By U. Kliff. Albion College. 2019.

Acute acalculous cholecystitis is often caused by recent trauma purchase eriacta 100 mg, major surgery order eriacta discount, bacterial sepsis buy genuine eriacta on line, cardiovascular disease generic 100mg eriacta overnight delivery, diabetes, debilitating diseases, prolonged illness, multiple transfusions and administration of total parenteral nutrition. This itself in­ creases higher mortality rate and late diagnosis of acute cholecystitis. The most significant physical findings are fever and tenderness in the right upper quadrant of the abdomen. Cholescintigraphy, which is the best investigative procedure in case of acute calculous cholecystitis is also accurate in about 85% of these cases. Higher incidence of false positive scans have been reported, as radionuclide may not be able to enter the otherwise normal gallbladder if the bile is viscid. During operation, if possible operative cholangiography may be per­ formed to exclude possibility of passage of single gallstone into the common bile duct. In difficult cases one may perform cholecystostomy It must be remembered that mortality rate of acute acalculous cholecystitis is more than acute calculous cholecystitis because of the antecedent and concomitant conditions. Anyway symptoms of chronic cholecystitis when present with absence of stone in the gallbladder, found out by repeated ultrasonography, is a condition known as chronic acalculous cholecystitis. The treatment is again confusing, though cholecystectomy has been reported to relieve the symptoms. In this condition the red mucosa of the gallbladder is studded with tiny yellow flecks giving a typical picture of ripe strawberry. Sometimes the entire gallbladder may be involved and other times only one portion is involved. This condition represents a local disturbance in cholesterol metabolism and not associated with disturbance of the cholesterol level in the blood. A few views have been put forward to explain this condition -— (a) excessive abnormal absorption of cholesterol from the bile by the epithelial cells of the gallbladder causes this condition; (b) Lymphatic and venous stasis predispose to the accumulation of cholesterol absorbed from the bile contents; (c) Failure of the mucosa to secrete cholesterol results in an abnormal deposition of cholesterol within the mucosa and submucosa. Histologically there is distension of the mucosal folds with aggregation of round and polyhedral histiocytes within these mucosal folds. When the deposits become more massive these cells die with release of lipids giving rise to precipitation of cholesterol crystals in the subepithelial region. The yellow material is sometimes confined to the summit of the ridges and sometimes it can be traced down into the depth of the recesses. Cholesterol content of the mucosa of strawberry gallbladder is enormously in excess to that found in the normal organ. Occasionally focal collections of lipid-laden histiocytes may take the form of polyp formation, which are known as cholesterol polyps. Some inflammatory reaction with presence of white cells, giant cells and fibroblasts may be seen around Clinical features. When symptoms are present they are usually due to associated cholecystitis or gallstones. One or more cholesterol stones may be present, supposedly derived from the deposits in the mucous membrane. Oral cholecystography will show gallbladder with dense contrast medium and slightly blurred edge of the gallbladder. It may happen that the stones found in the common bile duct are larger than the diameter of the cystic duct. The pathogenesis of such stones is thought to be precipitation of unconjugated bilirubin as the calcium salt. When this soluble bilirubin glucuronide is deconjugated by beta-glucuronidase, an enzyme produced by the epithelium of the biliary tract and by bacteria such as E. Occasionally stones may lie dormant for many years in the bile duct giving rise to only vague indigestion (ii) Pain. Biliary colic is characterised by right hypochonodrial pain, ill localised and with variable radiation to the back (to the inferior angle of the right scapula) or to right shoulder. The pain is often not truely colicky; it is more obstructive in nature, of gradual onset, rising to a pick which is sustained for some hours or even a day or two and gradually subsiding. The pain is sometimes merely a discomfort, while in other cases it is excruciating. As the pain is intermittent and sometimes excruciating, they are often called colics. The ‘biliary colic’ is even less common as there is very little smooth muscle in the wall of the common bile duct. Jaundice will be inter­ mittent if the obstruction is partial, or it may be progressive if the stone becomes impacted in the distal duct. Sometimes in late cases symptoms of cholangitis are accompanied by shock and confusion. In the beginning the stone remains floating in the bile duct and later on it gets impacted. When the proximal duct dilates the stone again becomes loose, but subsequently impacts again. But the commonest site is in the supraduodenal part just above the upper margin of the first part of the duodenum. The second common site is the retroduodenal part and the third common site is in the ampulla of Vater. This law states that if in a jaundiced patient the gallbladder is enlarged and palpable, it is probably not a case of stone in the common bile duct, because in that case previous cholecystitis has already made the gallbladder fibrotic and small (when gallbladder is palpably enlarged in a case of jaundice, it is probably due to neoplastic obstruction in the distal part ofthe bile duct either Cancer at ampulla of Vater or Cancer at the head of pancreas). There are however a few exceptions of the law, where gallbladder may be enlarged not due to cancer of the head of the pancreas. Ultrasonography should be done to detect presence or absence of gallstone and dilatation of the bile ducts This is not reliable in the detection of common duct stones. This is a dangerous condition which will cause liver failure and even death if timely surgical intervention and antibiotic therapy are not initiated. This is noticed when the liver function becomes seriously depressed usually after 4 weeks of impaction of stones. The ‘white bile’ or ‘surgical bile’ is nothing but mucus secreted from the glands lining the bile duct. So the white bile is not bile in the true sense as it is not secreted by the liver. This is only seen after cellular damage of the liver due to mounting pressure within the bile duct. This is one stage ahead of white bile in the common bile duct and more commonly seen in cases of obstructive due to carcinoma of head of pancreas rather than due to stone in the common bile duct. But this is extremely rare Stone may pass to the retroperitoneal tissue and the perforation may be too small to be detected on opening the abdomen. Treatment is obviously to drain the common bile duct and also the peritoneal cavity or the retroperitoneal tissue as the case may be 5. Rarely stone may ulcerate through the bile duct into the duodenum to cause natural cure. Due to deficiency of bile salts in the distal ileum, Vitamin K is not absorbed properly and this leads to prothrombin deficiency. Glucose drink is advised to combat liver failure by forming excessive glycogen in the liver. Adequate Vitamins, particularly Vitamin B complex and Vitamin C should be offered. Blood transfusion, particularly fresh blood should be kept at hand to be used during operation if required. Mannitol may be given intravenously to promote diuresis and to prevent renal failure which is often seen in jaundiced patients. If the jaundice gradually subsides, one should wait for complete clearance when the operation should be performed. If the jaundice is persistent or even increasing and is not responding to conservative manage­ ment, operation may be justified and it should be restricted to only drainage of the bile duct and removing stones as quickly as possible. If this suggests stone in the common bile duct or if there are other indications of choledochotomy one should perform this operation. The indications for common duct exploration are : (i) When there is history of intermittent jaundice or biliary colic.

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One must always note the extent of the swelling in vertical and horizontal directions on the case note buy eriacta 100 mg overnight delivery. Black colour of benign naevus and melanoma order 100 mg eriacta with amex, red or purple colour of haemangioma (Fig generic 100 mg eriacta with visa. The shape of the swelling must be noted — whether it is ovoid eriacta 100mg with amex, pear-shaped, kidney-shaped, spherical or irregular. A swelling cannot be circular as we do not know about the deeper dimension of the swelling. To have first hand knowledge about the swelling, one must know the size of the swelling. On inspection, we shall miss the deeper dimension, but shall have the other two dimensions. These must be mentioned clearly in your history sheet the vertical and horizontal dimensions. The swellings, which lie just superficial to the artery in close relation with it, will be pulsatile. This pulsation is called transmitted pulsation, whereas those which originate from the arterial walls give rise to expansile pulsation. The patient is asked to cough and the swelling will be seen giving rise to an impulse while the patient is coughing. The skin becomes tense, glossy with venous promi­ nence, where the swelling is a sarcoma with rapid growth. Pigmentation of the skin is venous return of the upper limb leading to excessive seen in moles, naevi or after repeated oedema and wrist drop from nerve involvement. Presence of scar indicates either previous operation (when the scar is a linear one with suture marks), injury (a regular scar) or previous suppuration (when the scar is puckered, broad and irregular). Presence of ulcer on the skin over the swelling is examined as discussed in the next Chapter. An axillary swelling with oedema of the upper limb means the swelling is probably arising from the lymph nodes. Wasting of the distal limb indicates the swelling to be a traumatic one and the wasting is due to either non-use of the limb or due to injury to the nerves. This should immediately give rise to suspicion of possibility of retro-sternal prolongation of the swelling, giving rise to venous obstruction. The students must be very methodical in this examination and follow a definite order, which is given below, so that they would not miss any important examination. The students should also be very gentle in palpation not to hurt the patients and a few swellings may be malignant and may well spread into the system due to reckless handling. This examination should be done first in palpation, as manipulation of the swelling during subsequent examinations may increase the temperature without any definite reason. To elicit tenderness, one should be very gentle and should not give too much pain to the patient. Inflammatory swellings are mostly tender, whereas neoplastic swellings are not tender. The vertical and horizontal dimensions of the swelling are also better clarified by palpation. It is a good practice to mention in cm the vertical and horizontal diameters and should be sketched on the history sheet clearly indicating the position of the swelling as well. If a portion of the swelling disappears behind a bone, it should be clearly mentioned and its importance cannot Fig. The surface of a swelling may be smooth (cyst), lobular with smooth bumps (lipoma), nodular (a mass of matted lymph nodes) or irregular and rough (carcinoma). Sometimes the surface of the lump may be varied according to variable consistency. Broadly speaking, neoplastic swellings and chronic inflammatory swellings have well-defined margins. Benign growths generally have smooth margins whereas malignant growths have irregular margins. The most important finding, which differentiates benign tumour like lipoma from the cyst is that the margin of the former slips away from the palpating finger, but does not yield to it, whereas the margin of the latter yields to the palpating Fig. The fingers and cannot slip away from the margin of a cyst yields to the palpating finger and does not examining finger (Slip sign in Fig. The consistencies, just described, are all solid except the cystic one, which contains liquid within it. It should be borne in mind that consistency of a solid swelling may also be soft as seen in case of a lipoma. The fingers of the hand ‘P’ finger but slips away from it; but in case of a cystic swelling the will remain passive and perceive the edge yields to the pressure of the palpating finger and does not movement of the fluid displaced by the slip away. While palpating for consistency, one must look for whether the swelling is getting moulded or not to pressure. So the swelling must be a sebaceous cyst or a dermoid cyst or even an abdominal (colonic) swelling containing faecal mass. This means that there is oedematous tissue and most often the swelling is an inflammatory one. This will increase pressure within the cavity of the swelling and will be transmitted equally at right angles to all parts of its wall. In the first figure it is shown how a small swelling may pressure within the swelling be displaced as a whole by the displacing finger (D) and it shifts towards passively. Very often fluctuation the watching finger (W) to elicit a false sense of fluctuation even when is elicited in this manner in case the swelling is a solid one. The second figure is the correct method of of hydrocele, (iv) In case of very eliciting fluctuation in case of a small swelling. Two fingers of the left small swelling, which cannot hand (watching fingers ‘W’) are placed on two sides of the swelling and the index finger of the right hand (displacing finger ‘D’) is pressed accommodate two fingers, this on the swelling to displace the fluid within the swelling. The swelling containing fluid, will be softer at the centre than its periphery, while a solid swelling will be firmer at the centre than its periphery. This test should be done in two planes at right angles to one another as the conventional method. The students should not try to perform traditional fluctuation test on a small swelling, as pressure exerted by one finger, will simply displace the swelling and fluctuation test cannot be performed, (v) For very large swelling more than one finger of each hand are used. Two or even three fingers may be used for providing pressure (displacing fingers) and palmar aspect of four fingers of the other hand may be used to perceive the movement of displaced fluid (watching fingers), (vi) Very soft swellings sometimes yield false positive sense in fluctuation test. The swellings which can be included in this list are : lipoma, myxoma, soft fibroma, vascular sarcoma etc. But if the students become careful while performing the fluctuation test, they will easily realise that these swellings yield to pressure, but fail to expand in other parts of the swelling like a true fluctuant swelling. In case of a big swelling, this can be demonstrated by tapping the swelling on one side with two fingers while the percussion wave is felt on the other side of the swelling with palmar aspect of the hand. In case of a small swelling, three fingers are placed on the swelling and the middle finger is tapped Fig. A swelling may be fluctuant as it contains fluid, but may not be translucent when it contains opaque fluid, such as blood or pultaceous material (dermoid or sebaceous cyst). In day time, this can be achieved by a roll of paper, which is held on one side of the swelling, while a torch light is held on the other side of the swelling. The torch light should not be kept on the surface of the swelling, but on one side of the swelling, while the roll of paper on the other side so that the whole swelling intervenes between the light and the roll of paper. The swellings, which are likely to give rise to impulse on coughing, are: (i) those, which are in continuity with the abdominal cavity (e. Due to coughing, pressure is increased within the abdominal, pleural, spinal and cranial cavities. This increase in pressure is transmitted to the swelling, where the impulse is felt. The compressible swellings may not have connections with the abdominal, pleural, spinal or cranial cavity. The most important differentiating feature between a compressible swelling and a reducible swelling is that in case of the latter, the swelling completely disappears as the contents are displaced into the cavities from where they have come out and may not come back until and unless an opposite force, such as coughing or gravity is applied. But in case of the former, the contents are not actually displaced, so the swelling immediately reappears as soon as the pressure is taken off. Two fingers, one from each hand, are placed on the swel­ ling as far apart as possible (Fig. When the two fingers are not only raised, but also separated with each beat of the artery, the pulsation is said to be an ‘expansile’ one. When the two fingers are only raised, but not separated, the pulsation is said to be ‘transmitted’.

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Hemostat and Ligature Pass the Mixter clamp behind the vessel again order eriacta 100mg overnight delivery, feed a second ligature into its jaws order 100 mg eriacta overnight delivery, and ligate the distal portion of the ves- A hemostat of the proper length and design is a suitable sel buy eriacta 100mg cheap. Divide the vessel purchase generic eriacta on line, leaving a 1 cm stump distal to the instrument for occluding most bleeding vessels, followed by proximal tie and about 0. Leaving a ligature of a size compatible with the diameter of the ves- a long stump of vessel distal to a single tie of 2-0 silk pre- sel. As demanded by the situation, hemostats the size of a vents the ligature from slipping off, even when it is subjected Halsted, Crile, Adson, Kelly, or Mixter may be indicated (see to the continuous pounding of arterial pulse waves. Silk provides greater security when tying major ves- sels, such as the left gastric or inferior mesenteric artery. If the splenic artery is being divided and Two simple ligatures of 2-0 silk placed about 3 mm apart, ligated during resection of a pseudocyst of the pancreas, use with a free 1 cm stump distal to the ligatures, ensure a 2-0 ligature of Prolene. If there is not a sufficient length of artery to meet these conditions, a 2-0 silk ligature supple- Tying “In Continuity” with a Ligature Passer mented by insertion of a transfixion suture ligature that pierces the wall of the artery 3 mm distal to the simple liga- When ligating large vessels such as the inferior mesenteric, ture is almost as good as a free 1 cm arterial stump. Pass the ileocolic, or left gastric artery, it is convenient to pass a blunt- suture part of the way through the vessel wall rather than tipped right-angle Mixter clamp behind the vessel. This maneuver avoids bleeding tip of the clamp separates the adventitia of the artery from through the needle hole. This problem may occur on the sur- passer, which consists of a long hemostat holding the 2-0 silk face of the pancreas, where attempts to grasp a retracted ves- sel with hemostats can be much more traumatic than a small figure-of-eight suture of atraumatic 4-0 silk. Chassin Hemostatic Clips a large grounding electrode placed on the patient’s thigh or back. Two types of current are supplied by most electrocau- Metallic hemostatic clips offer a secure, expedient method tery generators: cutting and coagulating. Cutting current is for obtaining hemostasis, provided the technique is properly continuous-wave, high-frequency, relatively low-voltage applied. It produces rapid tissue heating, which allows the ference of a vessel is visible, preferably before the vessel has blade of the cautery to cut through tissue like a scalpel. Coagulating current is pulsed- incomplete occlusion of the vessel and continued bleeding, waveform, low-frequency, high-voltage current that heats following which the presence of the metal clip obstructs any tissues slowly. The resulting protein coagulation seals small hemostat or suture ligature in the same area. The resulting coaptive coagula- tion, such as when performing a Kocher maneuver, the sub- tion seals the front and back wall of the collapsed vessel sequent surgical maneuvers often dislodge the clips and together. Small punctate bleeders may be secured by touch- lacerate the vessels, producing annoying hemorrhage. Hemostatic clips may similarly interfere with application of Bipolar cautery units generally have a forcepslike con- a stapling device. It is It is futile to apply multiple clips in the general area from less useful, however, for cutting. Again it must be emphasized that applying a clip is stasis, provided certain contraindications are observed. As with hemostatic clips, In the absence of these contraindications, hemostatic clips any tissue that will subsequently be subjected to blunt dissec- speed dissection and allow secure control of bleeding ves- tion or retraction may not be suitable for electrocautery, as the sels. An example is in the mediastinum during esophageal friction often wipes away the coagulum, causing bleeding to dissection or in the retroperitoneal area during colon resume. Similarly, when many subcutaneous bleeding points are subjected to electrocoagulation, the extensive tis- Staplers sue insult may contribute to wound infection. Laparoscopic surgeons are familiar with use of staplers, loaded with “vascular cartridges,” for control of vessels too Ultrasonic Shears large to securely clip or ligate. These staplers are gradually making their way into common use during open surgery as Ultrasonic shears were initially introduced for minimal well. These devices use ultrasound to They appear particularly useful for large diameter veins such heat and coagulate tissue in a coapted position. The tissue is as the adrenal vein during adrenalectomy or the splenic vein then cut with the device or with scissors. Physicochemical Methods Electrocautery Gauze Pack With electrocautery a locally high current density is passed Physical application of a large, moist gauze pad has been through the target tissues to achieve rapid tissue heating. It Monopolar cautery devices allow the surgeon to cut or cau- enhances the clotting mechanism because pressure slows terize with a bladelike tip. The return current path is through down the loss of blood, and the interstices of the gauze help 6 Control of Bleeding 47 form a framework for the deposition of fibrin. Unfortunately, Control of Hemorrhage after the gauze pack is removed, bleeding sometimes resumes. Packing has been lifesaving after major hepatic Temporary Control trauma or for persistent pelvic bleeding during abdomino- perineal resection, particularly when the patient has become During the course of operating, the equanimity of the surgeon is cold or developed a coagulopathy. Packs may be left in and jarred occasionally by a sudden hemorrhage caused by inadver- removed after 24 h when the patient is stable and all hemo- tent laceration of a large blood vessel. The sequence should go something like the following: A variety of topical hemostatic agents are available in pow- 1. They vary in chemical formula- controlling bleeding from an artery, is simple application tion, but most are collagen or cellulose derivatives and act as of a fingertip to the bleeding point. In the case of a large a matrix and stimulant for clot formation; thus, the patient vein, such as the axillary vein or vena cava, pinching the must be able to form clot for these agents to work. It is wise laceration between the thumb and index finger is some- to remember the old axiom that topical agents work best in a times effective. Ascertain that the patient is fully stop oozing but do not substitute for definitive hemostasis of resuscitated, that large-bore intravenous catheters are in individual bleeding vessels. References at the end give fur- place, and that blood and blood products are available. When the pack is removed 10–15 min later, step 1 is not applicable, sometimes the left hand can be the topical hemostatic agent remains adherent to the surface, placed behind a structure such as the hepatoduodenal preventing disruption of the coagulum that is forming under- ligament to control bleeding from the cystic artery or the neath. Choice of an agent is dictated in part by the physical pancreas or behind the portal vein for bleeding in that geometry of the bleeding site (powders are best for irregular area. Avitene (microfibrillar collagen) comes in powdered form Large lacerations of the liver may be temporarily con- to be sprinkled on a bleeding surface, or it can be applied trolled by compressing the liver between two hands while with clean, dry forceps. Massive venous bleeding gloves that come into contact with Avitene causes the Avitene from the presacral space can be controlled by applying a to stick to the moist instrument rather than to the bleeding large gauze pad. When direct pressure is not effective, a layer should be applied and pressure exerted over it. When partially occluding Satinsky-type vascular clamp may be flat surfaces of a denuded spleen or gallbladder bed are ooz- used to control the laceration of a large vessel. Avitene is better for irregular surfaces control of hemorrhage is impossible without proximal and because it is a powder. Microfibrillar collagen and oxidized distal occlusion of the vessel, in some cases involving the cellulose are valuable when some portion of the splenic cap- aorta or vena cava. Preferably, vascular clamps are used; sule has been avulsed during a vagotomy or splenic flexure but in their absence, umbilical tape is a satisfactory tempo- mobilization. The aorta may even be clamped or occluded by pressure in a suprarenal position for 15–20 min if no Fibrin Sealant other means of hemostasis is effective. This safe period Fibrin sealant is a hemostatic agent that mimics the final may be lengthened if iced sterile saline is poured over the stage of blood coagulation. There is no current consensus on the usefulness of this D e fi nitive Control agent in general surgical practice, although it is an area of active investigation. See references at the end for further Once hemorrhage has been temporarily controlled, the sur- information on these adjuncts. Chassin of all instruments and hemostats not relevant to the major geon should undertake to perform major surgery unless problem at hand. If additional exposure is needed, plans trained and experienced in suturing large arteries and veins. Optimal light and suction lines are put in place, and Further Reading arrangements are made with the blood bank for adequate support of the patient. Frequency and characteristics of coagulopathy in trauma patients treated with a low- or high-plasma- as necessary. Coagulation After all these steps have been completed and the patient’s management in multiple trauma: a systematic review. This step generally involves apply- vessel sealing among new electrosurgical and ultrasonic devices. Laparoscopic hemostasis: hemostatic products achieving proximal and distal control with vascular clamps, and adjuncts.

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Griseofulvin must be used for 6 to 12 months in the treatment of fingernails and has much less antifungal efficacy than terbinafine 100 mg eriacta with visa. Griseofulvin is no longer recommended in the treatment of onychomycosis of the toenails cheap eriacta express. There is no clear difference in efficacy or adverse effects between them when used topically buy eriacta 100mg low cost. Ketoconazole has more adverse effects when used systemically eriacta 100 mg amex, such as hepatotoxicity and gynecomastia. Fluconazole is also less efficacious for dermatophytes of the nails when used systemically. Antifungal medications generally should not be used in combination with topical steroids, unless a diagnosis has been confirmed. Steroids in a cream can relieve redness and itching and give the appearance of improvement even in impetigo and contact dermatitis. Tinea versicolor Tinea versicolor is a skin infection characterized by multiple macules (usually asymptomatic), varying in color from white to brown. It presents with lesions of different colors from tan to pink (hence the name versicolor). The lesions often do not tan, and they present with pale areas in the middle of a normal tan. This can be distinguished from vitiligo by the fact that vitiligo has no pigmentation, whereas tinea versicolor presents with altered pigmentation. The main therapeutic difference is the use of topical selenium sulfide every 2 to 3 weeks versus oral therapy with itraconazole or fluconazole. This is not because of antifungal resistance; it is because tinea versicolor is much more likely to involve large amounts of body surface area so it is difficult to cover this volume of skin with an ordinary topical cream or lotion. Tan, brown, or white scaling macular lesions that tend to coalesce; found on chest, neck, abdomen, or face. Treat with topical selenium sulfide, clotrimazole, ketoconazole, or oral itraconazole. Candidiasis Candidiasis is a yeast infection usually involving skin and mucous membranes, but it can also be systemic. Clinical Presentation Intertriginous infection: Well-demarcated, erythematous, itchy, exudative patches, usually rimmed with small red-based pustules that occur in the groin, gluteal folds (diaper rash), axilla, umbilicus, and inframammary areas. Vulvovaginitis: White or yellowish discharge with inflammation of the vaginal wall and vulva. Oral candidiasis (thrush): White patches of exudates on tongue or buccal mucosa Candidal paronychia: Painful red swelling around the nail Diagnosis. Treatment Topical nystatin, clotrimazole, miconazole, ciclopirox, econazole, or terconazole Systemic amphotericin in serious invasive infections. Antibiotics used to treat Staphylococcus are dicloxacillin, cephalexin (Keflex™), or cefadroxil (Duricef™). If a patient is allergic to penicillin, but the reaction is only a rash, then cephalosporins can be safely used. The alternative antibiotics that will treat the skin are macrolides, such as erythromycin, azithromycin, clarithromycin, or the newer fluoroquinolones (levofloxacin or moxifloxacin). Impetigo Impetigo is a superficial, pustular skin infection, seen mainly in children (ecthyma is an ulcerative form of impetigo), with oozing, crusting, and draining of the lesions. It is a superficial bacterial infection of the skin largely limited to the epidermis and not spreading below the dermal-epidermal junction. Because it is limited to the epidermis, the purulent material is easily able to express itself through the surface; therefore, the patient history will describe the infection with words such as “weeping,” “oozing,” “honey colored,” or “draining. More common on arms, legs, and face May follow trauma to skin Begins as maculopapules and rapidly progresses to vesicular pustular lesions or bullae. The crusts are described as having a golden or yellow appearance and if untreated can progress to lymphangitis, furunculosis, or cellulitis, and acute glomerulonephritis. Erysipelas involves both the dermis and epidermis and is most commonly caused by group A Streptococcus (pyogenes). Because it involves lymphatic channels in the dermis, erysipelas is more likely to result in fever, chills, and bacteremia. Often involves the face, giving a bright red, angry, swollen appearance Usually bilateral, shiny red, indurated edematous tender lesions on the face, arms, and legs Lesions are often sharply demarcated from the surrounding normal skin Differentiate from herpes, contact dermatitis, and angioneurotic edema Treatment. Semisynthetic penicillin or first-generation cephalosporin if you cannot distinguish it from cellulitis; penicillin (if Streptococcus is certain). Cellulitis Cellulitis is a bacterial infection of the dermis and subcutaneous tissues with Staphylococcus and Streptococcus. Cellulitis is characterized by redness, swelling, and warmth and tenderness of the skin. Because it is below the dermal-epidermal junction, there is no oozing, crusting, weeping, or draining. Cellulitis is treated with the antibiotics prescribed for erysipelas on the basis of the severity of the disease. Treatment is generally empiric because injecting and aspirating sterile saline for a specific microbiologic diagnosis has only a 20% sensitivity. Folliculitis, furuncles, and carbuncles Folliculitis, furuncles, and carbuncles represent 3 degrees of severity of staphylococcal infections occurring around a hair follicle. Occasionally, folliculitis can be the result of those who contract Pseudomonas in a whirlpool or from a hot tub. As folliculitis worsens from a simple superficial infection around a hair follicle, it becomes a small collection of infected material known as a furuncle. When several furuncles become confluent into a single lesion, the lesion becomes known as a carbuncle, which is essentially a localized skin abscess. Folliculitis is rarely tender, but furuncles and carbuncles are often extremely tender. Folliculitis mainly can be treated with warm compresses locally without the need for antibiotics. Furuncles and carbuncles require treatment with systemic antistaphylococcal antibiotics, and in the case of carbuncles, should be administered intravenously. Necrotizing fasciitis Necrotizing fasciitis is an extremely severe, life-threatening infection of the skin. Streptococcus and Clostridium are the most common organisms because they are able to produce a toxin that further worsens the damage to the fascia. The features which distinguish necrotizing fasciitis from simple cellulitis are a very high fever, a portal of entry into the skin, pain out of proportion to the superficial appearance, the presence of bullae, and palpable crepitus. All of these lab methods of establishing a diagnosis lack both sensitivity and specificity. Surgical debridement is the best way to confirm the diagnosis and is also the mainstay of therapy. The best empiric antibiotics are the beta-lactam/beta-lactamase combination medications, such as ampicillin/sulbactam (Unasyn™), ticarcillin/clavulanate (Timentin™), or piperacillin/tazobactam (Zosyn™). If there is a definite diagnosis of group A Streptococcus (pyogenes), then treat with clindamycin and penicillin. Paronychia Paronychia is an infection loculated under the skin surrounding a nail. It is generally treated with a small incision to allow drainage and with antistaphylococcal antibiotics. The antistaphylococcal antibiotics are dicloxacillin, cefadroxil, or cephalexin orally, or oxacillin, nafcillin, or cefazolin intravenously. The vesicles are usually obvious by examination, and antibiotic therapy should be initiated immediately without waiting for results of the tests. Topical acyclovir has extremely little efficacy; it will slightly improve resolution in primary lesions and will do absolutely nothing for recurrent herpes simplex lesions. Topical penciclovir has some use for oral herpetic lesions, but it must be applied every 2 hours. Herpes Simplex Lip Centers for Disease Control and Prevention Herpes zoster/varicella Chickenpox is primarily a disease of children. Episodes of dermatomal herpes zoster, also known as shingles, occur more frequently in the elderly and in those with defects of the lymphocytic portion of the immune system (i.

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