Primary Pyodermas

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Superficial skin infections, also called primary pyodermas, are the most common skin infections occurring in all age groups. These include impetigo, folliculitis, furuncles, carbuncles, and paronychia. Most of these infections are caused by group A streptococci or by Staphylococcus aureus. Pseudomonas aeruginosa is a cause of hot tub folliculitis, an infection associated with recreational use of contaminated whirlpools and hot tubs resulting in a self-limited pruritic papular eruption in a characteristic bathing suit distribution. Some cases of folliculitis and paronychia are caused by Candida albicans.

S. aureus colonizes the anterior nares in 20-40% of the normal population. The rate of nasal S. aureus colonization is increased in insulin-dependent diabetics, patients undergoing hemodialysis, individuals receiving allergy injections, and in intravenous drug users. Because the elderly often have coexisting diabetes mellitus or renal insufficiency, it is not surprising that asymptomatic nasal S. aureus carriage may be increased in the older patient.

From: Infectious Disease in the Aging Edited by: Thomas T. Yoshikawa and Dean C. Norman © Humana Press Inc., Totowa, NJ

Table 1

Skin and Soft-Tissue Infections in the Elderly

Type Major pathogens Other pathogens

Primary Staphylococcus aureus, Pseudomonas aeruginosa, pyoderma Group A streptococci Candida spp.

Erysipelas/ cellulitis

Group A streptococci,

S. aureus

Group B, C, G streptococci, Vibrio vulnificus, Aeromonas hydrophila, Erysipelothrix, Pasteurella multocida,

Necrotizing cellulitis/ fasciitis

Group A streptococci, Enterobacteriaceae

Bacteroides spp. Mycobacterium ulcerans

Infected ulcer Streptococci, Klebsiella,

S. aureus, Enterobacter

Escherichia coli

Colonization and infection with methicillin-resistant S. aureus (MRSA) has also become a problem in acute care hospitals, chronic care facilities, and hemodialysis units (2). It is not known why infection with staphylococci develops in some individuals and not in others, but it seems likely that the presence of chronic diseases, wounds, especially skin ulcers, debilitation, and nasal S. aureus carriage are all predisposing factors.

In the elderly, localized skin infections due to S. aureus include folliculitis, furuncles, carbuncles, hydradenitis suppurativa, and staphylococcal wound infections. Folliculitis, furunculosis, and the carbuncle all involve inflammation and infection around the hair follicle. Folliculitis is the most benign of these infections and presents as painful, erythematous, indurated pustules and crusts around a hair follicle. A furuncle or boil is a deeper infection involving the hair follicle and presents as a painful red nodule or induration that develops a fluctuant center containing purulent creamy material. Carbuncles are deep-seated infections of several hair follicles that often have multiple sinus tracts draining purulent material. Patients with carbuncles may have associated symptoms of fever and chills.

Hydradenitis suppurativa is a recurrent infection of apocrine sweat glands, usually due to S. aureus. Patients most often present with recurrent axillary furuncles. Most superficial localized S. aureus skin infections can be treated with warm compresses and topical antimicrobial therapy with bacitracin or mupirocin. Antistaphylococcal antibiotics such as penicillinase-resistant penicillins (cloxacillin), first-generation cephalosporins, clindamycin, or alternately minocycline or vancomycin (for MRSA)

should be reserved for more serious staphylococcal soft-tissue infections. Large fluctuant lesions usually require incision and draining.

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