Ekthyma L08

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 17.01.2021

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Synonym(s)

Ecthyma; Ecthyma gangrenosum; ecthyma simplex; Ecthyma simplex streptogenes; Ecthymata; Lochschwwäre; staphylodermia ecthymatosa; streptodermia ecthymatosa; Trench ulcer

History
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Stokes 1807

Definition
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Circumscribed, as if punched out (sharp-edged) ulcers of the skin, which are favoured by external conditions, e.g. by (sub-)tropical climate. While the disease was frequently observed in Central Europe during the scarcity years of World War II, it is rather rare today. It is increasingly found in people returning from tropical or subtropical regions and in immunocompetent persons (Ecthyma gangrenosum).

Remark: The term ecthyma or ecthyma is not clearly defined etiologically.

Pathogen
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Mostly beta-hemolytic streptococci, Streptococcus pyogenes or more rarely Staphylococcus aureus.

Classification
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In general the following forms are distinguished:

  • I. Ecthyma simplex: Streptococcus infection (Streptodermia ecthymatosa, Ecthyma simplex streptogenes) or Staphylococcus infection (Staphylodermia ecthymatosa).
  • II. ecthyma gangraenosum: caused by Pseudomonas aeruginosa; this form plays an increasing role especially in immunocompetent patients and in Pseudomonas aeruginosa sepsis

Occurrence/Epidemiology
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Rare

Etiopathogenesis
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Starting point for the development of ecthymata are small injuries, folliculitis, insect bites, scabies or prurigo simplex subacuta. A lack of hygiene, warm and humid climate, chronic venous insufficiency, weakened general condition, acrocyanosis, immunosuppression, HIV infection and diabetes mellitus also have a favourable effect.

Localization
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Especially lower leg.

Clinical features
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Initial stage of vesiculopustular disease, rapid tissue decay with formation of deep, sharply cut ulcers, with greasy purulent coatings and halo-like erythematous fringe. Spreading to the subcutaneous fatty tissue. Drying, dirty grey-yellow crusts. Lymphangitis and -adenitis possible. Healing with scarring.

Diagnosis
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Clinic, swab, antibiogram.

Differential diagnosis
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Syphilide (ulcerous) - rare

Syphilis maligna- rare

ulcerated gums - rare

Erythema induratum

Artifacts - Questioning anamesis, personality profile

Complication(s)
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Erysipelas, sepsis, glomerulonephritis.

Therapy
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Eliminate causal factors (e.g. lack of hygiene, boots, tight jeans, etc.) Treatment of underlying diseases.

External therapy
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Cleaning moist dressings (renew every 2 hours) with antiseptic additives such as polihexanide (Serasept, Prontoderm), quinolinol (e.g. Chinosol 1:1000), R042, potassium permanganate solution (light pink). If necessary, cover the area with Pasta zinci. In case of localisation on the leg with intact blood circulation, compression therapy.

Internal therapy
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Antibiosis with Penicillin V (e.g. Megacillin) 3 times/day 1 Mega IE p.o. for 10 days. For penicillin allergy erythromycin (e.g. Erythrocin Filmtbl.) 4 times/day 500 mg p.o. For V.a. mixed infection Flucloxacillin (e.g. Staphylex) 3-4 times/day 0.5-1.0 g p.o. or i.m.

Alternatively cephalosporins such as cefazolin (e.g. Elzogram) 2 times/day 1-2 g i.v. or cefixim (Cephoral) 400 mg/day p.o. Conversion after antibiogram as soon as possible.

Progression/forecast
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Chronic, week-long course, healing with scarring.

Note(s)
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In general, "ecthymata" or "ecthymata" refers to infectious ulcerations of the skin of different aetiologies, such as punched-out ulcerations. In this respect it is rather a morphological-descriptive term.
  • The most common finding, the ecthyma simplex, is in most cases a cutaneous streptococcal infection (beta-hemolytic S.) with deep ulcerations that look like "punched out". E. simplex preferentially occurs at higher temperatures and high humidity on the legs and develops after insect bites or minor traumas (see the clinical picture described here).
  • The Ecthyma gangraenosum is an infection caused by P. aeruginosa. The rather extensive, flat ulcerations of the intertriginous tissue with strong environmental erythema occur mainly in patients with Pseudomonas sepsis, but also as a pure local infection.
  • The cause of Ecthyma contagiosum (Orf) is an infection with the parapoxvirus ovis (group parapoxviruses) transmitted from animals (foot or mouth cattle in sheep, goats, etc.) to humans.

Literature
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  1. Gucluer H et al (1999) Ecthyma gangrenosum. Int J Dermatol 38: 299-302
  2. Inamadar AC et al (2003) Periocular ecthyma gangrenosum in a diabetic patient. Br J Dermatol 148: 821
  3. Kim EJ et al (1999) Ecthyma gangrenosum in an AIDS patient with normal neutrophil count. J Am Acad Dermatol 41: 840-841
  4. Kimyai-Asadi A et al (1999) Ecthyma secondary to herpes simplex virus infection. Clin Infect Dis 29: 454-55
  5. Mempel M et al (2015) Selected bacterial infections of the skin. dermatologist 66: 252-257
  6. Ramar K et al (2003) Ecthyma gangrenosum and chronic lymphocytic leukaemia. Lancet Infect Dis 3: 113
  7. Rieger H et al (2003) Ecthyma contagiosum (Orf) as an uncommon differential diagnosis of infections of the hand. Trauma surgeon 106: 204-206
  8. Vaiman M et al(2015) Ecthyma gangrenosum and ecthyma-like lesions: review article. Eur J Clin Microbiol Infect Dis 34:633-639.

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 17.01.2021