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This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.

Ecthyma is an ulcerative pyoderma of the skin caused by group A beta haemolytic streptococci. As it extends into the dermis, it is often referred to as a deeper form of impetigo.

Epidemiology

There are no figures for incidence but it is more frequent in children and the elderly.
There is no apparent predilection for race or sex.

Risk factors

  • Tissue damage from excoriations, insect bites or dermatitis and a compromised immune system as in diabetes or neutropenia, predisposes to the development of ecthyma. Other causes of immune compromise may include malignancy and HIV.
  • Poor hygiene aids spread as does overcrowded living conditions.
  • It is commoner in hot and humid climates.
  • Untreated impetigo with poor hygiene may progress to ecthyma.
Presentation

Ecthyma begins like impetigo, possibly in a pre-existing wound.

Symptoms

  • Ecthyma usually arises on the lower legs or feet of children, diabetics, or neglected elderly people.
  • Lesions are typically painful with associated lymphadenopathy.
  • In tropical climates, ulcers are commonly found on the ankles and dorsum of the feet.

Signs

  • The most commonly affected sites are buttocks, thighs, legs, ankle and feet.
  • It starts as a vesicle or pustule over inflamed skin and then deepens to ulcerate with an overlying crust.
  • The crust is grey-yellow and is thicker and harder than the crust of impetigo.
  • A shallow, punched-out ulcer is seen if the crust is removed.
  • The deep dermal ulcer has a raised and indurated margin.
  • Ecthyma lesions may remain of constant size and resolve without treatment or they can enlarge to 3cm in diameter.
  • Ecthyma heals slowly, usually with a scar.
  • Regional lymphadenopathy is common, even with solitary lesions.
Differential diagnosis
  • Ecthyma gangrenosum (a similar condition caused by pseudomonas). It tends to be more severe and if diagnosis is delayed there is a significant mortality.
  • Contagious ecthyma is a term sometimes used for orf.
  • Also consider:
Investigations
  • Swab for bacteriology
  • Check for diabetes (at least urinalysis for glucose and preferably fasting blood glucose)
  • FBC for neutropenia
Associated diseases

It is more likely to occur in association with diabetes or other conditions of immune compromise.

Management

Non-drug

  • Treatment depends on the progression of the disease.
  • Hygiene is important. Use bactericidal soap and frequently change bed linens, towels, and clothing.
  • Remove crusts and apply an antibiotic ointment daily.1
  • Povidone iodine and hydrogen peroxide may be used as antiseptics.

Drugs

  • Topical mupirocin ointment is very effective. Fusidic acid is an alternative. Topical antibiotics are quite satisfactory2 if the infection is localised.
  • More extensive lesions require oral antibiotics, possibly for several weeks to obtain full resolution.
  • Penicillin should be adequate to treat streptococci.
  • If staphylococcus are also present an antibiotic resistant to penicillinase may be advised.3
  • Consider parenteral antibiotics if there is widespread involvement.

Surgical

Gently debride the crusts

Complications
Prognosis

Healing is slow with scar formation but response to appropriate antibiotics occurs over several weeks.

Prevention

In tropical climates, pay attention to hygiene and use insect repellents to reduce bites.


Document references
  1. Witkowski JA, Parish LC; Bacterial skin infections: management of common streptococcal and stapylococcal lesions. Postgrad Med. 1982 Oct;72(4):166-8, 171-3, 176-8 passim. [abstract]
  2. Leyden JJ, Kligman AM; Rationale for topical antibiotics. Cutis. 1978 Oct;22(4):515-20, 522-8. [abstract]
  3. Pichichero ME; Group A beta-hemolytic streptococcal infections. Pediatr Rev. 1998 Sep;19(9):291-302. [abstract]
  4. Patel GK; Treatment of staphylococcal scalded skin syndrome. Expert Rev Anti Infect Ther. 2004 Aug;2(4):575-87. [abstract]

Internet and further reading Acknowledgements EMIS is grateful to Dr Richard Draper for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
DocID: 2087
Document Version: 21
DocRef: bgp24593
Last Updated: 18 Jan 2009
Review Date: 18 Jan 2011

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.

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