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Hendra Gunawan, dr. Sp.KK (K), Ph.D, FINSDV, FAADV
Departmen Dermatologi dan Venereologi Fakultas Kedokteran
Universitas Padjadjaran / Rumah Sakit Dr. Hasan Sadikin Bandung
h.gunawan2016@unpad.ac.idPendidikan :- Fakultas Kedokteran Universitas Padjadjaran Bandung, Indonesia Lulus 1994- Diploma Course in Dermatology Bangkok, Thailand Lulus 2002- Program Spesialis Ilmu Kesehatan Kulit dan Kelamin
Fakultas Kedokteran Universitas Padjadjaran Bandung, Indonesia Lulus 2005- Program Doktoral (S3) Juntendo University Tokyo, Jepang Lulus 2008- Fellowship in Dermatopathology and Dermoscopy
Toranomon Hospital Tokyo, Jepang Lulus 2014
Riwayat Pekerjaan :- Dokter Offshore Pertamina Jakarta Tahun 1994-1995- Kepala Puskesmas Mapin Kebak Sumbawa, NTB Tahun 1995-1998- Dokjter Rumah Sakit M.H. Thamrin Pondok Gede Jakarta Tahun 1998-1999- Staf Departemen I.K. Kulit dan Kelamin FK UNPAD Tahun 2006-2021
Organisasi :- Anggota Ikatan Dokter Indonesia (IDI)- Sekretaris II Kolegium Dermatologi dan Venereologi Indonesia (KDVI)- Koordinator Ujian Tulis Nasional Komisi Evaluasi Nasional KDVI - Anggota Perhimpunan Dokter Spesialis Kulit dan Kelamin Indonesia- Anggota Komisi III Perhimpunan Dokter Spesialis Kulit dan Kelamin Indonesia
(PERDOSKI) Cabang Bandung- Wakil Ketua Kelompok Studi Morbus Hansen Indonesia- Wakil Ketua Kelompok Studi Dermatologi Sosial Indonesia
- Anggota Kelompok Studi Dermatopatologi Indonesia- Anggota Kelompok Studi Imunodermatologi dan Dermatosis
Akibat Kerja- Anggota Komite Etik dan Penelitian Kesehatan Rumah Sakit
Dr. Hasan Sadikin Bandung
Hendra Gunawan, dr., SpKK, PhD
SUMMARY
Immunity to skin infection
Outline
Bacterialskin infection
Fungal skin infection
Viral skin infection
Parasites skin infestation
Clinical manifestation
Lab examination
Management
FORNAS FKTP
< 0.5 mm: eyelids > 5 mm: upper back
Largest organ of body*
1.5 to 2 m2 in area
12% of body weight
Varies in thickness
Introduction:
* High risk to get infection
Hairs
Nails
Gland
Appendages of
Skin
SKIN FUNCTIONS
Aesthetic
Vitamin D production
Sensory function
Excretion
Temperature regulation
Barrier against loss of body fluid
Protectionfirst line of defense against microorganisms.
SKININFECTION
IMMUNITY TO
Pathogens organisms that cause diseases
What are the four major types of pathogen?
bacteria fungi
protozoa
virus
Pathogens organisms that cause diseases
What are the four major types of pathogen?
Skin(pores, hair follicles)
Route of Infection
Wounds(scratches, cuts, burns)
Insect bites
First line of
defense
Immune System
Second line of
defense
Third line of
defense
123
Immune System
• First line of defense:
• Physical barriers
microorganisms must cross:
•Thick keratin
•Sebum (low pH),
•Sweat (low pH, high salt,
lysozyme)
Immune System
• Second line of defense:
• Innate immune system
(no adaptation to specific pathogens)
•Macrophages
•Neutrophils
•Natural killer (NK) cells
Immune System
• Third line of defense:
• Adaptive immune system
(adapts to defend against specific
pathogens using variable receptors)
•B cells: make antibody specific for
antigen
•T cells: cellular responses using
receptors (T cell receptors)
SKININFECTION
BACTERIAL
Bacterial Skin Infections
Pyoderma
Primary
Impetigo
Echtyma
Folliculitis, Furuncle,
Carbuncle
Erysipelas, Cellulitis
Secondary
Non-pyoderma
Erythrasma
Skin tuberculosis
Leprosy
•Caused by a single pathogen affect normal skin.
• Most common primary skin pathogens:
• S. aureus
• β-hemolytic streptococci.
•Occur in skin that is already diseased.
• Because of the underlying disease clinical picture & course of these infections vary.
PRIMARY INFECTIONS SECONDARY INFECTIONS
PYODERMA
•Superficial skin infection with bullae
(bullous) or crusting (non-bullous).
•Caused by Streptococci, Staphylococci,
or both
Impetigo
Vesicles, bullae, & bullae hypopion with surrounding erythema
(4A)
Bullous Impetigo (4A)
Non-bullous Impetigo (Crusted Impetigo)
• Initially a vesicular infection
rapidly evolves into pustules
that rupture
dried discharge forming honey
colored crust on an erythematous base.
(4A)
•Similar to impetigo more
deeply dermis of skin
possibly causing scars.
•Caused by Streptococcus
•Begin as vesicles rupture,
creating circular erythematouslesions with adherent crusts.
Ecthyma (4A)
Ecthyma
• Inflammation at the opening of
hair follicle.
•Erythematous papules & pustulessurrounding individual hairs.
•Caused by S. aureus.
Folliculitis (4A)
•Deep-seated inflammatory nodule
with a pustular center that
develops around a hair follicle
(painful, localized)
•Caused by Staphylococcal.
Furuncle (4A)
Furunculosis
Crops of boils occur over a longer period of time.
• Involvement of several adjacent
follicles, with pus discharging from
multiple follicular orifices.
•Clusters of furuncles connected
subcutaneously
Carbuncle (4A)
•Painful, fluctuant, red, tender
nodule, on which may rest a
pustule.
Cutaneous Abscesses
•Plaque-like edema of cutaneous
surface involves superficial
dermis.
•Occurs most frequently on legs and
face.
•Most often caused by group
A β-hemolytic streptococci.
Erysipelas (3A)
•Shiny, raised, indurated & tender
plaque-like edema with distinct
margins clear border between
normal & infected skin.
Erysipelas (3A)
Cellulitis
Affects the deeper tissues &less clearly defined than in erysipelas.
(3A)
•Rapidly spreading cellulitis to
fascia & muscle with necrosis of
subcutaneous tissue & overlying
skin.
•Fever, systemic toxicity, & severe
pain.
•Caused by a mixture of aerobic &
anaerobic organisms.
Necrotizing Fasciitis
•~ Lyell's disease
•Caused by epidermolytic toxin of
Staphylococcal.
•Starts as a localized lesion widespread erythema & exfoliation of skin.
•More common in infants than in adults.
Staphylococcal Scalded Skin Syndrome (SSSS)
Staphylococcal Scalded Skin Syndrome (SSSS)
Lab Examination
•Direct microscopy:
Gram stained smear is useful in
case of pus, where cocci are seen.
• Culture and sensitivity test.
Management
Non-medicamentosa therapy
Medicamentosa therapy
Personal Hygiene
Identifying predisposing
factors
Topical
Systemic
Management
FORNAS FKTP
FORNAS FKTP
FORNAS FKTP
FORNAS FKTP
FORNAS FKTP
FORNAS FKTP
FORNAS FKTP
NON-PYODERMA
•Super›cial bacterial skin infection
in intertriginous areas:
toes, armpits, or groin
•Well-de›fined but irregular reddish-brown patches.
•Caused by Corynebacterium
minutissimum.
Erythrasma (3A)
• Wood's lamp:
• Ultraviolet light causes the
organism to fluoresce a characteristic
coral red fluorescence.
Erythrasma (3A)
Management
Localized topical
Benzoyl peroxide gel
Clindamycin or erythromycin gel
Fusidic acid ointment
Widespread/not respond to topical therapy systemic
Oral erythromycin, 250 mg 4 times a day
for 2 weeks
Single dose of 1 g clarithromycin.
FORNAS FKTP
SKIN TUBERCULOSIS
• Caused by M. tuberculosis
• Primary infection: acquiring bacilli for first time.
• Post primary infection: occurs in patient with previous TB or previous BCG vaccination.
LEPROSY
• Caused by M. leprae
• Paucibacillary (PB)
• Multibacillary (MB)
CHRONICBACTERIAL SKIN INFECTION
SkinTuberculosis
Skin Tuberculosis(3A)
Skin Tuberculosis(3A)
Before Treatment
After 3 Weeks Treatment
Management FORNAS FKTP
LEPROSY
PB MB
WHO
Leprosy (4A)
Silva MR CM. Mycobacterial infections. Dermatology. New York: Elsevier; 2008. p. 1114-25.
BORDERLINE
“Cardinal Sign”Leprosy
“Cardinal Sign”Leprosy
Gynecomastia
Madarosis
The other signsof leprosy
• Lesi tunggal atau beberapa
• Hipopigmentasi
• Berkurangnya sensasi (hypoesthetic)
TIPE TUBERKULOID (TT)
BORDERLINE TUBERCULOID (BT)
• Lesi sedikit (< 5)
• Batas tegas
• Asimetris
• Plak eritem
• Berkurangnya sensasi(hypoesthaetic)
BORDERLINE BORDERLINE (BB)
Dimorphous leprosy
Plak eritem, skuama
Berbentuk anular (seperti cincin)
Well-defined internal & external borders
BORDERLINE BORDERLINE (BB)
BORDERLINE LEPROMATOUS (BL)
LEPROMATOUS LEPROSY (LL)
Diffuse infiltrations
LEPROMATOUS LEPROSY (LL)
LEPROMATOUS LEPROSY (LL)
LEPROMATOUS LEPROSY (LL)
PemeriksaanSaraf Tepi
n. aurikularis magnus
n. aurikularis magnus
n. ulnaris
n. ulnaris
n. peroneus komunis
n. peroneus komunis
n. tibialis posteriorn. tibialis posterior
Bakteri
• 2 cuping telinga kanan & kiri
• 1 lesi kulit aktif
• 2 cuping telinga kanan & kiri
• Atas lutut atau punggung tangan
Pemeriksaan BTA
The Presence of Acid-fast Bacilli
1
Bacterial Index & Morphological Index
MI = SOLID BACILLI
TOTAL BACILLI X 100%
The Presence of Acid-fast Bacilli
Management
FORNAS FKTP
FUNGALSKIN
INFECTION
Fungal Skin
Infection
Dermatophytosis
Candidiasiscutis
PityriasisVesicolor
FungalSkin Infection T capitis
T facialis
T corporis
T cruris
T manum
T pedis
T unguium
DERMATOPHYTOSIS
Tinea Capitis
Gray patch
Kerion
Favus
TineaCapitis
‘Back dot’
Childrenmost common cases
(3A)
Black dot type• Large alopecia without inflammation
• Black dot hairs & mild scaling
• Look like alopecia areata
Tinea Capitis
Gray patch type• Inflammatory circumscribed
erythematous scaly patches.
• Nonscarring alopecia with breakage hair
(3A)
Kerion• Inflammed, boggy, & tender
• Fever, adenopathy.
• Scaring alopecia may occur
• May look bacterial
Tinea Capitis
Favus• Severe form of tinea capitis
• Characterized by scutula:yellowish, circular, cup-shaped crusts
grouped in patches ~ honeycomb
(3A)
Normal Hair
Endothrix Exothrix
Direct microscopy:KOH 10%
Lab Examination
Tinea Facialis (4A)
•Erythematous papulosquamous
•Annular
•Scaling
•Crusting
• ‘Ringworm’
Tinea Corporis (4A)
Tinea Cruris (4A)
• Erythema with pronounced scales• Vesicles and bullae
Tinea Pedis Tinea Manus(3A) (3A)
•Types:
1. Distal subungal
2. Proximal subungal
May indicate HIV infection
4. White superficial
5. Candida onychomycosis
Normally hands with accompanying
paronychia
Onychomycosis (2)
Direct microscopy: KOH 10% septate, branching hyphae
Lab Examination
Management
Management
FORNAS FKTP
FORNAS FKTP
PITYRIASIS VESICOLOR
• Etiology: Malassezia
• Numerous, well-marginated, oval-to-
round macules with fine white scales
(when scraped).
• Pigmentary alteration in each individual:
• Redness
• Hypopigmented• Hyperpigmented
Pityriasis Vesicolor (4A)
• Asymptomatic to mildly pruritic
• Scattered over the trunk & neck
• Differential diagnosis:
• Intertrigo
• Erythrasma
Pityriasis Vesicolor (4A)
Woods Light: Yellow green fluorescence pityrialactone (tryptophan derivative).
Pityriasis Vesicolor
Direct microscopy: KOH 10% “spaghetti and meatballs”.
Pityriasis Vesicolor
Management
FORNAS FKTP
FORNAS FKTP
CANDIDIASIS CUTIS
• Etiology: Candida albicans (normal flora)
• Occurs in moist areas
• Primary lesion is red pustules.
• Most Common: red, denuded surface with
satellite lesions.
Candidiasis Cutis (4A)
Candidiasis Cutis (4A)
Candidiasis Cutis
Direct microscopy: KOH 10% pseudohyphae and blastospores
Management
FORNAS FKTP
FORNAS FKTP
VIRALSKIN
INFECTION
Varicella Zoster Virus (Vzv)
Clinical Forms: Herpes zoster
Clinical Forms: Varicella
• Mainly children highly contagious
• Generalized vesicular eruptions on skin
& mucous membranes
• Adults & immune-compromised
severe manifestations
• Prodrome: brief of low-grade fever, URT
symptoms, & mild malaise
• Rapid appearance of pruritic exanthem
Varicella (4A)
• Incubation period: 14-21 days.
• Begin in trunk & scalp spread
peripherally
• Lesions begin as tiny erythematouspapules develop central vesicles
surrounded by red halos
(‘dew drops on a rose petal’)
Varicella (4A)
Varicella (4A)
Management
FORNAS FKTP
• After primary infection virus lies
dormant in sensory nerve root cell.
• Reactivation results in a sensory
neuritis.
• Severity & risk of complications: age
& immunosuppression due to
decline in specific cell-mediated
immune response
Herpes Zoster (4A)
• Postulated triggers:
Mechanical trauma
Thermal trauma
Infection
Immunosuppression
Herpes Zoster (4A)
• PRODROME PHASE :
Pre-eruptive pain (pre-herpetic
neuralgia), unilateral, dermatomal
4 to 5 days precedes the eruption.
Pain/pruritis, tingling, hyperesthesia
Herpes Zoster (4A)
• ERUPTIVE PHASE:
Dermatome does not cross midline.
Red, swollen plaque & spreads to involve
part or all of a dermatome.
Vesicles arise in clusters on erythematous
base purulent fluid by day 3 or 4.
Rupture before forming crusts falls off
in 2 to 3 weeks.
Herpes Zoster (4A)
Direct microscopy:
Tzanck smear: Stain with Giemsa
multinucleated giant cells.
Lab Examination
Management
FORNAS FKTP
•Primary infections:• More severe• Frequently involve systemic signs and
symptoms• Have a higher rate of complications
compared to episodes reactivation
of HSV.
•Pain, burning, or itching at the site of subsequent eruption.
Herpes simplex (4A)
Management
HPV worldwide occurrence.
>150 genotypes of HPV
Affecting people of all ages most common children & young
adults.
Cutaneous warts (3A)
Well-defined, raised papules or plaques,
rough or hard surface, no inflammation.
Most common on hands or feet.
Cutaneous warts
Common warts
Filiform wartsMosaic warts Plane warts
(3A)
Management
Common benign cutaneous infection
due to Molluscum contagiosum virus.
Children most commonly affected.
Discrete firm, dome-shaped papules
have central umbilication.
Molluscum Contagiosum (3A)
Management
PARASITESSKIN
INFESTATION
• Caused by Sarcoptes scabiei var. hominis.
burrows tunnels into epidermis.
• Mites of deposit faeces behind them.
• Female lays eggs in tunnels.
Scabies (4A)
• Mode of Transmission:• Close person-to-person contact• Sexual intercourse• Fomites may transmit the infection
• Clinical Picture:1. Nocturnal pruritus scratching2. Lesions on predilection sites Circle of Hebra3. Attacks group of people
4. Finding mites or its products
Scabies (4A)
Scabies (4A)
• Represents an abnormal host immune
response:
• Mentally retarded (Down’s syndrome)
• Severe systemic diseases (leukemia,
diabetes )
• Severe immunesuppression.
Crusted Scabies (3A)
Crusted Scabies (3A)
• Direct microscopy:
• KOH preparation of skin scrapings
presence of mites, larva, eggs, scibala
within the skin .
Lab Examination
Management
FORNAS FKTP
• Infestation of sucking lice blood-feeding ectoparasitic.
• Lay their eggs on hair shafts or in the seams of clothing
Pediculosis (4A)
• Lice: small gray brown, blood sucking
insects crawl among hairs.
•Head louse nit attached to hair shaft.
Pediculosis capitis (4A)
• Infestations commonly found in homeless individuals.
•Pruritus only sign of body lice is excoriations, often linear.
•Primarily on back, neck, shoulders, & waist.
•Diagnosis presence of nits in lining of clothing, particularly the seams.
Pediculosis corporis
• Best to call “crab lice” rather than “pubic lice”
• Infestations involve other hair-bearing sites:
mustache, beard, axillae, eyelashes, & eyebrows.
• Transmitted by sexual or close contact & fomites.
• Therapy similar to pediculosis capitis.
Pediculosis Pubis (4A)
Management
FORNAS FKTP
• Caused by Ancylostoma braziliense, Ancylostoma caninum
• Tropical countries
• Contact with contaminated soil
• Feet & buttocks
Cutaneous Larva Migrans (4A)
•Typically 1 to 3 serpiginous lesions up to 20 cm in length
•May be vesicobullous; movement up to several cm per day.
• Intense pruritic
Cutaneous Larva Migrans
Management
FORNAS FKTP
• Skin infection can caused by bacteria, fungal, viral, and parasites.
• Clinical manifestation vary from mild to serious condition.
• Accurate medical history & carefully perform physical examination
is fundamental to provide a correct diagnosis.
• Many skin infections require treatment, both non-medicamentosa &
medicamentosa therapy (topical with/without systemic).
Some available in primary health care center.
Summary
HATUR NUHUN
h . a . g . e
h.gunawan2016@unpad.ac.id
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