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Dermatological Problems
FRANCISCO VEGA-LOPEZ  |  SARA RITCHIE
KEY POINTS
• Skin disease may represent a primary condition or be a
secondary manifestation of systemic illness and the
history and examination should be directed towards
both.
• Both infective and non-infective inflammatory condi-
tions need to be considered when formulating a dif-
ferential diagnosis for skin problems in the tropics.
• Skin malignancies should always be considered in the
differential diagnosis.
• Superimposed pyogenic infection can complicate many
other tropical skin infections.
• Syphilis occurs worldwide and should be considered in
the differential diagnosis of tropical skin presentations.
• Leprosy should always be considered in individuals who
have lived for several years in endemic areas.
• Infection with tuberculous mycobacteria or atypical
mycobacteria should be considered with either a history
of travel to areas of endemicity or a history of high-risk
activities.
• Fungal infection, either superficial or deep, should be
considered in the differential, particularly in the
immunocompromised.
• Cutaneous leishmaniasis can have protean manifesta-
tions and should be considered with a history of travel
to any endemic region.
• Detailed knowledge of geographical endemicity pat-
terns is vital in formulating the correct differential diag-
noses of skin conditions presenting in or from the
tropics.
Introduction
Poverty and disability characterize a number of skin diseases in
the tropics. A number of studies support the aetiological role
of poverty in skin conditions such as fungal diseases, leprosy,
scabies and impetigo. A vicious circle can arise as chronic or
recurrent skin disease results in further disability and loss of
economic activity. Clear examples of this complex problem are
overtly manifest in those individuals suffering from mycobacte-
rial infections, cutaneous leishmaniasis, leprosy and deep fungal
infection.
Skin infections and tropical diseases may present as a
primary condition or as a secondary manifestation of systemic
illness. Cutaneous larva migrans and localized cutaneous leish-
maniasis are examples of the former, whereas the latter can be
exemplified by systemic conditions such as disseminated leish-
maniasis secondary to kala-azar and coccidioidomycosis. The
clinical approach to a patient with tropical skin disease involves
a thorough history-taking that leads to establishing a morpho-
logical and topographical diagnosis. Table 68.1 shows examples
of lesions and symptoms that suggest or establish a particular
diagnosis in clinical practice.
The history must include detailed information on previous
skin disease, travel history, activities while travelling, occupa-
tion, drugs, wild or domestic animal contacts, precipitating
factors, duration of signs and symptoms, evolution of clinical
signs, symptoms in relatives or household contacts and an
assessment of the patient’s immune status. The examination
must include extracutaneous signs such as fever, enlarged lymph
nodes, hepatosplenomegaly and general malaise, which may
indicate systemic illness. In-depth epidemiological knowledge
of global geographical pathology is also required in the practice
of tropical dermatology.
Skin Diseases Caused by Bacteria
PYOGENIC INFECTIONS
Aetiology and Pathogenesis
Staphylococcus and Streptococcus spp. are ubiquitous in both
urban and rural environments worldwide. Healthy and immu-
nocompromised hosts may develop pyogenic infections of the
skin following direct inoculation of bacteria. Less commonly,
haematogenous dissemination or even bacteraemia may develop
as a result of a minor skin injury. The portal of entry for these
pathogenic organisms is often unnoticed by both the patient
and doctor, but minor injuries, insect bites, friction blisters or
superficial fungal infection are the commonest found in clinical
practice.
Pyogenic bacteria cause damage by the pathogenic action of
proteases, haemolysins, lipoteichoic acid and coagulases. Eryth-
rogenic toxins are responsible for the erythema commonly
observed in infections by Streptococcus spp.
Clinical Findings and Diagnosis
The clinical spectrum of skin pyogenic infections includes fol-
liculitis and furunculosis on hair-bearing skin, plaques of impe-
tigo (Figure 68.1), with thickened dermis commonly affecting
the lower limbs (Figure 68.2) and abscess formation, cellulitis
and necrotic ulceration at the more severe end of the
spectrum.
The perimalleolar regions are commonly affected as they are
exposed to mechanical trauma, however pyogenic infections
may present on the upper limbs, face (Figure 68.3) and trunk.
Common clinical signs of pyogenic infection include erythema,
inflammation, pus discharge, abscess formation, ulceration,
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