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Ecthyma Gangrenosum Clinical Presentation

  • Author: Mina Yassaee Kingsbery, MD; Chief Editor: Dirk M Elston, MD  more...
Updated: Nov 18, 2015


Ecthyma gangrenosum (EG) typically occurs in patients who are immunocompromised, including patients with hematologic malignancies, immunodeficiency syndromes, severe burns, malnutrition, recent chemotherapy, immunosuppressive therapy, and diabetes mellitus. While a few case reports describe the development of EG in previously healthy children, most of these patients had unrecognized risk factors for the development of EG, including intra-abdominal or appendiceal abscesses, recent viral illness such as influenza B leading to a transient severe neutropenia,[4] or antibiotic treatment for underlying medical conditions such as hypogammaglobulinemia and neutropenia.

Two reports describe toxic epidermal necrolysis followed by EG, one in a 62-year-old woman and the other in a 3-year-old boy.[5, 6]

Breakdown of mechanical defense barriers increases susceptibility to pseudomonal or fungal infections. Pseudomonas sepsis frequently occurs after surgical procedures, especially urologic procedures. Long-term indwelling urinary catheters, long-term intravenous placements, and tracheostomies have been associated with EG.

In several reported cases, patients with EG were on prolonged antibiotic therapy targeting non-Pseudomonas organisms. This may have led to elimination of normal flora and promoted Pseudomonas overgrowth.

Children with EG may develop diarrhea (30%) before the onset of cutaneous lesions.

Patients often present with fever a few days prior to developing EG.



Primary lesions

Primary cutaneous lesions of ecthyma gangrenosum (EG) initially appear as painless round erythematous macules that rapidly become pustular with surrounding erythema. A hemorrhagic focus appears in the center, forming a bulla. As the hemorrhagic bulla spreads peripherally, it evolves into a gangrenous ulcer with a central black/gray eschar surrounded by an erythematous halo. The transformation of an early lesion to a necrotic ulcer may occur in as little as 12 hours.

Distribution of lesions

The patient may have a single lesion or multiple lesions. EG may appear at any location on the body; however, it predominately affects the anogenital and axillary areas. Distribution occurs at the following frequencies: gluteal or perineal region (57%), extremities (30%), trunk (6%), and face (6%); bilateral periorbital manifestations are rare but have been reported.[7, 8]



Ecthyma gangrenosum (EG) is typically and most commonly caused by P aeruginosa; however, EG-like lesions have been observed in patients with other bacterial and fungal infections.[9] Organisms that cause ecthyma and EG-like lesions include the following:

Gram-positive bacteria are as follows:

  • Staphylococcus aureus
  • Streptococcus pyogenes

Gram-negative bacteria are as follows:

  • Aeromonas hydrophila
  • Burkholderia cepacia [10]
  • Chromobacterium violaceum [11]
  • Citrobacter freundii
  • Corynebacterium diphtheriae
  • Escherichia coli
  • Klebsiella pneumoniae
  • Morganella morganii [12]
  • Neisseria gonorrhea
  • Pseudomonas aeruginosa
  • Pseudomonas stutzeri
  • Serratia marcescens
  • Vibrio vulnificus
  • Yersinia pestis
  • Xanthomonas maltophilia

Fungi are as follows:

  • Aspergillus fumigatus
  • Candida albicans [13]
  • Curvularia species [14]
  • Exserohilum species
  • Fusarium solani [15]
  • Mucor and Rhizopus species
  • Pseudallescheria boydii [14]
  • Scytalidium dimidiatum

Viral causes include herpes simplex virus[16]

Contributor Information and Disclosures

Mina Yassaee Kingsbery, MD Co-Chief Resident, Department of Dermatology, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons

Mina Yassaee Kingsbery, MD is a member of the following medical societies: American Academy of Dermatology, Society for Pediatric Dermatology, Women's Dermatologic Society

Disclosure: Nothing to disclose.


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.

Specialty Editor Board

Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.


Sarina Berger Elmariah, MD, PhD Resident Physician, Robert O Perelman Department of Dermatology, New York University School of Medicine

Sarina Berger Elmariah, MD, PhD is a member of the following medical societies: Phi Beta Kappa

Disclosure: Nothing to disclose.

Frederick Fish, MD Director, Department of Dermatology and Cutaneous Surgery, St Paul Ramsey Medical Center; Associate Clinical Professor, Department of Dermatology, University of Minnesota

Frederick Fish, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American College of Physicians, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Dermatopathology, Pacific Dermatologic Association, and Sigma Xi

Disclosure: Nothing to disclose.

Nobuyoshi Kageyama, MD Resident Physician, Assistant Clinical Professor of Dermatology, Department of Dermatology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School

Disclosure: Nothing to disclose.

Ravi Ubriani, MD Assistant Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center

Disclosure: Nothing to disclose.

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Violaceous plaques and necrotic ulcers on the abdomen of a renal transplant patient. Tissue cultures were positive for Pseudomonas aeruginosa.
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