elevation of the involved area
 Treat tinea pedis, erythrasma, or strep of toe
spaces if present

24
Case Three
Mr. Jesse Hammel

25
Case Three: History
 HPI: Mr. Hammel is a 27-year-old man with a history of “skin
popping” (subcutaneous or intradermal injection of drug) who
presents to the emergency department with a painful, enlarging mass
on his right arm for the last two days.
 PMH: History of skin and soft tissue infections, hospitalized with
MRSA bacteremia two years ago
 Medications: none
 Allergies: no known drug allergies
 Family history: father with diabetes, mother with hypertension
 Social history: lives with friends in an apartment, works in retail
 Health-related behaviors: IVDU (intravenous drug use), including
skin popping. No tobacco or alcohol use.
 ROS: no fevers, sweats or chills

26
Case Three: Skin Exam

 Erythematous, warm,
fluctuant nodule with
several small pustules
throughout the surface
 Very tender to
palpation

27
Diagnosis: Abscess

 A skin abscess is a collection of pus within the

dermis and deeper skin tissues
 Present as painful, tender, fluctuant and
erythematous nodules
 May be have overlying pustule and be
surrounded by a rim of erythematous edema
 Spontaneous drainage of purulent material may
occur

28
Case Three, Question 1

What is the next best step in management?

a. Incision and drainage
b. Topical antibiotics
c. Offer HIV test
d. a and b
e. a and c

29
Case Three, Question 1

Answer: e
What is the next best step in management?
a. Incision and drainage (incision and drainage is the
treatment of choice for abscesses)
b. Topical antibiotics (not effective)
c. Offer HIV test (patients with risk factors for HIV
should be offered an HIV test, e.g. IVDU in this
patient)
d. a and b
e. a and c

30
Abscess: Treatment
 Abscesses require incision and drainage (I & D)
• Most experts recommend clearing pus and debris and probing the
entire cavity following incision and drainage
 Antibiotics are recommended for abscesses associated with:
• Severe or extensive disease (e.g., involving multiple sites)
• Rapid progression in presence of associated cellulitis
• Signs and symptoms of systemic illness
• Associated comorbidities or immunosuppression
• Extremes of age
• Abscess in an area difficult to drain (e.g., face, hand, or genitalia)
• Associated septic phlebitis
• Lack of response to I&D alone

31
Abscess: Treatment (cont.)
 Recommended oral antibiotics include:
clindamycin, TMP-SMZ, tetracyclines
 For hospitalized patients, consider vancomycin,
linezolid, daptomycin, or telavancin
 Wound cultures should be sent from purulence
and before antibiotics are started
 Patients with recurrent skin infections should be
referred to a dermatologist

32
Do you know the following
diagnoses?
HINT: Where are the bacteria and what are they
causing?

33
What is the diagnosis?

34
Furunculosis

 A furuncle (boil) is
an acute, round,
tender,
circumscribed,
perifollicular abscess
that generally ends
in central
suppuration

35
What is the diagnosis?

36
Carbunculosis

 A carbuncle is a
coalescence of
several inflamed
follicles into a single
inflammatory mass
with purulent
drainage from
multiple follicles

37
Furuncle, Carbuncle
 Furuncles and carbuncles are a subtype of abscesses, which
preferentially occur in skin areas containing hair follicles
exposed to friction and perspiration
• Common areas include the back of the neck, face, axillae, and
buttocks
 Usually caused by Staphylococcus aureus
 Patients are commonly treated with oral antibiotics
 For a solitary small furuncle: warm compresses to promote
drainage may be sufficient
 For larger furuncles and carbuncles: manage as you would an
abscess

38
More Examples:
Furuncle and Carbuncle

39
Case Four
Mr. Jeffrey Anders

40
Case Four: History
 Mr. Anders is a 19-year-old man who
presents to dermatology clinic with two
weeks of multiple “pimples” in his groin.
He is concerned he has an STD.
 When asked, he reports occasionally
shaving his pubic hair
 Sexual history reveals one female partner in
the last year

41
Case Four: Skin Exam

 Multiple follicular
pustules with
surrounding erythema
in the right groin

42
Case Four, Question 1
Which of the following recommendations would
you provide Mr. Anders?
a. Prescribe oral antibiotics
b. Stop shaving that area
c. Wash the area (antibacterial soap may be
used)
d. Check with his girlfriend to see if she has
any breakout
e. All of the above

43
Case Four, Question 1
Answer: e
Which of the following recommendations would
you provide Mr. Anders?
a. Prescribe oral antibiotics
b. Stop shaving that area
c. Wash the area daily (antibacterial soap may be
used)
d. Check with his girlfriend to see if she has any
breakout
e. All of the above

44
Folliculitis
 Folliculitis is a superficial bacterial infection of the hair
follicles
 Presents as small, raised, erythematous, occasionally
pruritic pustules less than 5 mm in diameter
 Genital folliculitis may be sexually transmitted
 Pathogens:
• Majority of cases are due to Staphyloccus aureus
• If there has been exposure to a hot tub or swimming pool,
consider Pseudomonas as a possible cause
• Pustules associated with marked erythema in the groin may
represent candidiasis

45
Folliculitis: Management
 Cleanse with antibacterial soap
 Superficial pustules will rupture and drain
spontaneously
 Oral or topical anti-staphylococcal agents as
mupirocin or retapamulin ointment; topical
clindamycin solution/lotion may be used
 Deep lesions of folliculitis represent small
follicular abscesses and should be drained

46
More Examples of Folliculitis

47
Case Five
Mr. Danny Holden

48
Case Five: History
 Mr. Holden is a 17-year-old man who presents
to his primary care provider with a three-week
history of a facial rash. The rash is not painful,
but occasionally burns and itches.
 About a month ago he babysat his 2 year old
niece and she had “a rash on the face.”
 He tried over the counter hydrocortisone
cream with no relief.

49
Case Five: Skin Exam
 Peri-oral vesicles, papules, and plaques
with overlying honey-colored crust
 Minimal surrounding erythema

50
Case Five, Question 1
What is the most likely diagnosis?
a. Acne vulgaris
b. Impetigo
c. Orolabial HSV
d. Seborrheic dermatitis
e. Tinea faciei

51
Case Five, Question 1
Answer: b
What is the most likely diagnosis?
a. Acne vulgaris (would expect comedones, papules, and pustules, but
not crusted plaques)
b. Impetigo
c. Orolabial HSV (would expect grouped and confluent vesicles with an
erythematous rim; can evolve to crusting and be confused with
impetigo)
d. Seborrheic dermatitis (would expect erythematous patches and
plaques with a greasy, yellow scale)
e. Tinea faciei (would expect erythematous, annular scaly plaques but often
are erythematous with slight scale)

52
Diagnosis: Impetigo
 Impetigo is a common superficial bacterial skin
infection
 Most commonly seen in children ages 2-5, but
older children and adults can be affected
 Impetigo is contagious, easily spread among
individuals in close contact
 Most cases are due to S. aureus with the remainder
either being due to Strep pyogenes or a
combination of these two organisms

53
Examples of Non-bullous Impetigo
 Also called impetigo
contagiosum; most
common form
 Lesions begin as papules
surrounded by erythema
 They progress to form
pustules that enlarge and
break down to form thick,
adherent crusts with a
characteristic honey-
crusted appearance
 Facial area is common
location

54
Example of Bullous Impetigo
 A form of impetigo seen in
young children is
characterized by flaccid
bullae with clear yellow
fluid, which later becomes
purulent
 Ruptured bullae leave a
thick brown crust
 Common locations are the
face, extremities, and diaper
area

55
Ecthyma
 Ecthyma is an ulcerative
papule or plaque which
extends through the
epidermis and into the
dermis
 Consist of “punched out”
ulcers covered with yellow
crust surrounded by raised
margins
 Heals slowly and may scar
 S. aureus and/or Strep
pyogenes may be the cause

56
Back to Case Five
Danny Holdon was diagnosed with non- bullous
impetigo based on clinical findings

57
Case Five, Question 2
Which of the following treatment recommendations
is most appropriate for Danny?
a. Hand washing to reduce spread
b. Topical or oral antibiotics
c. Wash the affected area with antibacterial
soap
d. Check to see if his niece still has her rash
e. All of the above

58
Case Five, Question 2
Answer: e
Which of the following treatment recommendations is
most appropriate for Danny?
a. Hand washing to reduce spread
b. Topical or oral antibiotics
c. Wash the affected area with antibacterial
soap
d. Check to see if his niece still has her rash
e. All of the above

59
Impetigo: Treatment
 Topical therapy with mupirocin or retapamulin
ointment may be equally effective to oral
antibiotics if the lesions are localized in an
otherwise healthy patient and there are not
multiple outbreaks in a family or group
 Otherwise, oral antibiotics are used

60
Impetigo: Treatment (cont.)
 Oral antibiotics are used to treat impetigo when it is
extensive or affecting several people (close contacts) and
for treatment of ecthyma
 Effective antibiotics include:
• Dicloxacillin
• Cephalexin
• Erythromycin (some strains of Staphyloccocus aureus
and Streptococcal pyogenes may be resistant)
• Clindamycin
• Amoxicillin/clavulanate
• If concern for MRSA, clindamycin, trimethoprim-
sulfamethoxazole, or doxycycline can be used

61
Case Six
Mr. Rodney Gorton

62
Case Six: History
 HPI: Mr. Gorton is a 68-year-old man who presented to outpatient surgery
for hernia repair. He reported that he had not been feeling well yesterday
but did not wish to cancel his surgery. On PE, he was febrile, tachycardic,
and found to have an expanding tender red rash on his left thigh. He was
admitted to medicine and the dermatology service was consulted for
evaluation of the rash.
 PMH: hypertension, diabetes mellitus type 2
 Medications: lisinopril, insulin, oxycodone
 Allergies: none
 Family history: noncontributory
 Social history: retired, lives with his wife
 Health-related behaviors: no alcohol, tobacco, or drug use
 ROS: fatigue, rash is very painful; deep bruise occurred last week while
cutting wood in area of rash; also had skin tear from branch

63
Case Six: Exam
 Vital signs: T 102.5, HR 110, BP 90/50, RR 20
 General: ill-appearing gentleman lying in bed
 Skin: ill-defined, large erythematous plaque with central dusky
blue patches, which are anesthetic; upon re- examination 60
minutes later the redness had spread; the subcutaneous tissue
had a woody induration

Andrews’ Diseases of the Skin Clinical Dermatology. 11th ed. Philadelphia, Pa: Saunders Elsevier;
2011. Image copyright Elsevier.

64
Case Six, Question 1
Which of the following would the
dermatologist recommend for initial
management?
a. An urgent surgery consult
b. IV fluids and narrow antibiotic coverage
c. Schedule an MRI for tomorrow
d. Schedule a skin biopsy in am
e. All of the above

65
Case Six, Question 1
Answer: a
Which of the following would the dermatologist recommend for initial
management?
a. An urgent surgical consult (necrotizing fasciitis is a surgical emergency)
b. IV fluids and narrow antibiotic coverage (do need IV fluids but also need
broad spectrum coverage initially)
c. Schedule an MRI for tomorrow (If MRI done, should be stat; could show
edema along fascial plane but sensitivity and specificity not well defined; never
delay surgery for MRI if necrotizing fasciitis is clinically suspected)
d. Schedule a skin biopsy in am (if biopsy done, should be an immediate deep biopsy;
if diagnosis is suspected and general surgeon is present, deep tissue can be obtained
during exploratory procedure; involved fascia would be edematous and dull gray
with areas of necrosis; should order Gram stain and C&S
e. All of the above (no, only a)

66
Necrotizing Fasciitis: Treatment
 Necrotizing fasciitis is a clinical diagnosis characterized by
rapidly progressing erythema, edema, fever, systemic
symptoms, crepitus, skin necrosis and ecchymosis. There is
local anesthesia over the plaque but overall severe pain out of
proportion to exam findings in some cases
 Poor prognostic factors include: delay in diagnosis, age>50, diabetes,
atherosclerosis, infection involving the trunk
 Necrotizing soft tissue infections can involve the skin, subcutaneous fat,
superficial or deep fascia, and/or muscle
 Considered a medical/surgical emergency with up to a 30-70%
mortality rate with group A Streptococcus
 If you suspect necrotizing fasciitis: consult surgery immediately
 Treatment includes widespread debridement and broad-spectrum
systemic antibiotics
 Do not delay treatment to obtain MRI

67
Take Home Points
 Cellulitis is a bacterial infection of the dermis that often begins
with a portal of entry such as a wound, insect bite, fungal
infection (tinea pedis), or maceration between toes
 Untreated cellulitis may lead to sepsis and death
 The differential diagnosis of lower extremity cellulitis
includes non-infectious etiologies
 Erysipelas is a superficial cellulitis with marked dermal
lymphatic involvement
 A skin abscess is a loculated infection within the dermis and
deeper skin tissues and is best treated with I&D
 Furuncles and carbuncles are subtypes of abscesses, which
preferentially occur in skin areas containing hair follicles
exposed to friction and perspiration

68
Take Home Points (cont.)
 Folliculitis is a superficial bacterial infection of the
hair follicles presenting as follicular pustules
 In impetigo, papules and vesicles progress to form
pustules that enlarge and break down to form thick,
adherent crusts with a golden or honey-colored
appearance; ecthyma is a deeper form of impetigo and
results in ulcers
 Necrotizing fasciitis presents as an expanding
dusky, edematous, red plaque with blue
discoloration with associated anesthesia
 Necrotizing fasciitis is a medical/surgical emergency

69
Acknowledgements
 This module was developed by the American Academy of
Dermatology Medical Student Core Curriculum Workgroup
from 2008-2012.
 Primary authors: Laura S. Huff, MD; Cory A. Dunnick, MD,
FAAD.
 Contributor: Sarah D. Cipriano, MD, MPH.
 Peer reviewers: Timothy G. Berger, MD, FAAD; Susan K.
Ailor, MD, FAAD, Daniela Kroshinsky, MD, FAAD.
 Revisions and editing: Sarah D. Cipriano, MD, MPH, Alina
Markova. Last revised August 2011.
 Revisions and editing: Susan K. Ailor, MD. Last revised Dec
2014.
 2018 Review and Update by Karolyn Wanat, MD. Peer Reviewed
by Kevin Luk, MD, and Joslyn Kirby, MD, MEd, MS.

70
References
 Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web-Based Illustrated
Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from:
[Link]/publication/462.
 Hirschman JV, Raugi GJ. Lower limb cellulitis and its mimics: Part I. Lower limb
cellulitis. J Am Acad Dermatol 2012 Aug, p163-175.
 Hirschman JV, Raugi GJ. Lower limb cellulitis and its mimics: Part II. Conditions that
simulate lower limb cellulitis. J Am Acad Dermatol 2012 Aug, p177-185.
 Drucker CR. Update on topical antibiotics in dermatology. Dermatologic Therapy
Jan/Feb 2012, 25(1), p 6-11.
 Paller AS, Mancini AJ, “Chapter 14: Bacterial, Mycobacterial, and Protozoal Infections of
the Skin. Hurwitz Clinical Pediatric Dermatology, 4th ed, Elsevier, 2011.
71
References
 James WD, Berger TG, Elston DM, “Chapter 14. Bacterial Infections”. Andrews’
Diseases of the Skin Clinical Dermatology. 11th ed. Philadelphia, Pa: Saunders
Elsevier; 2011: Fig Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions
for cellulitis and erysipelas (Review). Cochrane Library. 2010; 6.
 Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and
management of skin and soft tissue infections: 2014 update by the Infectious Disease
Society of America. Clin Infect Dis 2014; 59:e10-52.
 Saavedra Arturo, Weinberg Arnold N, Swartz Morton N, Johnson Richard A, "Chapter
179. Soft-Tissue Infections: Erysipelas, Cellulitis, Gangrenous Cellulitis, and
Myonecrosis" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS,
Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e.
 Stevens DL, Bryant AE. Necrotizing Soft-tissue Infections. N Engl J Med
2017; 377-2253.
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RESOURCES

• Thanks to the American Academy of

Dermatology for allowing use of their
digital teaching library.

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