• Clinical science

Skin and soft tissue infections

Summary

Skin and soft tissue infections comprise a group of heterogeneous conditions that primarily develop as a result of pathogens infiltrating the skin via minor injuries. Most skin infections are caused by Staphylococcus, but they may also be caused by Streptococcus or mixed infections in select cases. Risk factors include diabetes mellitus, immunodeficiency, and chronic edema. Skin and soft tissue infections primarily present as painful, warm, erythematous skin lesions. Systemic symptoms, such as fever and malaise, may also occur. Elevated inflammatory markers in the blood support the clinical diagnosis. Imaging may be considered to establish the extent and localization of infection. Treatment includes antibiotic therapy and immobilization of the affected area while severe cases and abscesses require surgery (debridement or incision and drainage). With the exception of necrotizing fasciitis, the majority of cases respond well to treatment and have a favorable prognosis. In the event of generalization, sepsis and spread of infection to local and distant sites may result.

Overview

General

Treatment of skin and soft tissue infections

  • Management principles
Mild infection Moderate infection Severe infection
Nonpurulent infections (erysipelas, cellulitis, necrotizing fasciitis)
  1. Surgical debridement (with culture and sensitivity testing)
  2. Empiric antibiotic treatment: vancomycin PLUS piperacillin/tazobactam [1]
Purulent infections (furuncle, carbuncle, abscess)
  • Incision and drainage
  1. Incision and drainage
  2. Empiric antibiotic treatment: TMP/SMX or doxycycline
  1. Incision and drainage
  2. Empiric antibiotic treatment covering MRSA: vancomycin or daptomycin or linezolid

Adapt antibiotic treatment according to the results of the culture and sensitivity testing.

References:[2][3][4][5][6][7]

Necrotizing fasciitis

Necrotizing fasciitis is a life-threatening condition! If necrotizing fasciitis is suspected, radiographic imaging should not, under any circumstances, delay surgical treatment!

References:[8][9][10][8][1][11]

Differential diagnoses

Pathogen Tissue involvement Clinical features
Impetigo
Staphylococcal scalded skin syndrome (generalized form of impetigo)
Erysipelas
Cellulitis
  • Rapidly spreading infection; erythematous skin lesion with indistinct margins
  • May present with or without purulent exudate
Skin abscess
  • Deeper layers of the skin
  • Walled-off infection with a collection of pus
Folliculitis
Necrotizing fasciitis

Skin involvement (from superficial to deep): impetigo (superficial epidermis), erysipelas (superficial dermis and lymphatic vessels), cellulitis (deep dermis and subcutaneous tissue), necrotizing fasciitis (superficial fascia).

The differential diagnoses listed here are not exhaustive.

Ecthyma gangrenosum

Folliculitis

References:[12][13][14][15][16][17]

Skin abscess

References:[16][9][18]

Erysipelas

The most common point of entry for the pathogen is a small skin lesion (e.g., interdigital tinea pedis).

References:[2][4][7][19][20]

Cellulitis

References:[21][4][9][22][23][24][25]

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  • 8. Edlich RF. Necrotizing Fasciitis. In: Bronze MS. Necrotizing Fasciitis. New York, NY: WebMD. http://emedicine.medscape.com/article/2051157. Updated August 9, 2016. Accessed January 27, 2017.
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  • 15. Pinney SS. Malassezia (Pityrosporum) Folliculitis. In: James WD. Malassezia (Pityrosporum) Folliculitis. New York, NY: WebMD. http://emedicine.medscape.com/article/1091037-overview#showall. Updated April 12, 2016. Accessed January 29, 2017.
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last updated 09/17/2020
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