CARING FOR COMMON SKIN CONDITIONS

Common Bacterial Skin Infections

DANIEL L. STULBERG, M.D., MARC A. PENROD, M.D., and RICHARD A. BLATNY, M.D.
Utah Valley Family Practice Residency, Provo, Utah

Family physicians frequently treat bacterial skin infections in the office and in the hospi-
tal. Common skin infections include cellulitis, erysipelas, impetigo, folliculitis, and furun-
cles and carbuncles. Cellulitis is an infection of the dermis and subcutaneous tissue that
has poorly demarcated borders and is usually caused by Streptococcus or Staphylococcus
species. Erysipelas is a superficial form of cellulitis with sharply demarcated borders and
is caused almost exclusively by Streptococcus. Impetigo is also caused by Streptococcus or
Staphylococcus and can lead to lifting of the stratum corneum resulting in the commonly
seen bullous effect. Folliculitis is an inflammation of the hair follicles. When the infection
is bacterial rather than mechanical in nature, it is most commonly caused by Staphylo-
coccus. If the infection of the follicle is deeper and involves more follicles, it moves into
the furuncle and carbuncle stages and usually requires incision and drainage. All of these
infections are typically diagnosed by clinical presentation and treated empirically. If
antibiotics are required, one that is active against gram-positive organisms such as peni-
cillinase-resistant penicillins, cephalosporins, macrolides, or fluoroquinolones should be
chosen. Children, patients who have diabetes, or patients who have immunodeficiencies
are more susceptible to gram-negative infections and may require treatment with a sec-
ond- or third-generation cephalosporin. (Am Fam Physician 2002;66:119-24. Copyright©
2002 American Academy of Family Physicians.)

B
This article is one in a acterial skin infections are the Lake City). Knowledge of the presentation,
series coordinated by 28th most common diagnosis in histopathology, and microbiology for each type
Daniel L. Sulberg,
hospitalized patients.1 Cellulitis, of infection is important for proper care of the
M.D., director of
dermatology curricu- impetigo, and folliculitis are the patient. The presentation, etiology, and current
lum at the Utah Valley most common bacterial skin management of these diseases are presented.
Family Practice Resi- infections seen by the family physician. The
dency, Provo, Utah. percentage of office visits for cellulitis was 2.2 Cellulitis
percent, and for impetigo, it was 0.3 percent, in Cellulitis is a painful, erythematous infec-
a cohort of almost 320,000 health plan mem- tion of the dermis and subcutaneous tissues
bers (data taken from primary physician diag- that is characterized by warmth, edema, and
nosis codes from January 1, 1999 to December advancing borders (Table 1). Cellulitis com-
1, 1999 for Intermountain Health Care, Salt monly occurs near breaks in the skin, such as
surgical wounds, trauma, tinea infections
(Figure 1), or ulcerations, but occasionally
TABLE 1
Descriptions of Bacterial Skin Infections

Disease Description

Carbuncle A network of furuncles connected by sinus tracts

Cellulitis Painful, erythematous infection of deep skin with poorly
demarcated borders
Erysipelas Fiery red, painful infection of superficial skin with sharply
demarcated borders
Folliculitis Papular or pustular inflammation of hair follicles
Furuncle Painful, firm or fluctuant abscess originating from a hair follicle
Impetigo Large vessicles and/or honey-crusted sores
FIGURE 1. Cellulitis secondary to tinea infection.

JULY 1, 2002 / VOLUME 66, NUMBER 1 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 119
 Marking the margins of erythema with ink is helpful in
following the progression or regression of cellulitis.

presents in skin that appears normal. Patients

may have a fever and an elevated white blood
cell count. Cellulitis can occur on any part of FIGURE 2. Inked margins of cellulitis.
the body. Among the patients in the cohort
above, the most common sites of cellulitis
were the legs and digits, followed by the face, have diabetes, immunocompromised patients,
feet, hands, torso, neck, and buttocks (data those with unresponsive infections, or in
taken from primary physician diagnosis codes young children.5 The patient may also require
from January 1, 1999 to December 1, 1999 for a plain radiograph of the area or surgical
health plan members of Intermountain debridement to evaluate for gas gangrene,
Health Care, Salt Lake City). osteomyelitis, or necrotizing fasciitis.6
In otherwise healthy adults, isolation of an Recurrent episodes of cellulitis or undergo-
etiologic agent is difficult and unrewarding. If ing surgery, such as mastectomy with lymph
the patient has diabetes, an immunocompro- node dissection, can compromise venous or
mising disease, or persistent inflammation, lymphatic circulation and cause dermal fibro-
blood cultures or aspiration (some physicians sis, lymphedema, epidermal thickening, and
inject sterile nonpreserved saline before aspira- repeated episodes of cellulitis. These patients
tion) of the area of maximal inflammation may benefit from prophylaxis with erythro-
may be useful.2-4 For infection in patients mycin, penicillin, or clindamycin (Cleocin).5,7
without diabetes, empiric treatment with a Periorbital cellulitis is caused by the same
penicillinase-resistant penicillin, first-genera- organisms that cause other forms of cellulitis
tion cephalosporin, amoxicillin-clavulanate and is treated with warm soaks, oral antibi-
(Augmentin), macrolide, or fluoroquinolone otics, and close follow-up.8 Children with
(adults only) is appropriate.5 Limited disease periorbital or orbital cellulitis often have
can be treated orally, but more extensive dis- underlying sinusitis.9 If the child is febrile and
ease requires parenteral therapy. Marking the appears toxic, blood cultures should be per-
margins of erythema with ink is helpful in fol- formed and lumbar puncture considered.
lowing the progression or regression of celluli- Haemophilus influenzae type b (Hib) in young
tis (Figure 2). Outpatient therapy with injected children was a significant concern until the
ceftriaxone (Rocephin) provides 24 hours of widespread use of the Hib vaccine and cover-
parenteral coverage and may be an option for age with a parenteral third-generation
some patients. The patient should be seen the cephalosporin was used routinely. Recently,
following day to reassess disease progression. some researchers have recommended no
Most cases of superficial cellulitis improve longer routinely covering for H. influenzae.8-10
within one day, but patients who exhibit Orbital cellulitis occurs when the infection
thickening of the dermis usually take several passes the orbital septum and is manifested by
days of parenteral antibiotics before signifi- proptosis, orbital pain, restricted eye move-
cant improvement occurs. Antibiotics should ment, visual disturbances, and concomitant
be maintained for at least three days after the sinusitis. Complications include abscess for-
resolution of acute inflammation.5 Adjunctive mation, persistent blindness, limited eye
therapy includes the following: cool com- movement, diplopia, and, rarely, meningitis.11
presses; appropriate analgesics for pain; This ocular emergency requires intravenous
tetanus immunization; and immobilization antibiotics, otorhinolaryngology, and ophth-
and elevation of the affected extremity.6 almologic consultation.12
A parenteral second- or third-generation Perianal cellulitis is caused by group A beta-
cephalosporin (with or without an aminogly- hemolytic streptococcal infection and occurs
coside) should be considered in patients who most often in children. A study13 of children

120 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 1 / JULY 1, 2002
 Skin Infections

dle aspiration of the site for bacteriology being

more accurate than a skin swab.14

Erysipelas
Erysipelas (Figure 3), also known as St.
Anthony’s fire, usually presents as an intensely
erythematous infection with clearly demar-
cated raised margins, and often with associated
FIGURE 3. Erysipelas. lymphatic streaking (Table 1). Common sites
are the legs and face.15 Most cases do not have
an inciting wound or skin lesion and are pre-
ceded by influenza-like symptoms. The inci-
dence of erysipelas is rising, especially in young
children, the elderly, persons with diabetes,
alcoholic persons, and patients with compro-
mised immune systems or lymphedema.6
Erysipelas is caused almost exclusively by
beta-hemolytic streptococcus and thus can be
treated with standard dosages of oral or intra-
venous penicillin. However, most physicians
treat this infection the same as cellulitis, which
is outlined earlier. Adjunctive treatment and
FIGURE 4. Nonbullous impetigo. complications are the same as for cellulitis.

Impetigo
Impetigo is most commonly seen in chil-
dren aged two to five years and is classified as
bullous or nonbullous (Table 1). The nonbul-
lous type predominates and presents with an
erosion (sore), cluster of erosions, or small
vesicles or pustules that have an adherent or
oozing honey-yellow crust. The predilection
for the very young can be remembered by the
common lay misnomer, “infant tigo.”
Impetigo usually appears in areas where there
FIGURE 5. Ruptured bullous impetigo. is a break in the skin, such as a wound, herpes
simplex infection, or maceration associated
with angular cheilitis (Figure 4), but Staphylo-
with perianal cellulitis found a mean age of coccus aureus can directly invade the skin and
onset of 4.25 years. Ninety percent of patients cause a de novo infection.6
presented with dermatitis, 78 percent with The bullous form of impetigo presents as a
itching, 52 percent with rectal pain, and 35 large thin-walled bulla (2 to 5 cm) containing
percent with blood-streaked stools. Despite 10 serous yellow fluid. It often ruptures leaving a
days of oral antibiotics (primarily penicillin or complete or partially denuded area with a ring
erythromycin), the recurrence rate was high at or arc of remaining bulla (Figure 5). More
39 percent. If there is recurrence, the presence than one area may be involved and a mix of
of an abscess should be considered, with nee- bullous and nonbullous findings can exist.

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 Studies now indicate that both forms of impetigo are primar-
ily caused by Staphylococcus aureus with Streptococcus usu-
ally being involved in the nonbullous form.

Nonbullous impetigo was previously thought alternatives.5 Broad-spectrum fluoroquino-

to be a group A streptococcal process and bul- lones have also been shown to be effective, and
lous impetigo was primarily thought to be several have been approved by the U.S. Food
caused by S. aureus. Studies16,17 now indicate and Drug Administration for treating skin
that both forms of impetigo are primarily and soft tissue infections.21 These medications
caused by S. aureus with Streptococcus usually have excellent skin penetration and good
being involved in the nonbullous form. If the bioavailability, but no generic forms are cur-
infection is a toxin-producing, phage group II, rently available, and they are only approved
type 71 Staphylococcus (the same toxin seen for use in adults.
in Staphylococcus scalded skin syndrome, a As with other diseases involving Strepto-
medical emergency where large sheets of the cocci, there is a small chance of developing
upper epidermis slough off), large bullae will glomerulonephritis, especially in children
form as the toxin produces intradermal cleav- aged two to six years. Presenting signs and
age.18 Otherwise, smaller bullae develop and symptoms of glomerulonephritis include
the honey-crusted lesions predominate. edema and hypertension; about one third of
A study19 published in 1990 concluded that patients have smoky or tea-colored urine.
topical mupirocin (Bactroban) ointment is as Streptococcal glomerulonephritis usually
effective as oral erythromycin in treating resolves spontaneously although acute symp-
impetigo. However, because the lesions of bul- toms and problems may occur.22
lous impetigo can be large and both forms of Impetigo can be spread by direct person-to-
impetigo can have satellite lesions, an oral person contact, so appropriate hygiene is war-
antibiotic with activity against S. aureus and ranted. Nasal carriage of S. aureus has been
group A beta-hemolytic streptococcal infec- implicated as a source of recurrent disease and
tion is warranted in nonlocalized cases. can be reduced by the topical application of
Because of developing resistance, erythro- mupirocin twice daily for five days.23
mycin is no longer the drug of choice.17
Azithromycin (Zithromax) for five days and Folliculitis
cephalexin (Keflex) for 10 days have been Hair follicles can become inflamed by phys-
shown to be effective and well-tolerated.20 ical injury, chemical irritation, or infection
Dicloxacillin (Pathocil), oxacillin (Pros- that leads to folliculitis (Table 1). Classifica-
taphlin), first-generation cephalosporins, or tion is by the depth of involvement of the hair
amoxicillin-clavulanate are also acceptable follicle. The most common form is superficial
folliculitis that manifests as a tender or pain-
less pustule that heals without scarring.24 The
The Authors hair shaft will frequently be seen in the center
of the pustule. Multiple or single lesions can
DANIEL L. STULBERG, M.D., is director of dermatology curriculum at the Utah Valley
Family Practice Residency in Provo, Utah. Dr. Stulberg received his medical degree from appear on any skin bearing hair including the
the University of Michigan Medical School, Ann Arbor, where he also completed a head, neck, trunk, buttocks, and extremities.
family practice residency. He also publishes a bimonthly e-mail dermatology quiz. Associated systemic symptoms or fever rarely
MARC A. PENROD, M.D., is a third-year and chief resident at the Utah Valley Family exist. S. aureus is the most likely pathogen;
Practice Residency. He received his medical degree from the University of Virginia however, commensal organisms such as yeast
School of Medicine, Charlottesville.
and fungi occasionally appear, especially in
RICHARD A. BLATNY, M.D., is in private family practice in Fairbury, Neb. He received his immunocompromised patients. These lesions
medical degree from the University of Nebraska College of Medicine, Omaha. Dr. Blatny
completed a family practice residency at the Utah Valley Family Practice Residency. typically resolve spontaneously. Topical ther-
apy with erythromycin, clindamycin, mupiro-
Address correspondence to Daniel L. Stulberg, M.D., Utah Valley Family Practice Resi-
dency, 1134 N. 500 West, Provo, UT 84604 (e-mail: [email protected]). Reprints are cin, or benzoyl peroxide can be administered
not available from the authors. to accelerate the healing process.25

122 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 1 / JULY 1, 2002
 Skin Infections

out from the follicle (Table 1). Commonly

known as an abscess or boil, a furuncle is a
tender, erythematous, firm or fluctuant mass
of walled-off purulent material, arising from
the hair follicle. These lesions may occur any-
where on the body, but have a predilection for
areas exposed to friction. Furuncles rarely
FIGURE 6. Folliculitis caused by contamination of
appear before puberty. The pathogen is usu-
undertreated water in a hot tub or whirlpool.
ally S. aureus. Typically, the furuncle will
develop into a fluctuant mass and eventually
Staphylococci will occasionally invade the open to the skin surface, allowing the purulent
deeper portion of the follicle, causing swelling contents to drain, either spontaneously or fol-
and erythema with or without a pustule at the lowing incision of the furuncle.
skin surface. These lesions are painful and Carbuncles are an aggregate of infected hair
may scar. This inflammation of the entire fol- follicles that form broad, swollen, erythema-
licle or the deeper portion of the hair follicle tous, deep, and painful masses that usually
(isthmus and below) is called deep folliculitis. open and drain through multiple tracts. Con-
Oral antibiotics are usually used in the treat- stitutional symptoms, including fever and
ment and include first-generation cephalo- malaise, are commonly associated with these
sporins, penicillinase-resistant penicillins, lesions but are rarely found with furuncles.
macrolides, and fluoroquinolones. With both of these lesions, gentle incision and
Gram-negative folliculitis usually involves drainage is indicated when lesions “point”
the face and affects patients with a history of (fluctuant or boggy with a thin shiny appear-
long-term antibiotic therapy for acne. ance of the overlying skin); caution should be
Pathogens include Klebsiella, Enterobacter, taken to not incise deeper than the pseudo
and Proteus species. It can be treated as severe capsule that has been built at the site of infec-
acne with isotretinoin (Accutane), but use of tion. Loculations should be broken with a
isotretinoin is associated with major side hemostat. The wound may be packed (usually
effects, including birth defects.26 with iodoform gauze) to encourage further
“Hot tub” folliculitis is caused by Pseudo- drainage. In severe cases, parenteral antibi-
monas aeruginosa contamination of under- otics such as cloxacillin (Tegopen), or a first-
treated water in a hot tub or whirlpool. Multi- generation cephalosporin such as cefazolin
ple pustular or papular perifollicular lesions (Ancef), are required.27 The physician should
appear on the trunk and sometimes extremities be aware of the potential for gas-containing
within six to 72 hours after exposure (Figure 6), abscesses or necrotizing fasciitis, which
and mild fever and malaise may occur. Lesions require immediate surgical debridement.
in the immunocompetent patient typically
resolve spontaneously within a period of seven Final Comment
to 10 days.25 Treatment is directed at prevention The majority of bacterial skin infections are
by appropriately cleaning the whirlpool or hot caused by the gram-positive bacteria Staphy-
tub and maintaining appropriate chlorine lev-
els (bromine and copper solutions are less
common alternatives) in the water. Nasal carriage of Staphylococcus aureus has been implicated
Furuncles and Carbuncles as a source of recurrent impetigo and can be reduced by the
Furuncles and carbuncles occur as a follicu- topical application of mupirocin.
lar infection progresses deeper and extends

JULY 1, 2002 / VOLUME 66, NUMBER 1 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 123
Skin Infections

lococcus and Streptococcus species. Antibi- 9. Barone SR, Aiuto LT. Periorbital and orbital cellulitis
in the Haemophilus influenzae vaccine era. J Pedi-
otics are used empirically with consideration atr Ophthalmol Strabismus 1997;34:293-6.
for resistance patterns. Current antibiotic rec- 10. Ambati BK, Ambati J, Azar N, Stratton L, Schmidt
ommendations include penicillinase-resistant EV. Periorbital and orbital cellulitis before and after
the advent of Haemophilus influenzae type B vac-
penicillins, first-generation cephalosporins, cination. Ophthalmology 2000;107:1450-3.
azithromycin, clarithromycin, amoxicillin- 11. Weiss A, Friendly D, Eglin K, Chang M, Gold B.
clavulanic acid, or a second-generation fluoro- Bacterial periorbital and orbital cellulitis in child-
hood. Ophthalmology 1983;90:195-203.
quinolone in the skeletally mature patient. 12. Martin-Hirsch DP, Habashi S, Hinton AH, Kotecha B.
Gram-negative coverage with a second-, Orbital cellulitis. Arch Emerg Med 1992;9:143-8.
third-, or fourth-generation cephalosporin is 13. Kokx NP, Comstock JA, Facklam RR. Streptococcal
perianal disease in children. Pediatrics 1987;80:
usually indicated in children under three years 659-63.
and in patients with diabetes or who are 14. Brook I. Microbiology of perianal cellulitis in chil-
immunocompromised. dren: comparison of skin swabs and needle aspira-
tion. Int J Dermatol 1998;37:922-4.
The photographs in Figures 1, 2, 4, and 5 were pro- 15. Chartier C, Grosshans E. Erysipelas: an update. Int
J Dermatol 1996;35:779-81.
vided by Utah Valley Family Practice Residency,
16. Barton LL, Friedman AD. Impetigo: a reassessment
Provo, Utah. The photographs in Figures 3 and 6 of etiology and therapy. Pediatr Dermatol 1987;
were provided by Richard Usatine, M.D., of the Uni- 4:185-8.
versity of California-Los Angeles, Los Angeles, Calif. 17. Misko ML, Terracina JR, Diven DG. The frequency
of erythromycin-resistant Staphylococcus aureus in
The authors indicate that they do not have any con- impetiginized dermatoses. Pediatr Dermatol 1995;
flicts of interest. Sources of funding: none reported. 12:12-5.
18. Edlich RF, Horowitz JH, Nichter LS, Silloway KA,
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