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Bacterial Skin Infections

There are many kinds of skin infections, some common, some uncommon or even rare. Skin infections can be caused by bacteria, viruses, fungi or parasites. This handout will cover skin infections caused by bacteria.

Staphylococcus aureus (“Staph”) and Streptococcus pyogenes (“Strep”) are the bacteria that cause most skin infections. Examples discussed here include:

  • Impetigo
  • Folliculitis and furuncles
  • Abscesses
  • Cellulitis

What do bacterial infections look like on the skin?

Bacterial infections look different on the skin depending on how deep they are:

Impetigo

Impetigo is a superficial skin infection that is common in children. It may occur on any part of the body but is usually in areas that are not covered by clothes (face, neck, arms, hands, and legs). It starts as small, red bumps or pus-filled bumps. These break open and a yellow liquid dries on the skin and forms a “honey-colored” crust. Sometimes thin blisters form and leave behind round painful sores.

Folliculitis and furuncles

Folliculitis is a bacterial infection of the hair follicles. It usually is on skin covered by clothes such as the buttocks, thighs, and back. Folliculitis looks like small pimples or pus bumps on the hair follicles. When the bumps go away, small dark spots may be left behind. These fade over time. If the infection gets deeper in the hair follicle, painful red boils may form, and these are called furuncles.

Abscesses

An abscess is a painful, pus-filled lump under the skin. Abscesses can be anywhere on the body. They look like red boils, similar to furuncles, but larger. They can also be more painful. Pus may drain from the center. An abscess can make you sick with a fever.

Cellulitis

Cellulitis is a bacterial infection that is deeper in the skin. It usually occurs on the legs but can be anywhere including the face. The skin is red, warm, swollen, and painful. In more severe infections, pus-filled bumps or blisters can form on top. Red streaks near cellulitis may mean that the infection is spreading through the lymphatic system. Fevers and chills often occur.

How are bacterial skin infections spread?

  • Most bacterial skin infections are contagious and can be spread by skin contact with someone who has the infection.
  • Hot tubs or heated swimming pools that are not well treated may have bacteria that can cause “hot tub folliculitis.”
  • Bacteria can get into the skin through small injuries caused by scratching, cuts and scrapes, insect bites, eczema, and shaving.
  • While it is normal to have some bacteria in your nose, sometimes Staph bacteria lives there. This is called being “colonized.” This often causes no symptoms in the nose but can cause skin infections.

How are bacterial skin infections diagnosed?

Healthcare professionals can usually diagnose bacterial skin infections by how they look. Often a culture is taken by rubbing a swab on the crust, scab, liquid, or pus. The culture will show which type of bacteria is causing the infection, so that the right antibiotic can be prescribed.

How are bacterial skin infections treated?

Bacterial infections are treated with antibiotics. Which antibiotic is used depends on the type of bacterial skin infection.

  • Impetigo on a small area of skin can usually be treated with antibiotic ointment.
  • Impetigo that has spread or involves more areas of the skin is treated with oral antibiotics.
  • Folliculitis can be treated with antibacterial cleansers or lotions. Oral antibiotics are sometimes needed if it is widespread.
  • Furuncles and abscesses often need to be drained by a healthcare professional. Oral antibiotics and warm compresses may also be used.
  • Cellulitis is treated with oral antibiotics. If the cellulitis does not improve or is more severe, intravenous antibiotics may be needed.
  • If a skin infection does not get better with common antibiotics, it may be a MRSA infection or the lesion may require drainage and/or skin culture.

How do I know if I have a bacterial skin infection?

  • Red painful skin, sometimes around a cut, scrape or other skin injury
  • Pus or fluid leaking out of the skin
  • A painful, red, warm lump under the skin
  • Crusts or blisters with redness on the skin

What are the warning signs of a serious skin infection?

  • Redness, swelling and pain getting worse or larger
  • Red streaks spreading out from the infected area
  • Fever, feeling unwell

How can I prevent bacterial skin infection?

  • Keep hands clean by washing with soap and water.
  • Hands may also be cleaned using hand sanitizer. Rub hands together until they are dry.
  • Keep the nails trimmed.
  • Avoid sharing personal items, such as razors, loofahs, washcloths and towels.
  • Make sure that the temperature and chlorine in hot tubs and heated pools is checked frequently.
  • Remove swimsuits and shower after swimming.
  • Shower after sports.
  • Clean surfaces in the house that are touched a lot, like door knobs and counters.
  • Check pets for skin infections and treat them.

What can be done about recurrent skin infections?

Your healthcare professional may recommend:
  • Dilute bleach baths to decrease Staph bacteria on your skin. This is often used for children with eczema as they have more Staph bacteria on their skin than people without eczema.
  • Other antibacterial washes that have chlorhexidine or sodium hypochlorite may be recommended instead of bleach baths.
  • Antibiotic ointment applied inside the nose of the person who is getting infections. Family members or close contacts may also carry Staph bacteria inside the nose even without a history of infections. They need to be treated too.

Viral Skin Infections

WARTS (“Verruca Vulgaris”)

Warts are common viral infections caused by the human papilloma virus (HPV). There are many different strains of this virus causing different types of warts and specific tests are usually not necessary.

  • Warts are much more common in children than adults.
  • Warts can go away without treatment as our own immune system learns how to fight them. About 60% of warts will disappear within about 2 years.
  • There are many possible ways to treat warts and sometimes several different treatments are needed to get the warts to go away completely. There is no single perfect treatment for warts, and successful treatment can take many months. Your health care professional will help you find the right treatment tailored to your individual needs.
  • For in-office treatments, multiple visits are usually required.

Common “in-office” wart treatments

Cryotherapy. This is a cold spray (usually liquid nitrogen) used to freeze the wart.

Common “at-home” wart treatments

Over-the-counter wart treatment: Salicylic acid liquid, pads or tape (e.g., Dr. Scholl’s, Compound W, Duofilm, Mediplast)

  • Soak the warts in warm water for 5 minutes every night.
  • Gently file the surface of thick warts with a nail file or pumice stone used only for this purpose. Remember, warts are a virus that can be spread.
  • Apply the wart medicine directly to the warts, avoiding the normal skin (applying petroleum jelly to surrounding skin can help protect it).
  • Cover the wart medicine/pad/tape with duct tape. If using liquid salicylic acid, make sure it dries completely before applying the duct tape.
  • Leave the tape in place at least overnight or, if possible, for 24 hours.
  • Repeat these steps nightly until the wart is gone.
  • Expect the skin of the wart to appear moist and white during treatment. If the skin becomes too irritated, take a treatment break.
  • Do not use this medicine on the face or groin area unless instructed to do so by your physician.
Prescription treatments
  • Retinoids (adapalene, tretinoin, tazarotene) or imiquimod (Aldara) creams are sometimes used to treat flat warts or warts on the face and other sensitive anatomical areas. They are usually applied directly to the warts once a day for 2-4 months and can be irritating. These treatments should only be used as directed by your health care provider.
  • Systemic treatment with oral Ranitidine may help boost the immune system against the wart virus in patients, some of the time.

Molluscumcontagiosum

Molluscumcontagiosum is a viral skin infection seen most commonly in young to school-age children. It typically causes small bumps on the skin, which can occur anywhere on the body.

The virus is contagious and spread by direct contact with the skin of an infected person or sharing damp towels, clothing, personal items and gym mats (e.g., wrestlers, gymnasts, etc.) with someone who has Molluscum. Siblings bathing together and swimming together (especially when sharing kickboards and towels) also seem to be risk factors to develop the bumps, but this is not a reason to limit swimming.

What are molluscum?

Molluscum are usually small, flesh-colored to pink bumps with a shiny appearance and slightly depressed center. They can develop on the face, eyelids, trunk, extremities, and genitalia but usually do not involve the palms or soles. Molluscum bumps can only affect the skin and mucous membranes (fleshy lining of the eyes and
genitals) – the virus never affects the internal organs. Molluscum bumps are painless, but may be itchy and can last for several months to sometimes years.

After contact with the virus that causes them, molluscum may incubate for 2-8 weeks before appearing in the skin. Scratching or picking the bumps is one way the virus can be spread. Areas of the body where rubbing/friction of skin surfaces occurs (for example, the inner arm and sides of the belly) are common locations for molluscum infection.

Molluscum virus is extremely common in children, although it may more rarely be seen in adolescents and adults. It is especially common in warm environments as well as in children with eczema/ atopic dermatitis. In adults it may be considered a sexually transmitted infection, but this is generally NOT the case in kids. Similarly, people with HIV infection may develop severe viral infections including molluscum. By far, normal, healthy children are the most likely to have molluscum. In most cases, having the virus does not mean there is anything wrong with their immune system.

Diagnosis

Your doctor can make a diagnosis through a direct visual examination of the skin.

Prevention

As the virus is contagious through direct contact, it is best to take measures to avoid the spread of the virus.

  • Try to prevent your child from scratching or picking at the bumps. If eczema/ rash is forming around the bumps, topical steroid preparations can be helpful to reduce the inflammation and the urge to scratch.
  • Do not have children with molluscum bumps share towels or clothing; you may want to consider having siblings bathe separately.
  • Avoid direct contact with a known infection.
  • Molluscum is not dangerous. In general, it is not a reason a child should be held out of daycare or school activities.

Treatment

Once diagnosed, there are several methods of managing molluscumcontagiosum. The virus usually lasts for a period of several months to years and resolves on its own over time. If the bumps are not causing symptoms, many doctors recommend watchful waiting for improvement and resolution. Management options, such as no active treatment/monitoring alone, topical therapy, or direct destructive treatment, can be considered.

At-home topical therapies may include

Retinoids

These prescription topicals are used to irritate the surface of the skin, to help the body’s own immune system clear the virus sooner.

In office treatments that you provider may consider include

Liquid nitrogen

Directly freezing the molluscum bumps, similar to treatment for warts. While effective, this method is somewhat painful, thus limiting its application in young children with many bumps.

Curettage

Directly scraping the molluscum to remove them. This can be very effective in older kids and teenagers but is not generally performed in young children with many bumps.

Herpes

What is herpes?

Herpes is a viral skin infection caused by the herpes simplex virus (HSV). HSV infections are very common. HSV infections have different names depending upon the location on the body that is affected. It most commonly affects the lips and mouth (orolabial herpes or ‘cold sores‘), as well as genitalia (genital herpes). It can also affect fingertips (herpetic whitlow). In patients with active eczema, open areas can get infected with HSV (eczema herpeticum).

How do people get herpes?

Herpes is very contagious and spreads by direct contact with the affected skin or mucosa of a person who has HSV. HSV is most easily spread when someone has visible lesions affecting the mouth, genitals, or other skin sites. Occasionally, herpes can spread even if there are no visible sores and it may also live on surfaces contaminated with infected saliva or skin.

Once herpes simplex virus infects a person, the virus remains inactive in the surrounding nerves of that person. This inactive virus can reactivate and cause recurrent outbreaks in the same area that was initially infected. Stress, dehydration, sunburns and being sick are all triggers for an outbreak.

What does herpes look like on the skin and what are the symptoms?

Herpes looks like a cluster of tiny fluid-filled blisters that last anywhere between 4-10 days. It may leave a sore behind that takes longer to resolve. Symptoms related to herpes are different for each person. Some patients have painful outbreaks with many sores. Others only have mild symptoms that may go unnoticed. During the first outbreak (or primary infection), there may be fever, chills, muscle aches and swollen nodes before the herpes lesions appear. Recurrent outbreaks (or recurrent infection) are usually less painful and the number of outbreaks tends to decrease over time.

Orolabial herpes (‘cold sores’)

This is the most common type of herpes infection. It is usually caused by herpes simplex type 1 (HSV-1). The first outbreak, especially in children, can present with fever, irritability and difficulty feeding associated with several painful mouth sores.

Recurrent outbreaks usually start with tingling, itching, burning or a sensation of pain on the skin before the lesions appear. Small, fluid-filled blisters in clusters with red swollen skin develop shortly after. These later become crusted and heal without leaving scars. They often occur around the mouth or on the lips.

Genital herpes

This type is usually sexually transmitted and most commonly caused by herpes simplex type 2 (HSV-2). It presents as sores or grouped blisters on the genitals or buttocks. A stinging or burning feeling while urinating may be associated.

Herpetic whitlow

This herpes infection is more common in thumbsucking children who have oral herpes. It presents as painful fluid-filled blisters on red and swollen skin usually involving one or more fingertips. Commonly these can look infected, since the fluid inside the blisters can look like pus.

Eczema herpeticum

This affects infants and children who have active or poorly controlled eczema. The child will usually present with high fever and feel unwell. It starts with fluid-filled small blisters and round open areas which tend to spread to areas affected by eczema. Eczema herpeticum can be more severe than other forms of HSV and usually requires prompt care by a doctor, particularly if widespread or if it affects skin close to the eyes.

How is herpes simplex diagnosed?

A diagnosis may be made based on the appearance of skin changes alone. If the diagnosis is not clear, a skin swab may be needed. Young babies may require testing of other bodily fluids to confirm a diagnosis.

How is herpes simplex treated?

Some HSV infections are mild and treatment is not necessary. For these infections, the immune system will fight the virus naturally and skin changes resolve in 5-10 days. Your dermatologist may recommend treatment if infection is severe or recurrent; if the patient has a weakened immune system; or if pregnant with genital herpes.

HSV infections are treated with antiviral medications which fight the infection by affecting the way the virus multiplies. These medicines can be given to shorten the duration of an episode or taken daily to decrease the frequency of flare-ups. The most commonly used medicines are acyclovir and valacyclovir. They are most effective when given by mouth or through an IV and when treatment is started early in the infection. Unless otherwise instructed, you should complete the full course of prescribed medicine and contact your doctor if not improving.

Tips to prevent spread:
  • Do not touch an active site of infection.
  • Wash your hands frequently with soap and water.
  • If you have HSV infection, limit contact with at-risk individuals including those with a weakened immune system or eczema.
  • If the lips/mouth are affected, avoid contact with the affected area (e.g. kissing) and sharing items which come in contact with the mouth (e.g. spoons and forks).
  • If another skin site is affected, avoid direct contact with others including contact sports.
  • If the genitalia are affected, please discuss prevention with your doctor.

Chicken Pox

CHICKEN POX is a common, very itchy and highly contagious viral skin infection affecting children and young adults. It is caused by the Varicella-Zoster Virus (VZV). 90% of the reported cases occur in children less than 10 years of age. Its onset is marked with fever, which is often associated with fatigue, muscle aches, headaches, throat pain and eye congestion. Within 24 hours, the patient notices pink spots which rapidly turn into small fluid-filled blisters. These blisters can occur anywhere on the body, including scalp, genitals and inside the mouth; but are most numerous over the trunk. The diagnosis is made based on clinical appearance alone. Chicken pox is spread through inhalation and not direct skin to skin contact. Thus it is very common for a patient to not have any recollection of coming in contact with an infected individual.

The disease is contagious 1 day before the appearance of the rash to 6 days after. When the rash starts to scab, it becomes non-infectious. The symptoms of chicken pox are much more severe in adults, who will require anti – viral medication. The anti-viral medication will not completely stop the appearance of new rashes and blisters, but it will protect you from secondary infections like pneumonia and encephalitis. Consult your physician immediately if you have symptoms of breathlessness or chest pain. In children, the symptoms are quite mild and your dermatologist may decide to treat your child with paracetamol, vitamins and anti – histamines (for the itch) alone. You can continue to bathe, but you must remember to pat dry post-shower and not rub. Complete bed rest is essential, and you will have to take leave from your school or office since this is a communicable disease. Ask your dermatologist for a medical certificate.

Pregnant women with chicken pox, suspected chicken pox or who have been exposed to a child with chicken pox, MUST NOT neglect it. They should consult their dermatologists and obstetricians immediately.

Once you have had chicken pox, you will remain immune to it for the rest of your life. Second attacks are practically unheard of. However you are likely to develop SHINGLESon your next exposure to the VZV virus. This is because, even after you have recovered from the chicken pox, the VZV remains dormant in some of your nerve ganglions for several years. It gets activated again on a second exposure to the same virus, and can cause Shingles.

After the end of your treatment, and when all your lesions have scabbed, remember to wash all clothes and bed linen in hot water. Clean your room and furniture with an antiseptic like Lysol or Savlon. Do not itch and resist the urge to pick at your scabs, if you want to prevent marks and scars. The rashes are very superficial and will heal without scarring if they are cared for well and not picked at. Stay out of the sun. Do not skip meals. Drink plenty of water and get enough rest and sleep. You can continue to bathe.

Shingles (Medical term Herpes Zoster)

It is a highly contagious infection caused by the same virus which is responsible for chicken pox. It presents as blisters which appear on only one area and one side of the body. The blisters are preceded by pain and burning at the affected site. Zoster too becomes non-infectious when the blisters scab. But unlike chicken-pox, shingles can heal with scarring, pigmentation or persistent pain and burning over the affected site. Zoster is common in middle-aged individuals and complications are more likely in the elderly. It is important to treat zoster with anti-virals.

Vaccine – A single dose vaccine given under the skin can protect against Chicken pox. Individuals older than 13 years, will require a booster dose after 8 weeks. There is a separate single dose vaccine against Zoster as well. Vaccines only provide temporary protection but can protect you from severe illness and complications. Consult your Pediatrician for more information.

Fungal skin infections

What is Tinea?

Tinea is a fungal infection of the skin, hair or nails. These fungal infections are named for where they occur on the body. Some examples are:

  • Tineacapitis(scalp)
  • Tineacorporis(body)
  • Tineacruris(groin) – “jock itch”
  • Tineafaciei(face)
  • Tineapedis(feet) – “athlete’s foot”
  • Tineaunguiumor onychomycosis(nail)
Tinea is contagious

People usually get tinea by touching a person who has it. Family members and close contacts may pass the fungus back and forth. Wrestlers are particularly at risk because of skin contact during the sport. The fungus that causes tinea can also live on sheets, brushes, hats, damp floors, gym mats, in the soil, and on pets. People can get tineafrom touching these things too.

Some tips to prevent spreading tinea to others or back to yourself:

  • Avoid sharing combs, hair brushes, hats, pillowcases and towels.
  • Keep combs and hair brushes clean.
  • Towel dry well after baths or showers. Pay special attention to body folds and feet, including the skin between toes.
  • Wear sandals or flip flops in locker rooms, public showers and around the pool.
  • Change your socks at least once daily.

Why is tinea sometimes called “ringworm”? Is it caused by a worm?

On much of the body and face, tinea can look like a red, scaly ring. Because of the ringed shape, it is sometimes called “ringworm” even though it is not caused by a worm.

What does tinea look like on the body?

The appearance of tinea, as well as the symptoms, may be different on different parts of the body.

Tineacapitis (scalp):

The scalp may show flakes of skin resembling dandruff. There may also be pus bumps or patches of hair loss or broken hairs. In some people, the fungus causes more inflammation with redness, crusting and weeping on the scalp, and there may be enlarged lymph nodes in the neck (“swollen glands”). When hair loss occurs, it is usually temporary, and the hair will grow back. However, if the fungus has caused too much inflammation or scarring, the hair may not grow back completely.

Tineacorporis, faciei, and cruris (body, face and groin):

These are typically the areas where the name “ringworm” is used, as the fungal infection looks like a red, scaly ring with clearing in the center. Sometimes there are multiple rings or partial rings or rings that have come together to become irregular shapes, still with the edge being red and scaly and notably clear areas in the center.

Tineapedis (“athlete’s foot”):

The skin is usually moist and flaky between the toes. There are sometimes also the red, scaly rings on top of the toes and feet, as well as flaky skin on the bottoms or sides of the feet. Sometimes, blisters may be present.

Onychomycosis (nail fungus):

This type of fungus is more common in adults than in children. Children with onychomycosis frequently have a household member who also has nail fungus. In this type of tinea, the nails get thick and yellow, and there is a buildup of loose skin and fungus under the affected nails, especially at the outer edge of the nails.

Diagnosis and treatment

How is tinea diagnosed?

A healthcare professional can often diagnose tinea by doing a careful examination of your skin and nails. Special tests, such as a skin scraping or swab, KOH examination may be done to make or confirm the diagnosis. The fungus can sometimes be seen by looking at the scraping under the microscope. Culture of the sample at a lab is sometimes necessary and may take four to six weeks to be complete.

How is tinea treated?

There are a variety of over-the-counter and prescription medications to treat tinea infections. The type and length of treatment that is recommended or prescribed will differ depending on the type of tinea.

Tinea on the face, body, groin and feet is usually treated with medications that you apply directly to the skin (topical medications). These include creams, lotions and gels. These medications generally need to be used for several weeks. If the infection is extensive, oral antifungal medications may be needed.

Tineacapitis (scalp) and onychomycosis (nail fungus) usually need to be treated with prescription medications taken by mouth. These medications need to be taken for several weeks to months. Examples include griseofulvin, terbinafine, fluconazole and itraconazole. A medicated shampoo is also recommended for tineacapitis both for the person with the infection and people who live in the same house. The shampoo will not clear the infection but can prevent spread to other people.