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Ecthyma Clinical Presentation

  • Author: Loretta Davis, MD; Chief Editor: William D James, MD  more...
Updated: Jun 07, 2016


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.



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.



Ecthyma can be seen in areas of previously sustained tissue injury (eg, excoriations, insect bites, dermatitis). Insect bites in the setting of recent travel have been associated with ecthyma.[2]

Ecthyma can be seen in patients who are immunocompromised (eg, diabetes, neutropenia, HIV infection).[4]

Important factors that contribute to the development of streptococcal pyodermas or ecthyma include the following:

  • High temperature and humidity [5, 6]
  • 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.[3] Ecthyma has also been reported in the setting of perianal streptococcal disease.[7]

Contributor Information and Disclosures

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

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

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

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

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: New York County Medical Society, Noah Worcester Dermatological Society, Phi Beta Kappa, American Contact Dermatitis Society, Dermatology Foundation, Dermatologic Society of Greater New York, Alpha Omega Alpha, American Academy of Dermatology

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Carmen Mays, MD, to the development and writing of this article.

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

  2. Hochedez P, Canestri A, Lecso M, Valin N, Bricaire F, Caumes E. Skin and soft tissue infections in returning travelers. Am J Trop Med Hyg. 2009 Mar. 80 (3):431-4. [Medline].

  3. 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. 2009 May 1. 48(9):1213-9. [Medline].

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

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

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

  7. Gunawardane ND, Laumann A. An immunocompromised patient with recent-onset skin lesions. JAMA. 2014 Mar 5. 311 (9):957-8. [Medline].

  8. 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. 1992 Feb. 36(2):287-90. [Medline].

  9. [Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15. 59(2):e10-52. [Medline]. [Full Text].

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

  11. Barclay L. IDSA: skin and soft tissue infections guidelines updated. Medscape Medical News. Available at Accessed: June 26, 2014.

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 with adherent crust.
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