Ecthyma Clinical Presentation

  • Author: Loretta Davis, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 11, 2012
 

History

  • Ecthyma usually arises on the lower extremities of children, persons with diabetes, and neglected elderly patients.
  • During wartime in tropical climates, ecthymatous ulcers are commonly found on the ankles and dorsi of the feet.
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Physical

  • Ecthyma begins as a vesicle or pustule overlying an inflamed area of skin that deepens into a dermal ulceration with overlying crust.
    • The crust of ecthyma lesions is gray-yellow and is thicker and harder than the crust of impetigo.
    • A shallow, punched-out ulceration is apparent when adherent crust is removed.
    • The deep dermal ulcer has a raised and indurated surrounding margin.
  • Ecthyma lesions can remain fixed in size (sometimes resolving without treatment) or can progressively enlarge to 0.5-3 cm in diameter.
  • Ecthyma heals slowly and commonly produces a scar.
  • Regional lymphadenopathy is common, even with solitary lesions.
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Causes

  • Ecthyma can be seen in areas of previously sustained tissue injury (eg, excoriations, insect bites, dermatitis).
  • Ecthyma can be seen in patients who are immunocompromised (eg, diabetes, neutropenia, HIV infection).[2]
  • Important factors contribute to the development of streptococcal pyodermas or ecthyma.
    • High temperature and humidity[3, 4]
    • Crowded living conditions
    • Poor hygiene
  • Untreated impetigo that progresses to ecthyma most frequently occurs in patients with poor hygiene.
  • Some strains of Streptococcus pyogenes have a high affinity for both pharyngeal mucosa and skin. Pharyngeal colonization of S pyogenes has been documented in patients with ecthyma.[1]
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Contributor Information and Disclosures
Author

Loretta Davis, MD  Professor, Department of Internal Medicine, Division of Dermatology, Medical College of Georgia

Loretta Davis, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Donald Belsito, MD  Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center

Donald Belsito, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Dermatology Foundation, New York County Medical Society, New York Dermatological Society, Noah Worcester Dermatological Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Lester F Libow, MD  Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association

Disclosure: Nothing to disclose.

Joel M Gelfand, MD, MSCE  Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania

Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology

Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds Investigator; Genentech Grant/research funds investigator; Centocor Consulting fee Consulting; Abbott Grant/research funds investigator; Abbott Consulting fee Consulting; Novartis investigator; Pfizer Grant/research funds investigator; Celgene Consulting fee DMC Chair; NIAMS and NHLBI Grant/research funds investigator

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, and previous author, Carmen Mays, MD, to the development and writing of this article.

References

  1. [Best Evidence] Wasserzug O, Valinsky L, Klement E, et al. A cluster of ecthyma outbreaks caused by a single clone of invasive and highly infective Streptococcus pyogenes. Clin Infect Dis. May 1 2009;48(9):1213-9. [Medline].

  2. Ko WT, Adal KA, Tomecki KJ. Infectious diseases. Med Clin North Am. Sep 1998;82(5):1001-31, v. [Medline].

  3. Singh G. Heat, humidity and pyodermas. Dermatologica. 1973;147(5):342-7. [Medline].

  4. Allen AM, Taplin D, Twigg L. Cutaneous streptococcal infections in Vietnam. Arch Dermatol. Sep 1971;104(3):271-80. [Medline].

  5. Dagan R, Bar-David Y. Double-blind study comparing erythromycin and mupirocin for treatment of impetigo in children: implications of a high prevalence of erythromycin-resistant Staphylococcus aureus strains. Antimicrob Agents Chemother. Feb 1992;36(2):287-90. [Medline].

  6. Kelly C, Taplin D, Allen AM. Streptococcal ecthyma. Treatment with benzathine pencillin G. Arch Dermatol. Mar 1971;103(3):306-10. [Medline].

  7. Duve S, Voack C, Rakoski J, Hoffmann H. Extensive inguinal lymphadenitis. Ecthyma with inguinal lymphadenitis. Arch Dermatol. Jul 1996;132(7):823, 826. [Medline].

  8. Epstein ME, Amodio-Groton M, Sadick NS. Antimicrobial agents for the dermatologist. I. Beta-lactam antibiotics and related compounds. J Am Acad Dermatol. Aug 1997;37(2 Pt 1):149-65; quiz 166-8. [Medline].

  9. Hewitt WD, Farrar WE. Bacteremia and ecthyma caused by Streptococcus pyogenes in a patient with acquired immunodeficiency syndrome. Am J Med Sci. Jan 1988;295(1):52-4. [Medline].

  10. Leyden JJ, Kligman AM. Rationale for topical antibiotics. Cutis. Oct 1978;22(4):515-20, 522-8. [Medline].

  11. Peter G, Smith AL. Group A streptococcal infections of the skin and pharynx (first of two parts). N Engl J Med. Aug 11 1977;297(6):311-7. [Medline].

  12. Pichichero ME. Group A beta-hemolytic streptococcal infections. Pediatr Rev. Sep 1998;19(9):291-302. [Medline].

  13. Ray WA, Murray KT, Meredith S, Narasimhulu SS, Hall K, Stein CM. Oral erythromycin and the risk of sudden death from cardiac causes. N Engl J Med. Sep 9 2004;351(11):1089-96. [Medline].

  14. Sadick NS. Current aspects of bacterial infections of the skin. Dermatol Clin. Apr 1997;15(2):341-9. [Medline].

  15. Witkowski JA, Parish LC. Bacterial skin infections: management of common streptococcal and stapylococcal lesions. Postgrad Med. Oct 1982;72(4):166-8, 171-3, 176-8 passim. [Medline].

 
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Typical ecthyma lesions of the lower extremities.
The stages of ecthyma. The lesion begins as a pustule that later erodes and ultimately forms an ulcer.
 
 
 
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