Diphtheria of the skin A36.3

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 20.01.2024

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Skin diphtheria

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Very rare notifiable (suspected disease, illness, death, pathogen detection) infection of the skin with Corynebacterium diphtheriae (can occur today as traveler's dermatosis). A distinction is made between:

  • Wound diphtheria (pathogen entry on a pre-existing wound)
  • primary skin diphtheria (entry of the pathogen via healthy skin)
  • secondary skin diphtheria (autoinoculation of the skin in case of pre-existing diphtheria).

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Corynebacterium diphtheriae (optionally anaerobic).

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Penetration of the pathogen into small skin lesions by droplet or smear infection, also through infected material.

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Wound diphtheria: any part of the body. Primary diphtheria: especially lower extremities. Secondary diphtheria: on pre-existing eczematous skin lesions.

Clinical features
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Wound diphtheria: Infection of a pre-existing wound results in the formation of a purulent wound covered with membranous coatings and an oedematous, strongly reddened area.

Primary skin diphtheria: Entry of the pathogen into the organism via the skin (heteroinoculation). Initially development of one (or more) small pustule or a haemorrhagic blister in swollen and highly red surrounding skin; with pronounced, usually strongly reddened collateral edema, rapid flat ulceration and development of a peripherally growing skin ulcer with grey-white, later also brown-black coatings.

Secondary skin diphtheria: Autoinoculation of the skin in pre-existing diphtheria with superficial membranous coatings on a discretely edematous environment.

S.a.o. ecthyma-like diphtheria, gangrenous diphtheria, impetiginous diphtheria, phlegmonous diphtheria and diphtheria, ulcerous form.

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Membrane-like coatings, detection of bacteria (methylene blue preparation and cultural).

External therapy
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Local brushing with aqueous antiseptic solutions, e.g. potassium permanganate solution(light pink), quinolinol solution(e.g. Chinosol 1:1000), R042 or polyvidone-iodine solution(e.g. Betaisodona).

Internal therapy
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  • Systemic antibiosis with penicillin: infants, children (e.g. megacillin dry juice) 3 times/day 1/4-3 ml. (1 measuring spoon per 5-6 kg KG). Adolescents, adults (e.g. penicillin film): 3 times/day 0.5-1.5 mega for 10 days (possibly higher doses see case history).
  • For penicillin allergy erythromycin (e.g. erythro of ct dry juice): children up to 8th LJ: 30-50 mg/kg bw/day p.o. adolescents and adults: 1.5-2 g/day p.o. in 3-4 ED.

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Favorable with appropriate therapy. With regard to toxin formation, it is unclear whether an antitoxin should be applied systemically. However, it appears that only very small amounts of toxin are absorbed in cutaneous infestations, so that systemic toxin effects (polyneuritis (A36.0), myocarditis (A36.8) ) do not occur. However, some authors advocate the early use of an antitoxin.

Case report(s)
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The 65 year old German holidaymaker (holiday resort Sri Lanka) developed a massive (erysipelas-like) painful swelling and reddening of the back of the forefoot after a 21-day beach holiday with the formation of several blisters and pustules, which developed into extensive ulcerations after a few days. "He stepped in something on the beach", but did not pay any further attention.

BSG: 70/95; CRP: 50.0 mg/dl (normal value < 0.5 mg/dl); neutophilic leukocytosis (leukocyte count 12,000 per ml), ASL: 511IU/ml.

Wound swab: C.diphtheriae mitis and group G streptococci

Therapy: Pencillin G 3 x 10 million IU/day i.v. + erythromycin 2x500mg/day p.o. over a period of 14 days.

Wound swab:

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  1. Abdul Rahim NR et al (2014) Toxigenic cutaneous diphtheria in a returned traveller. Commun Dis Intell Q Rep 38: E298-E300.
  2. Berg L et al (2016) Cutaneous diphtheria after minor injury in Sri Lanka. Dermatologist 66: 169-170
  3. Cassir N et al (2015)Cutaneous diphtheria: easy to be overlooked. Int J Infect Dis 33:104-105.
  4. Flor-Henry P (1961) Cutaneous diphtheria: A brief historical review and discussion of recent literature, with presentation of two cases. Med Serv J Canada 17: 823
  5. Garman ME et al (2003) Unusual infectious complications of dermatologic procedures. Dermatol Clin 21: 321-335
  6. Höfler W (1991) Cutaneous diphteria. Internal J Dermatol 30: 845-847
  7. Moore LS et al (2015) Corynebacterium ulcerans cutaneous diphtheria. Lancet Infect Dis 15:1100-1107.
  8. Nelson TG et al (2015) Cutaneous ulcers in a returning traveller: a rare case of imported diphtheria in the UK. Clin Exp Dermatol 41:57-59.
  9. Wagner J et al (2001) Infection of the skin caused by Corynebacterium ulcerans and mimicking classical cutaneous diphtheria. Clin Infect Dis 33: 1598-1600


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Last updated on: 20.01.2024