Impetigo and cellulitis,
so this is an infection of the superficial
skin structure down into the dermis.
That's the difference.
But they are –
they appear very similarly.
Pain, tenderness, calor, erythema,
those are the hallmarks of both of these.
But impetigo is more superficial.
And I have a hard time sometimes differentiating between the
two just based on what I'm seeing in front of me in clinic.
The important difference in treatment is mild impetigo
could be treated with topical antibiotics alone,
which is great.
So, if it seems very – it’s not very –
there’s not a lot of calor.
The pain is not that severe.
It’s just a red area.
It doesn't bother the patient a lot.
That one might be conducive
to using topical antibiotics.
But because they are so related,
it can be difficult to differentiate them.
If there's a question,
I'm likely to treat it with oral antibiotics.
I don’t see a ton of cases of either
of these conditions either.
I also have a lot of high-risk patients with things like diabetes
and heart failure and other other types of comorbidities
that can make these
infections more likely to spread.
So, therefore, I'm more
aggressive at treatment.
And I am aggressive when it comes to the potential
for methicillin-resistant staph aureus (or MRSA).
If there is somebody who has frequent healthcare contact
or certainly with a history of MRSA in the past,
I’m going to treat them with
a different set of antibiotics.
Maybe for a patient who is naïve,
for a child for example,
that child might receive cephalosporin,
But for the patients like mine
who have all those comorbidities,
go to the doctor a lot,
get admitted to the hospital,
sometimes are in a rehabilitation center or nursing home,
could be good options for them
because that will handle the
MRSA more effectively.
And just a warning,
always be cognizant of the fact that cellulitis
can progress into an necrotizing fasciitis.
A necrotizing fasciitis can masquerade
initially as just a simple cellulitis.
So, patients who feel really sick,
who have a rapid progression of their rash,
who have other evidence like neurovascular or
neurological changes that suggest infection in deeper layers,
those are patients you want to
stay on top of and refer urgently.
Don't wait to send them to the emergency
department for a surgical referral.
Do it right now.
So, moving on to zoster,
and this just – the figure there shows
the progression of shingles or zoster.
It’s related, of course, to the varicella
virus, which sits in your dendrites dormant.
And once it's awakened,
it travels up nerve fibers
and creates its blistering rash.
Again, just like it did when the kid got
chickenpox like many years ago,
zoster comes back.
So, the key with herpes zoster
is the dermatomal distribution
because it is related to those nerve fibers,
so that's what separates it from
other types of blistering rashes.
It’s usually found over
this thoracic dermatome,
but one important factor is that if it –
don't be shocked if it
crosses the midline.
About one in five cases do,
but it should stay dermatomal as well.
can be absolutely debilitating.
Luckily, it's still uncommon,
but certainly it does happen.
About 13% of cases of herpes zoster
develop post-herpetic neuralgia.
More common as patients grow older.
So, luckily, we can prevent both herpes
zoster and post-herpetic neuralgia as well.
And that's with the application of the
varicella vaccine or the shingles vaccine.
Now, this is a one dose
vaccine given at age 60.
It’s recommended by the US Centers for
Disease Control and Prevention.
And it is effective in preventing zoster.
It's actually more effective though
in preventing post-herpetic neuralgia.
So, we can cut the cases of post-herpetic neuralgia
by about two-thirds compared with no vaccination.
Once you see a case of zoster in your clinic,
prescribe antiviral agents,
there are a number out
there that are all effective.
So, it's really based on dosing,
as to which one you prefer.
That can reduce the
duration of symptoms.
It also reduces viral shedding,
but it's important to
get it on board early.
Most patients, in my experience,
do come in fairly early with this
because they are concerned,
it hurts for one thing and, therefore,
they want pain relief from
the pain of the shingles,
but they also want to get treated
and that improves things.
Very important to keep these patients
while they have the active lesions
away from young children,
away from pregnant women who could
be at special risk if they contract varicella
and also anybody who's immunocompromised.
Corticosteroids have been used for
the management of herpes zoster.
They don't seem to be effective.
And because they have a lot of
side effects even in a short course,
they are not routinely recommended.
So, that just took you through some localized rashes.
you have a good
sense of how to treat them.
And I guess my question is,
how itchy do you feel right now?
You'll be fine.
And just use some emollients
and we’ll see you next time.