eMedicine Specialties > Dermatology > Bacterial Infections

Ecthyma

Author: Loretta Davis, MD, Professor, Department of Internal Medicine, Division of Dermatology, Medical College of Georgia
Contributor Information and Disclosures

Updated: Nov 6, 2009

Introduction

Background

Ecthyma is an ulcerative pyoderma of the skin caused by group A beta-hemolytic streptococci. Because ecthyma extends into the dermis, it is often referred to as a deeper form of impetigo.

Typical ecthyma lesions of the lower extremities.

Typical ecthyma lesions of the lower extremities.

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Typical ecthyma lesions of the lower extremities.

Typical ecthyma lesions of the lower extremities.


The stages of ecthyma. The lesion begins as a pus...

The stages of ecthyma. The lesion begins as a pustule that later erodes and ultimately forms an ulcer.

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The stages of ecthyma. The lesion begins as a pus...

The stages of ecthyma. The lesion begins as a pustule that later erodes and ultimately forms an ulcer.


Pathophysiology

Ecthyma begins similarly to superficial impetigo. Group A beta-hemolytic streptococci may initiate the lesion or may secondarily infect preexisting wounds. Preexisting tissue damage (eg, excoriations, insect bites, dermatitis) and immunocompromised states (eg, diabetes, neutropenia) predispose patients to the development of ecthyma. Spread of skin streptococci is augmented by crowding and poor hygiene.

Frequency

International

The exact incidence of ecthyma worldwide remains unknown.

Mortality/Morbidity

Ecthyma rarely leads to systemic symptoms or bacteremia. Lesions are painful and can have associated lymphadenopathy. Secondary lymphangitis and cellulitis can occur. Ecthyma does heal with scarring. The rate of poststreptococcal glomerulonephritis is approximately 1%.

Race

No racial predisposition is recognized for ecthyma.

Sex

No sexual predisposition is recognized for ecthyma.

Age

Ecthyma has a predilection for children and elderly individuals. Outbreaks have also been reported in young military trainees.1

Clinical

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.

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.

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 humidity3,4
    • 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

More on Ecthyma

Overview: Ecthyma
Differential Diagnoses & Workup: Ecthyma
Treatment & Medication: Ecthyma
Follow-up: Ecthyma
Multimedia: Ecthyma
References
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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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Further Reading

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Keywords

ecthyma, ulcerative pyoderma, cutaneous pyoderma, impetigo, deep impetigo, pyodermic lesion, skin streptococci, group A beta-hemolytic streptococci, group A beta-hemolytic Streptococcus, GABHS, ecthymatous ulcer, ecthymatous ulceration, group A streptococci, GAS, group A Streptococcus

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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.

Medical Editor

Donald Belsito, MD, Clinical Professor, Department of Internal Medicine, Division of Dermatology, University of Missouri at Kansas City; Private Practice, American Dermatology Associates, LLC
Donald Belsito, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, Dermatology Foundation, Kansas Medical Society, Noah Worcester Dermatological Society, Phi Beta Kappa, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

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.

Managing Editor

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.

CME Editor

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 None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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