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Pyoderma

Pyoderma is a common bacterial infection of the skin characterized by the formation of pus-filled lesions, typically caused by Staphylococcus aureus or Streptococcus pyogenes.^[1]^[2] It encompasses a range of conditions from superficial infections like impetigo to deeper ones such as cellulitis, and is classified as primary (occurring on intact skin) or secondary (complicating underlying dermatoses like eczema or scabies).^[3]^[4] Superficial pyodermas are highly contagious and spread through direct contact or shared items, with risk factors including warm humid climates, poor hygiene, crowding, and skin trauma.^[5]^[2] Globally, pyoderma imposes a significant burden, particularly in low-resource settings where it affects millions annually and can lead to complications like post-streptococcal glomerulonephritis if untreated.^[6] Symptoms vary by type and depth but commonly include erythematous, pus-filled lesions such as papules, pustules, or nodules, which may crust, ulcerate, or cause pain, itching, and systemic symptoms like fever in severe cases.^[5]^[7] Diagnosis is primarily clinical, supported by bacterial culture or Gram stain when needed, while treatment involves topical or systemic antibiotics tailored to local resistance patterns, with emphasis on hygiene to prevent recurrence.^[3]^[2]

Overview

Definition and Classification

Pyoderma is defined as a pus-forming bacterial infection of the skin, primarily caused by pyogenic bacteria such as Staphylococcus aureus or Streptococcus pyogenes.^[8] The term derives from the Greek words "pyon" (pus) and "derma" (skin), reflecting its characteristic purulent nature.^[9] Pyodermas are classified in multiple ways to reflect their etiology, depth of involvement, and clinical context. Primary pyodermas arise from direct bacterial invasion of otherwise intact skin, without an underlying dermatosis, and include conditions such as impetigo, folliculitis, furunculosis, and carbunculosis.^[8] Impetigo, a common superficial primary pyoderma, is subdivided into non-bullous (characterized by honey-crusted lesions) and bullous forms (featuring fluid-filled blisters).^[2] In contrast, secondary pyodermas occur as superimposed bacterial infections on pre-existing skin conditions, such as eczema, scabies, or ulcers, where compromised barriers facilitate microbial entry.^[8] Another key classification distinguishes superficial from deep pyodermas based on the extent of tissue involvement. Superficial pyodermas are confined to the epidermis and upper hair follicles, manifesting as pustules or crusts without deeper extension, as seen in impetigo or superficial folliculitis.^[8] Deep pyodermas, however, penetrate into the dermis and subcutaneous tissues, leading to abscesses, furuncles, or cellulitis-like features, exemplified by ecthyma or carbuncles.^[8] This terminology should not be confused with deeper non-suppurative infections like cellulitis, which involves diffuse subcutaneous inflammation without prominent pus formation, or erysipelas, a superficial streptococcal infection marked by sharply demarcated, raised erythematous plaques rather than pustules.^[10]^[11] Note that the term pyoderma can sometimes refer to non-infectious inflammatory conditions, such as neutrophilic dermatoses, which are covered in a separate section.

Epidemiology

Pyoderma represents a major public health concern, particularly among children in resource-limited settings. Globally, it affects an estimated 162 million children at any one time (as of 2015), primarily through impetigo, positioning it as one of the three most common pediatric skin disorders alongside scabies and tinea.^[12] More recent analyses suggest over 111 million children affected (GBD 2019).^[6] Earlier estimates from the World Health Organization suggested over 111 million children impacted, underscoring the condition's persistent burden despite potential underreporting in surveillance data.^[13] Demographically, pyoderma is most prevalent in children under 10 years of age; in one study, this group accounted for 48% of cases, reflecting heightened susceptibility due to immature immune responses and environmental exposures.^[14] A male predominance is observed, with males comprising 61% of cases in one community-based analysis.^[14] The condition disproportionately affects lower socio-economic classes, where approximately 60% of cases occur, driven by overcrowding, limited access to hygiene resources, and inadequate sanitation.^[15] Geographically, incidence rates are markedly higher in tropical and developing regions, where humid climates facilitate bacterial proliferation and poverty exacerbates transmission. In these areas, pyoderma prevalence can exceed 10-20% among children, strongly associated with malnutrition and suboptimal living conditions that impair skin barrier function.^[12]^[14] Certain populations face elevated risks, including immunocompromised individuals such as those with HIV or diabetes, who experience more severe and recurrent infections due to impaired host defenses. In select communities, methicillin-resistant Staphylococcus aureus (MRSA) contributes to a variable percentage of pyoderma cases (3-60% across studies), complicating treatment and increasing morbidity.^[16] Historically, pyoderma incidence has shown a modest global uptick since the 2000s, with age-standardized rates rising by about 7% from 1990 to 2019, largely attributable to escalating antibiotic resistance among causative pathogens like S. aureus.^[17]^[18] Projections indicate a 3% increase in age-standardized incidence rates from 2020 to 2030.^[6]

Etiology and Pathogenesis

Microbial Causes

Pyoderma is predominantly caused by bacterial pathogens, with Staphylococcus aureus being the most common isolate. This gram-positive coccus initiates infection through colonization of disrupted skin barriers, often leading to superficial or deep suppurative lesions. Methicillin-resistant S. aureus (MRSA) strains are increasingly implicated, particularly in community-acquired cases, though their prevalence varies widely by region, ranging from less than 5% to over 20% among pyodermas.^[19] β-Hemolytic streptococci, such as group A Streptococcus pyogenes, are also frequently involved, and are especially associated with non-bullous impetigo through the production of enzymes like streptokinase that facilitate tissue invasion. Co-infections with both S. aureus and S. pyogenes are common, occurring in a substantial proportion of cases. Less common pathogens include gram-negative bacteria such as Klebsiella species, Escherichia coli, and Pseudomonas aeruginosa, which typically contribute to secondary or deep pyodermas in immunocompromised hosts or chronic wounds. The pathogenic mechanisms of these bacteria involve adhesion to keratinocytes via surface proteins and the secretion of virulence factors. For instance, S. aureus produces exfoliative toxins (ETA and ETB) that cleave desmoglein 1 in the epidermis, causing acantholysis and blister formation characteristic of bullous impetigo.^[20] In recurrent pyodermas, biofilm formation by S. aureus enhances persistence by shielding bacteria from host immunity and antibiotics. Severe strains often express Panton-Valentine leukocidin (PVL), a pore-forming toxin that lyses neutrophils and macrophages, exacerbating tissue necrosis and promoting dissemination.^[21] Transmission occurs primarily through direct skin-to-skin contact, contaminated fomites, or autoinoculation from colonized sites, facilitated by the high prevalence of nasal carriage of S. aureus in 30-40% of the general population.^[22] This carriage serves as a reservoir, increasing the risk of endogenous infection in predisposed individuals.

Predisposing Factors

Pyoderma development is significantly influenced by environmental factors that facilitate bacterial entry and proliferation on the skin. Poor hygiene, often linked to limited access to clean water and sanitation, increases susceptibility by allowing bacterial colonization. Overcrowding in living conditions promotes close contact transmission, particularly in resource-limited settings. Malnutrition compromises overall immune function and skin integrity, further elevating risk. Tropical climates, characterized by high humidity and temperature, create ideal conditions for bacterial growth and are associated with higher incidence rates. Trauma, such as cuts or abrasions, and insect bites serve as common entry points for pathogens like Staphylococcus aureus, enabling superficial infections.^[6]^[23] Host-related factors play a critical role in individual vulnerability to pyoderma. Immunodeficiencies, such as those seen in HIV infection, impair the skin's defensive mechanisms, leading to recurrent bacterial infections; children with HIV are particularly prone due to combined immature and compromised immunity. Diabetes mellitus disrupts wound healing and glycemic control, increasing infection risk through impaired neutrophil function. Skin barrier defects, exemplified by atopic dermatitis, allow easier microbial invasion via disrupted epidermal integrity. Age is a notable determinant, with young children under 5 years exhibiting higher susceptibility owing to an immature immune system that limits effective bacterial clearance.^[24]^[25]^[26]^[27] Underlying conditions often precipitate secondary pyoderma by altering the skin environment or immunity. Dermatoses like scabies and eczema provide breached barriers or chronic irritation that predispose to superinfection. Low socioeconomic status correlates strongly with incidence due to compounded effects of poverty, poor nutrition, and inadequate healthcare access.^[28] Genetic predispositions to pyoderma are rare but significant in certain immunodeficiencies. Hyper-IgE syndrome, for example, markedly increases the risk of recurrent staphylococcal pyoderma through defects in STAT3 signaling that impair Th17-mediated immunity and antifungal defenses, often presenting with severe skin and lung infections.^[24]

Clinical Features

Primary Pyodermas

Primary pyodermas represent superficial or deep bacterial infections of the skin that arise directly from microbial invasion of intact skin, without an underlying dermatological condition predisposing the site. These infections typically manifest as localized lesions that evolve through stages of inflammation and suppuration, often beginning as erythematous papules or vesicles that progress to pustules and may rupture to form crusts or abscesses. Common sites include the face, extremities, and trunk, with lower extremities affected in approximately 60% of cases and the head and neck region in about 47.5%.^[14] The primary causative pathogen is Staphylococcus aureus, though Pseudomonas aeruginosa can play a role in specific scenarios like folliculitis associated with contaminated water.^[14]^[29] Impetigo is the most prevalent form of primary pyoderma, accounting for 53% of cases in clinical studies. It characteristically presents with thin-walled vesicles or bullae that rupture easily, leading to the formation of golden-yellow, honey-crusted lesions on an erythematous base, primarily on the face and exposed extremities.^[14]^[2] These lesions are pruritic or mildly painful and highly contagious through direct contact or fomites, often spreading via autoinoculation. The bullous variant, caused by exfoliative toxins (ETA and ETB) produced by certain S. aureus strains, features flaccid, fluid-filled blisters that evolve from small vesicles without the typical crusting, commonly appearing in intertriginous areas or on the trunk.^[2]^[30] Folliculitis constitutes about 39% of primary pyodermas and involves superficial inflammation of hair follicles, manifesting as small, dome-shaped pustules centered on follicular openings, surrounded by erythema.^[14] These lesions are often itchy and tender, predominantly affecting the trunk, beard area, or scalp in adults during the second or third decade of life. S. aureus is the usual culprit, but P. aeruginosa causes the distinctive "hot tub" folliculitis, presenting as pruritic follicular papulopustules 12–48 hours after exposure to inadequately chlorinated water sources.^[29] Unlike deeper infections, superficial folliculitis rarely progresses to scarring unless secondarily traumatized. Furunculosis and carbunculosis account for 6.5% and 1.5% of primary pyodermas, respectively, representing deeper follicular extensions with more significant tissue involvement. Furunculosis appears as solitary or clustered painful, erythematous nodules that evolve into fluctuant abscesses with central necrosis, commonly on the neck, back, or thighs.^[14]^[31] Carbunculosis involves coalescence of multiple furuncles into a larger, indurated plaque with multiple draining sinuses and overlying pustules, often on the posterior neck or upper back, accompanied by greater local tenderness and potential for systemic symptoms like fever.^[31] These deeper forms typically progress from follicular papules to suppurative nodules over days, emphasizing the need for clinical differentiation from superficial variants.^[14]

Secondary Pyodermas

Secondary pyodermas arise as bacterial superinfections complicating pre-existing dermatological conditions, where disruption of the skin barrier facilitates microbial invasion. Common associations include infections superimposed on eczema, scabies, or chronic ulcers, leading to exacerbated inflammation and purulent discharge. For instance, in eczematous pyoderma, the affected areas often present as weeping, crusted plaques due to secondary colonization by Staphylococcus aureus, transforming chronic dermatitis into an acute infectious process.^[14]^[32] In scabies, bacterial superinfection of excoriated lesions similarly results in pustular eruptions and crusting, with S. aureus being the predominant pathogen in up to 77.5% of cases.^[14]^[33] Systemic conditions such as diabetes mellitus and immunosuppression further predispose individuals to secondary pyodermas, often resulting in more aggressive disease with deeper tissue involvement. In diabetic patients, impaired wound healing and neuropathy promote bacterial entry through minor trauma, leading to cellulitis-like presentations with erythema, swelling, and potential abscess formation; recurrence rates can reach 60% in uncontrolled cases.^[33]^[34] Immunosuppressed individuals, including those on corticosteroid therapy or with HIV, exhibit heightened susceptibility, where infections may disseminate rapidly due to reduced immune surveillance. Post-surgical or traumatic wounds also serve as entry points, evolving into secondary pyodermas characterized by delayed healing and polymicrobial involvement, including Gram-negative organisms.^[34]^[33] These secondary infections typically manifest as more widespread and recurrent lesions compared to primary forms, with a higher propensity for systemic spread; for example, infected insect bites or varicella lesions can progress to multifocal pustules and erosions, increasing the risk of bacteremia in vulnerable patients.^[32]^[35] S. aureus remains the primary isolate, often with methicillin-resistant strains in 20% of cases, complicating management.^[14] Complications include scarring from chronic inflammation and post-inflammatory hyperpigmentation, particularly in darker skin types, alongside potential for deeper extension into subcutaneous tissues if untreated.^[35] In secondary pyodermas linked to atopic dermatitis, recurrent episodes heighten the risk of antimicrobial resistance and chronic skin barrier dysfunction.^[32]

Diagnosis

Clinical Assessment

The clinical assessment of pyoderma begins with a detailed history to identify risk factors and contextual clues suggestive of bacterial skin infection. Key elements include the onset and duration of lesions, which are often acute and rapidly spreading in primary forms like impetigo, typically developing within days of exposure.^[2] Inquire about preceding trauma such as cuts, insect bites, or abrasions, which serve as portals of entry for bacteria like Staphylococcus aureus or Streptococcus pyogenes.^[7] Assess for underlying immunosuppression (e.g., diabetes, HIV, or corticosteroid use), which predisposes to more severe or recurrent infections, and recent travel to tropical or resource-limited areas where poor hygiene may facilitate acquisition.^[36] Family or community clustering, particularly in impetigo among children in households or schools, highlights its contagious nature via direct contact or fomites.^[37] Physical examination focuses on inspection and palpation to characterize lesions and guide suspicion of pyoderma. Inspect for hallmark superficial features such as erythematous macules progressing to fragile pustules, vesicles, or bullae that rupture to form honey-colored crusts, often with surrounding erythema; in folliculitis, perifollicular pustules predominate in hair-bearing areas.^[2] Palpate for tenderness, fluctuance indicating deeper involvement, or regional lymphadenopathy, which may signal extension beyond the epidermis. Distribution patterns are informative: facial and perioral involvement is common in pediatric impetigo, while extremities or trunk lesions suggest secondary pyoderma or ecthyma.^[7] For example, impetigo lesions frequently cluster on exposed skin in children. Differential diagnosis requires distinguishing pyoderma from mimicking conditions through history and exam findings. Viral exanthems like varicella or herpes simplex may present with vesicles but lack crusting and are often pruritic or febrile from onset; fungal infections such as candidiasis show satellite lesions in moist areas without rapid spread.^[2] Contact dermatitis typically involves geometric patterns from irritants and responds to avoidance rather than antibiotics. Red flags for deeper involvement include fever, chills, extensive lymphadenopathy, or systemic symptoms, prompting urgent evaluation to rule out cellulitis or sepsis.^[2] Severity grading relies on lesion depth and systemic impact to inform initial management urgency. Superficial pyoderma is confined to the epidermis, manifesting as limited pustules or crusts without systemic signs, as seen in uncomplicated impetigo or folliculitis.^[36] In contrast, deep pyoderma involves the dermis or subcutaneous tissue, evidenced by painful nodules, ulcers (e.g., ecthyma with punched-out craters), fluctuance, or accompanying fever and malaise, indicating potential for bacteremia.^[2]

Microbiological Confirmation

Microbiological confirmation supports the clinical diagnosis of pyoderma by identifying the causative pathogens, particularly in atypical presentations, treatment failures, severe cases, recurrent infections, or to guide antimicrobial therapy in settings with high resistance.^[2]^[38] This involves a systematic approach to sample collection, laboratory processing, and interpretation, ensuring accurate pathogen isolation while minimizing false negatives due to contamination or prior antibiotic exposure. Sampling techniques prioritize obtaining uncontaminated specimens from active lesions to maximize diagnostic yield. For superficial pyodermas, such as impetigo or folliculitis, swabs are collected from the base of intact pustules or vesicles after gentle cleansing with sterile saline to remove surface debris, avoiding disruption of the lesion that could introduce skin flora.^[2] In deeper infections like cellulitis or abscesses, punch biopsies or aspirates from the advancing edge of the lesion provide more representative tissue samples, with care taken to use aseptic techniques such as alcohol disinfection of the skin prior to incision. These methods reduce the risk of overgrowth by commensal bacteria, which can confound results.^[38] Culture methods form the cornerstone of pathogen identification, employing selective and non-selective media tailored to common pyoderma isolates. Specimens are inoculated onto blood agar for general bacterial growth and mannitol salt agar to selectively isolate Staphylococcus aureus, which ferments mannitol and produces yellow colonies indicative of coagulase-positive strains. For streptococcal involvement, β-hemolytic streptococci are presumptively identified on blood agar by their characteristic hemolysis patterns, with further confirmation via bacitracin sensitivity testing, where group A Streptococcus pyogenes shows resistance. Incubation occurs at 35-37°C under aerobic conditions for 24-48 hours, allowing for colony morphology assessment and subculture if needed.^[2] Additional tests complement culture by providing rapid preliminary insights and resistance profiling. Gram staining of smears from lesion swabs or biopsies reveals initial bacterial morphology—such as Gram-positive cocci in clusters for staphylococci or chains for streptococci—offering immediate clues to the likely pathogen before culture results. Antibiotic susceptibility testing, typically via disk diffusion (Kirby-Bauer method) on Mueller-Hinton agar, determines minimum inhibitory concentrations for key agents like oxacillin or clindamycin, crucial for managing resistant strains. For suspected methicillin-resistant S. aureus (MRSA), polymerase chain reaction (PCR) assays targeting the mecA gene provide same-day detection with high specificity, particularly in high-prevalence settings. These tests are performed in accredited clinical laboratories adhering to Clinical and Laboratory Standards Institute (CLSI) guidelines.^[2]^[38] The diagnostic yield of these microbiological methods is high, with positive cultures obtained in 80-90% of untreated bacterial pyoderma cases, reflecting the predominance of S. aureus and streptococci as pathogens.^[33] However, limitations include false-negative results in early-stage infections with low bacterial loads or in patients recently treated with antibiotics, which can suppress growth; in such scenarios, molecular methods like PCR may offer superior sensitivity. Contamination remains a challenge, particularly with superficial swabs, underscoring the need for strict procedural protocols.^[2]

Management

Treatment Approaches

The treatment of bacterial pyodermas in humans primarily involves antimicrobial therapy tailored to the depth and extent of infection, with topical agents preferred for localized superficial cases such as impetigo. For such instances, mupirocin ointment applied two to three times daily is recommended, typically for 5 to 7 days, as it effectively targets Staphylococcus aureus and Streptococcus pyogenes.^[2]^[5] Systemic antibiotics are indicated for widespread superficial pyodermas, bullous impetigo, or deeper infections such as cellulitis, with first-line options including cephalexin at 500 mg orally every 6 hours or dicloxacillin 500 mg orally every 6 hours for a course of 7 to 10 days.^[2]^[39] In cases of suspected methicillin-resistant S. aureus (MRSA), clindamycin 300-450 mg orally every 6-8 hours or trimethoprim-sulfamethoxazole (one double-strength tablet twice daily) is selected based on culture and sensitivity results.^[2] For severe deep infections with confirmed resistant organisms, intravenous vancomycin (15-20 mg/kg every 8-12 hours, adjusted for renal function) may be used.^[2] Adjunctive care enhances outcomes by addressing complications such as abscess formation, where incision and drainage is essential to remove purulent material and promote healing.^[2] Wound care involves gentle cleaning with soap and water, followed by non-adherent dressings to protect lesions, while analgesics such as ibuprofen manage pain associated with infections.^[5] Therapeutic monitoring involves reassessing the patient 48 to 72 hours after initiating treatment, with expected signs of resolution including reduced erythema and exudate; if no improvement occurs, therapy should be adjusted based on cytology, culture, or sensitivity results.^[2] Minimum treatment durations are 5 to 7 days for uncomplicated superficial pyodermas and 7 to 14 days for deeper infections to prevent relapse, with follow-up cultures recommended for recurrent or resistant cases.^[2]^[39]

Prevention Strategies

Preventing pyoderma, a common bacterial skin infection often caused by Staphylococcus aureus or Streptococcus pyogenes, relies on multifaceted strategies emphasizing hygiene and risk reduction to minimize incidence and recurrence. Personal hygiene practices form the cornerstone of prevention, with regular handwashing using soap and water for at least 20 seconds significantly reducing bacterial transmission, particularly in households or communities with active cases. Keeping fingernails trimmed short helps prevent scratching of the skin, which can introduce bacteria through minor abrasions and exacerbate spread during outbreaks. Additionally, avoiding the sharing of personal items such as towels, clothing, or linens is crucial in outbreak settings, as these can harbor pathogens and facilitate indirect transmission among close contacts.^[5] Environmental controls play a vital role in high-transmission areas, such as schools and communities with poor sanitation. Improving access to clean water and sanitation infrastructure has been shown to lower pyoderma prevalence by enabling consistent hygiene practices and reducing overcrowding, a key risk factor in endemic regions. In tropical or humid endemic areas where insect bites contribute to skin breaches leading to secondary infections, the use of mosquito nets alongside insect repellents can help mitigate entry points for bacteria.^[5] Vaccination efforts and prophylactic measures target underlying bacterial carriage to curb pyoderma onset. While no licensed vaccine exists for group A streptococcus (GAS), which causes many pyoderma cases, prompt antibiotic treatment of strep throat infections prevents GAS dissemination and associated complications like post-streptococcal glomerulonephritis, indirectly reducing skin infection risks in vulnerable populations. For S. aureus carriers prone to recurrent pyoderma, intranasal mupirocin ointment applied twice daily to the nares for 5 days monthly can eradicate nasal colonization and decrease recurrence rates by approximately 50%.^[2] In high-risk groups, tailored interventions address specific vulnerabilities. Individuals with atopic dermatitis benefit from diligent skin care routines, including daily moisturizing with emollients to maintain the skin barrier and prevent fissures that predispose to bacterial entry. For those with diabetes, achieving and maintaining glycemic control through diet, medication, and monitoring significantly lowers the incidence of skin infections, including pyoderma, by bolstering immune function and wound healing. Immunocompromised patients require vigilant surveillance, such as regular skin examinations and protective measures against trauma, to enable early detection and intervention, thereby averting severe or recurrent episodes.^[2]

Non-Bacterial Forms

Pyoderma Gangrenosum

Pyoderma gangrenosum (PG) is a rare, sterile, inflammatory neutrophilic dermatosis characterized by the rapid development of painful ulcers with undermined, violaceous borders and a necrotic base, often beginning as a tender papule, nodule, or pustule that breaks down within days.^[40] The classic presentation involves lower extremities, particularly the pretibial area, though lesions can occur anywhere on the body, including peristomal sites or surgical wounds, and are frequently exacerbated by minor trauma due to pathergy—a hyperreactive inflammatory response to injury.^[41] Unlike infectious bacterial pyodermas, PG shows negative bacterial cultures and lacks response to antimicrobial therapy.^[40] The pathogenesis of PG is autoimmune in nature, involving dysregulated neutrophil recruitment, cytokine overproduction (such as TNF-α and IL-8), and T-cell mediated inflammation, without evidence of bacterial involvement.^[42] It is strongly associated with underlying systemic conditions, including inflammatory bowel disease in 20-30% of cases, rheumatoid arthritis in approximately 10-12%, and hematologic malignancies in 3-5%.35894-2/fulltext) Pathergy plays a central role, where even trivial trauma can trigger or worsen lesions, highlighting the role of aberrant innate immune responses.^[41] Epidemiologically, PG primarily affects adults over 50 years of age, with a slight female predominance (female-to-male ratio >1.8), though it can occur across all ages.^[43] The annual incidence is estimated at 3-10 cases per million population, making it a uncommon disorder with significant morbidity.^[44] Complications of PG include permanent scarring with cribriform or atrophic patterns, secondary bacterial infections due to ulceration, and severe pain often requiring opioid management.^[40] Extracutaneous involvement occurs in about 5% of cases, most commonly manifesting as sterile pulmonary infiltrates, but can affect other organs such as the eyes, lungs, or gastrointestinal tract.^[45]

Other Neutrophilic Dermatoses

Other neutrophilic dermatoses encompass a group of inflammatory skin conditions characterized by sterile infiltration of neutrophils into the dermis, mimicking pyoderma but without bacterial involvement. These disorders often present with painful plaques, ulcers, or pustules and may be associated with systemic symptoms or underlying diseases. Unlike bacterial pyodermas, they respond to immunosuppressive therapies rather than antibiotics. Pyoderma gangrenosum serves as a prototype for these conditions, featuring rapid ulceration with neutrophilic histology, though its detailed features are covered separately.^[46] Sweet's syndrome, also known as acute febrile neutrophilic dermatosis, manifests with sudden onset of tender, erythematous papules, nodules, or plaques, predominantly on the face, neck, and upper extremities, accompanied by fever and neutrophilia in approximately 50-70% of cases. It is associated with malignancies (15-30%, particularly hematologic like acute myeloid leukemia), infections, inflammatory conditions such as inflammatory bowel disease, or drug exposures like granulocyte colony-stimulating factor. The condition is often self-limited, resolving within weeks, but systemic corticosteroids (e.g., prednisone 0.5-1 mg/kg/day) induce rapid improvement in most patients.^[47] Behçet's disease involves recurrent oral and genital ulcers alongside skin lesions resembling pyoderma, such as papulopustular eruptions, erythema nodosum-like nodules, or pyoderma gangrenosum-like ulcers, primarily affecting the lower extremities and trunk. These lesions arise from neutrophilic vascular inflammation and leukocytoclastic vasculitis, contributing to a systemic vasculitis that also impacts eyes (uveitis in >50%), joints, and vessels. Skin manifestations occur in 70-90% of patients and are driven by heightened neutrophil activation and chemotaxis defects.^[48] PAPA syndrome (pyogenic arthritis, pyoderma gangrenosum, and acne) is a rare autoinflammatory disorder caused by mutations in the PSTPIP1 gene, leading to hyperactivation of the inflammasome and excessive interleukin-1 production. Clinically, it features sterile pyogenic arthritis starting in childhood, severe cystic acne, and pyoderma gangrenosum-like skin ulcers with neutrophilic infiltrates. The pyoderma lesions are non-infectious, often recurring and resistant to antibiotics, requiring immunosuppressive agents similar to those for pyoderma gangrenosum.^[49] These neutrophilic dermatoses are differentiated from bacterial pyoderma by the absence of microbial organisms on biopsy, Gram stain, and culture, revealing instead a dense, sterile dermal neutrophilic infiltrate without evidence of infection. Clinical clues include pathergy (lesion exacerbation by trauma) and lack of response to antimicrobials, with histopathology showing papillary edema and fragmented nuclei in Sweet's syndrome or ulceration with neutrophils in PAPA and Behçet's, confirming the non-infectious etiology.^[46]

Pyoderma in Animals

In Dogs

Pyoderma is one of the most common bacterial skin infections in dogs, accounting for a significant portion of dermatological cases in veterinary practice, with superficial forms being the most frequent reason for antimicrobial prescriptions. It often occurs as a secondary condition to underlying issues such as allergies, particularly atopic dermatitis, or endocrinopathies like hypothyroidism, affecting up to 60% of recurrent cases.^[50]^[51] The primary causative agent is Staphylococcus pseudintermedius, a canine-specific staphylococcal species isolated in approximately 90% of superficial pyoderma cases, though other bacteria like Pseudomonas species may contribute in deep infections. Pyoderma is classified as superficial, involving folliculitis and furunculosis with epidermal involvement, or deep, such as pododermatitis affecting the foot pads or intertrigo in skin folds. Predisposing factors include impaired skin barrier function from atopy, ectoparasites, trauma, or conformational issues like skin folds that trap moisture and promote bacterial overgrowth.^[50]^[52]^[53] Clinical signs of superficial pyoderma typically include follicular papules, pustules, epidermal collarettes, alopecia, and scaling, often on the trunk, ventrum, or face, with variable pruritus. Deep pyoderma presents with more severe features such as painful nodules, draining tracts, ulceration, exudation, and a malodorous discharge, particularly in intertriginous areas or pododermatitis of the paws. Approximately 60% of recurrent pyodermas are associated with underlying atopic dermatitis, leading to chronic relapses if the primary condition is not managed.^[54]^[51] According to the 2025 ISCAID guidelines, treatment prioritizes topical antimicrobials for superficial pyoderma, using chlorhexidine-based shampoos or leave-on products (2–4% concentration) applied 2–3 times weekly until resolution, to minimize systemic antibiotic use and resistance. Systemic antibiotics, such as cephalexin at 25–30 mg/kg orally every 12 hours for 3–4 weeks (or until clinical resolution plus 7 days), are first-line for deep pyoderma or extensive/non-responsive superficial cases, with alternatives like amoxicillin-clavulanate if beta-lactamase resistance is suspected; durations may extend to 6–8 weeks for deep infections. Culture and sensitivity testing is recommended for recurrent, deep, or non-responsive cases, particularly given the increasing prevalence of methicillin-resistant S. pseudintermedius (MRSP; 0–28% regionally as of 2025), which requires alternative therapies like clindamycin if susceptible. Addressing underlying causes, such as hypothyroidism through hormone supplementation, is critical to prevent recurrence.^[50]^[54]^[53]^[55]

In Other Species

Pyoderma in cats is less common than in dogs but often presents as a secondary infection to underlying conditions such as allergies, ectoparasites like fleas, immune deficiencies (e.g., FIV or FeLV), or trauma from scratches and bites.^[56] The primary pathogens include Staphylococcus pseudintermedius and Pasteurella multocida, leading to symptoms like excessive scaling, crusting, miliary dermatitis, alopecia, erythema, and pruritus.^[56] Diagnosis typically involves cytology to identify bacterial rods and neutrophils, with treatment requiring systemic antibiotics for at least 3 weeks, often extended to 8–12 weeks for deep infections, alongside topical therapies like chlorhexidine shampoos.^[56] In horses, pyoderma is frequently staphylococcal, caused by Staphylococcus aureus, and manifests as pruritic dermatitis with circular crusts, scaling, and alopecia, commonly affecting the pasterns, neck, and thighs.^[57] It often arises secondarily to environmental irritants like insect bites or moisture, with methicillin-resistant strains (MRSA) increasingly reported, necessitating culture-guided antibiotic therapy such as trimethoprim-sulfamethoxazole.^[57]^[58] Topical antiseptics aid in lesion management, and hygiene improvements prevent recurrence.^[57] Pigs commonly experience pyoderma as exudative epidermitis (greasy pig disease), a generalized superficial infection primarily due to toxin-producing Staphylococcus hyicus in piglets aged 5–60 days.^[59] Clinical signs include nonpruritic erythema, greasy exudates, crusting, and pustules spreading from the face and limbs, with morbidity up to 90% and mortality of 5–90% in affected litters.^[59] Predisposing factors involve poor hygiene, stress, and mycotoxins; treatment with penicillin or amoxicillin, combined with topical chlorhexidine, resolves most cases, though resistant S. aureus strains like MRSA can complicate outbreaks.^[59]^[60] In cattle, pyoderma is uncommon but associated with Staphylococcus aureus infections, often secondary to trauma or immunosuppression, presenting as localized abscesses or dermatitis; drug-resistant strains, including MRSA, have been documented in herds.^[58]^[61] Among exotic species, superficial pyoderma is rare but occurs in guinea pigs as a complication of pododermatitis, featuring nonpruritic bacterial overgrowth with crusting foot lesions, typically managed with topical antimicrobials after addressing obesity or wire flooring.^[62] In rodents like mice and rats, it may arise from barbering behaviors, leading to secondary staphylococcal infections treated via environmental enrichment and antibiotics.^[62] Marine mammals can develop secondary pyoderma from chronic parasitic infestations, with lesions showing pustules and requiring systemic therapy.^[63]

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Pyoderma refers to a group of superficial bacterial infectious syndromes involving the skin and follicular structures. These include impetigo contagiosa, ...Missing: etymology classification
[11]
Clinical and Bacteriological Aspects of Pyoderma - PMC
Pyoderma is one of the commonest clinical conditions encountered in dermatological practice.[1] Primary pyodermas are impetigo, follicultis, furuncle, ...
[12]
Pyoderma Gangrenosum - StatPearls - NCBI Bookshelf
Pyoderma gangrenosum is an ulcerative disorder that falls into the category of neutrophilic dermatoses.
[13]
Impetigo, Erysipelas and Cellulitis - Streptococcus pyogenes - NCBI
Feb 10, 2016 · Cellulitis and erysipelas can be mild or moderately severe, while necrotizing fasciitis, myonecrosis and StrepTSS are life-threatening. This ...
[14]
Erysipelas - an overview | ScienceDirect Topics
First, the distinction between erysipelas and cellulitis is the depth of infection. Erysipelas is a more superficial infection affecting the superficial dermis, ...
[15]
The Global Epidemiology of Impetigo: A Systematic Review of the ...
Aug 28, 2015 · We estimate the global population of children suffering from impetigo at any one time to be in excess of 162 million, predominantly in tropical, resource-poor ...
[16]
A Systematic Review of the Population Prevalence of Impetigo and ...
Based on population surveillance, 82 studies included data on 145,028 children assessed for pyoderma or impetigo. ... 111 million children with impetigo.[1] ...
[17]
Clinico-bacteriological study of pyodermas in children - PubMed
Primary pyodermas were observed in 72% of the children, and secondary pyodermas in 28%. Impetigo was the commonest primary pyoderma (48.61%); among secondary ...Missing: 10 predominance 61.2% 65.5%
[18]
Association of socio‐demographic factors and personal hygiene ...
A total of 364 children were enroled with mean age of 6.97 ± 4.23 years. Females (52.5%) were slightly more than males (47.5%). There were 201 (55.2%) ...
[19]
Epidemiology, Virulence Factors, and Antimicrobial Resistance in ...
Aug 4, 2025 · The prevalence of S. aureus and MRSA was 33.6% (n = 76) and 8% (n = 18), respectively. At the nine LTCFs studied, the prevalence ...
[20]
Positive Methicillin-Resistant Staphylococcus Aureus
Dec 22, 2023 · The prevalence of CA-MRSA among all pyodermas was 3.5% in our community. The PVL gene was not detected in all tested CA-MRSA and CA-MSSA ...
[21]
Global Burden of Bacterial Skin Diseases: A Systematic Analysis ...
In 2019, age-standardized incidence rates were 146.84 million [143.21–151.34] for pyoderma and 0.28 million [0.21–0.34] for cellulitis (Supplementary Table 1).Missing: demographics gender
[22]
Genetic diversity and antimicrobial resistance profiles of ... - NIH
Apr 17, 2023 · Pyoderma treatment is a challenge in veterinary medicine due to increasing antimicrobial resistance and limited antimicrobials approved for use ...
[23]
Regulatory Mechanism for Exfoliative Toxin Production in ...
The exfoliative toxin (ET) is a major virulence factor of Staphylococcus aureus that causes bullous impetigo and its disseminated form, staphylococcal scalded- ...
[24]
Virulence Potential of Biofilm-Producing Staphylococcus ... - NIH
Sep 30, 2022 · In this study, we demonstrated that biofilm formation is a frequent trait in CoPS causing pyoderma in companion animals, with 65.4% (155/237) ...
[25]
Skin Infections Due to Panton-Valentine Leukocidin–Producing S ...
Panton-Valentine leukocidin (PVL)–producing Staphylococcus aureus (PVL-SA) strains are frequently associated with large, recurring abscesses in otherwise ...
[26]
A Quantitative Assessment of Staphylococcus aureus Community ...
In the United States, carriage is estimated at approximately one third of the population [8–12]. Carriage is higher in children than in adults and peaks between ...Abstract · METHODS · RESULTS · DISCUSSION
[27]
https://nepjol.info/index.php/NJDVL/article/view/6417/5220
[28]
Relation between Risk Factors of Pyoderma and Pyoderma Incidence
Oct 28, 2025 · PDF | Background: Pyoderma is a purulent bacterial infection of the skin ... In this review, we summarize the findings of epidemiological ...
[29]
Staphylococcus aureus and Hyper-IgE Syndrome - MDPI
Dec 1, 2020 · Hyper-immunoglobulin E syndrome (HIES) is a primary immunodeficiency disease characterized by recurrent Staphylococcus aureus (S. aureus) infections, eczema, ...
[30]
Cutaneous Manifestations of HIV - Medscape Reference
Jan 1, 2025 · Atopic eczema may be severe in children infected with HIV. Increased serum IgE levels have been found in these children; however, increased IgE ...
[31]
Superficial Cutaneous Infections and Pyodermas - Plastic Surgery Key
Jun 11, 2016 · Conditions predisposing to S. aureus colonization include atopic dermatitis, diabetes mellitus (insulin dependent), dialysis (hemo- and ...Staphylococcal Skin... · Etiology And Pathogenesis · Clinical Findings<|control11|><|separator|>
[32]
[PDF] Socioeconomic and Nutritional Status of Children with Pyodermas
2 Skin of the children is more susceptible to cutaneous infections and infestations due to immature immune system and more exposure to sub clinical ...
[33]
Folliculitis - StatPearls - NCBI Bookshelf - NIH
Aug 8, 2023 · Folliculitis is a common, generally benign, skin condition in which the hair follicle becomes infected/inflamed and forms a pustule or erythematous papule.Etiology · Treatment / Management · Review Questions
[34]
Staphylococcal Scalded Skin Syndrome and Bullous Impetigo - PMC
Oct 24, 2021 · In contrast to nonbullous impetigo, bullous impetigo does not form a honey-colored crust.6. Differential Diagnosis · Table 2 · 4. Differential Diagnosis
[35]
Overview: Boils and carbuncles - InformedHealth.org - NCBI Bookshelf
Nov 22, 2022 · A boil (furuncle) is a pus-filled bump in the skin that is caused by a bacterial infection. It is a bit like a very big yellow pimple, ...Missing: carbunculosis | Show results with:carbunculosis
[36]
Secondary Bacterial Infections in Patients with Atopic Dermatitis or ...
Apr 5, 2024 · Secondary bacterial infections of common dermatoses such as atopic dermatitis, ectoparasitosis, and varicella zoster virus infections are frequent.
[37]
A Clinico-Bacteriological Study of Pyodermas at a Tertiary Health ...
Furuncle was the most common primary pyoderma while infective eczema, the commonest secondary pyoderma. · Although Staphylococcus aureus was the most common ...
[38]
Bacterial skin and soft tissue infections in adults: A review of their ...
Among hospitalized patients, the estimated prevalence of SSTIs is 7% to 10% (8,9). Among all hospitalized patients with infections only, SSTIs take on a more ...
[39]
Bacterial Skin Infections (bacteria) - DermNet
Skin infections can be caused by bacteria (often Staphylococcal or Streptococcal) either invading normal skin, or affecting a compromised skin barrier.Missing: classification | Show results with:classification
[40]
Superficial Cutaneous Infections and Pyodermas
Pyodermas are infections of the skin that are pyogenic (ie, filled with pus). The majority of the cutaneous pyodermas are caused by Staphylococcus aureus or ...<|control11|><|separator|>
[41]
Case-based learning: impetigo - The Pharmaceutical Journal
Sep 15, 2020 · History-taking should include onset, duration and location of lesions and potential sources of infection (e.g. skin trauma, insect bites and ...
[42]
Topical Treatment of Canine Superficial Pyoderma
Dec 8, 2023 · Mupirocin 2% ointment can be used for localized superficial and deep pyoderma in dogs.
[43]
Topical therapy for canine pyoderma: what is new? in - AVMA Journals
Specifically, extracts of Melaleuca alternifolia (tea tree oil) have been proven to be highly effective in killing isolates of S aureus and E coli at ...
[44]
Treating pyoderma without the use of systemic antibiotics - PMC - NIH
Topical therapy with twice weekly 4% chlorhexidine shampoo combined with daily 4% chlorhexidine spray was found to be as effective as systemic antibiotic ...
[45]
Antimicrobial use guidelines for canine pyoderma by the ...
May 7, 2025 · To provide clinicians with antimicrobial treatment guidelines for staphylococcal pyoderma, including those involving meticillin‐resistant staphylococci.
[46]
Table 4: Antimicrobials for Skin Infections in Dogs - AAHA
Oct 28, 2023 · Find out which antimicrobials are recommended for treating skin infections in dogs. Learn about dosage and administration to effectively ...<|control11|><|separator|>
[47]
Parenterally administered vancomycin in 29 dogs and 7 cats (2003 ...
A successful vancomycin treatment of multidrug‐resistant MRSA‐associated canine pyoderma. J Dermatol Res Ther. 2016;1:12‐18. [Google Scholar]; 20. Sykes JE ...
[48]
Point prevalence of canine pyoderma of Staphylococcus aureus
aureus was intermediately sensitive or resistant to all the antibiotics except vancomycin and clindamycin. The dogs took 36.67 ± 6.09 days, 55.00 ± 5.44 ...
[49]
Pyoderma in Dogs and Cats - Integumentary System
"Pyoderma" generally refers to bacterial dermatitis. Clinical signs of pyoderma vary depending on the pathogenic organism involved and the depth of infection.Etiology Of Pyoderma In Dogs... · Topical Therapy For Pyoderma · Key Points
[50]
Challenges & New Developments in Canine Pyoderma: Topical ...
As discussed in Part 1 of this series (Disease Overview & Diagnosis), canine pyoderma can be classified by depth of infection as: Superficial or surface ...Missing: flags | Show results with:flags
[51]
Pyoderma Clinical Trial: How Long Should You Treat?
May 12, 2023 · Current recommendations for superficial pyoderma say to treat with oral antibiotics for at least three weeks, or one week past resolution of symptoms.
[52]
Pyoderma gangrenosum – a review
Apr 15, 2007 · Pyoderma gangrenosum (PG) is a primarily sterile inflammatory neutrophilic dermatosis. It is characterized by recurrent cutaneous ulcerations ...Clinical Presentation · Treatment · Systemic Therapy<|control11|><|separator|>
[53]
The Pathophysiology and Treatment of Pyoderma Gangrenosum ...
Feb 19, 2024 · Pyoderma gangrenosum (PG) is an uncommon inflammatory dermatological disorder characterized by painful ulcers that quickly spread peripherally.
[54]
Prevalence estimates for pyoderma gangrenosum in the United States
Conclusion: PG is a rare disease that most commonly affects women and those aged ≥50 years. Keywords: epidemiology; female; prevalence; pyoderma gangrenosum.
[55]
Epidemiology of pyoderma gangrenosum: Results from an Italian ...
The world‐wide incidence of PG is estimated to be around 3 to 10 cases per million population per year, usually affecting patients aged 25 to 54 years without a ...
[56]
Pyoderma Gangrenosum: Background, Epidemiology, Prognosis
Dec 3, 2024 · Pyoderma gangrenosum is an uncommon ulcerative cutaneous condition whose cause is uncertain. Although the etiology of this condition is poorly understood.
[57]
Neutrophilic Dermatoses: a Clinical Update - PMC - PubMed Central
Neutrophilic dermatoses are defined by the presence of a sterile neutrophilic infiltrate on histopathology. This review focuses on the pathogenesis, ...
[58]
Acute Febrile Neutrophilic Dermatosis - StatPearls - NCBI Bookshelf
Feb 1, 2024 · Acute febrile neutrophilic dermatosis (AFND), also known as Sweet syndrome or Gomm-Button disease, manifests as erythematous plaques and papules.
[59]
Behcet Disease - StatPearls - NCBI Bookshelf - NIH
Feb 22, 2023 · ... neutrophil chemotaxis, and phagocytosis have been observed in lesions of Behcet disease. Mucocutaneous lesions, including oral aphthae, skin ...
[60]
Clinical and genetic analyses in a patient with PAPA syndrome ... - NIH
Sep 30, 2015 · PAPA (pyogenic arthritis, pyoderma gangrenosum and acne) syndrome is an autoinflammatory disease linked to mutations in the PSTPIP1 gene.
[61]
Canine Pyoderma: Disease Overview & Diagnosis
In one prospective study of 30 cases of canine recurrent pyoderma:8 • Atopic dermatitis was found in 60% of cases. Atopic dogs are prone to recurrent skin ...
[62]
Canine pyoderma: predisposing factors and preventive treatment
Most superficial pyodermas in dogs are caused by Staphylococcus pseudintermedius (90% of cases). This bacterium is considered resident biota in a dog's skin in ...
[63]
The Complex Diseases of Staphylococcus pseudintermedius ... - NIH
Jan 18, 2021 · Canine pyoderma is one of the most common bacterial skin infections diagnosed in small veterinary medicine and is associated with redness, ...
[64]
Pyoderma in Dogs - Dog Owners - Merck Veterinary Manual
Pyoderma literally means “pus in the skin.” It can be caused by infection, inflammation, or cancer and is common in dogs.
[65]
Bacterial Skin Infections (Pyoderma) in Cats - PetMD
May 25, 2023 · Bacterial skin infections in cats may be referred to as pyoderma. Both phrases relate to disease of the skin caused by germs.
[66]
Staph Pyoderma and Pruritus in Horses - Veterinary Partner - VIN
Dec 2, 2007 · One of the most common causes of itchy skin is a bacterial infection of the skin. According to the equine dermatologists at U.C. Davis, the most ...
[67]
If drug-resistant pyoderma scares you, don't panic. Plan. - DVM360
Sep 24, 2020 · Minimize pet contact with young and immunocompromised people. · Practice good hand hygiene. · Administer the full antibiotic prescription. · Wear ...Missing: surveillance | Show results with:surveillance
[68]
Exudative Epidermitis in Pigs - Integumentary System
Exudative epidermitis is a generalized staphylococcal infection that affects young pigs. Clinical signs include depression and reddening of skin.
[69]
Exudative Epidermitis in Combination with Staphylococcal ...
Jul 9, 2021 · All piglets in three out of four litters showed a generalized dermatitis with typical signs of EE: exudation, crusting, pyoderma and erythema ( ...
[70]
Staphylococcus aureus in Animals - PMC - PubMed Central
Staphylococcus aureus is a mammalian commensal and opportunistic pathogen that colonizes niches such as skin, nares and diverse mucosal membranes of about ...
[71]
Itchy Exotics - WSAVA2007 - VIN
Superficial Bacterial Pyoderma is relatively rare in exotics. It may complicate barbering in Mice & Rats. It is frequent in pododermatitis of Guinea pigs (non- ...
[72]
Parasitic Diseases of Marine Mammals - Merck Veterinary Manual
Secondary bacterial infection that results in pyoderma is seen in chronic cases. ... These coccidia are probably susceptible to anticoccidial drugs (eg, amprolium) ...