Clinical presentation

The woman shown in the photographs had acute erysipelas due to streptococcal infection, and all four features of inflammation were present. She was referred to the clinic with a diagnosis of an acute allergic response, which, from the appearance alone, was understandable. However, malaise and fever were also present and the lesions were warm and tender. The condition responded well to antibiotic treatment. The point of entry in such cases is thought to be a small erosion on the face. Erysipelas of the leg or foot may follow the development of a small fissure between the toes, but often there is no discernible portal of entry.

Erysipelas is the local manifestation of a Group A streptococcal infection, in the case illustrated the infection is confined to deep dermis as a form of cellulitis. However the same organism at distal sites, through the production of toxins or superantigens, can cause other skin lesions such as: (a) the rash of scarlet fever; (b) erythema nodosum; (c) guttate psoriasis; and (d) an acute generalised vasculitis.

Other forms of local bacterial infection include impetigo, folliculitis, and furuncles (boils). These conditions are caused by Staphylococcus aureus and in the case of folliculitis or boils the infection is associated with a local abscess. Staph. aureus colonises the anterior nares or perineum of normal people; it also commonly colonises eczema and may cause an acute exacerbation of atopic dermatitis.

Impetigo is a superficial infection of the skin of which there are two forms. In the non-bullous form the affected skin is covered with crusts. Both staphylococci and streptococci are responsible. However the bullous form which presents with blisters is due to staphylococci. Folliculitis, an inflammation of the hair follicle, is commonly caused by Staph. aureus. Infection of the scalp or beard hair (sycosis barbae) is uncommon but may become chronic. Abscess formation around the hair follicles may result in furuncles or boils; where several furuncles coalesce the lesion is known as a carbuncle.

Ecthyma, which is most common on the leg, is due to bacterial infection penetrating through the epidermis to the dermis causing a necrotic lesion with a superficial crust and surrounding inflammation. Both streptococci and staphylococci are responsible.

Acute erysipelas: presentation
Acute erysipelas: patient shown in same patient two weeks later
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