Page |1

MICROBIAL DISEASES OF THE SKIN, EYES AND EARS

WARTS

 also known as papillomas, verucca

 common viral infections of the skin and adjacent mucous membranes
 benign, squamous epithelial growths
 painless, elevated, rough growths
 most, but not all, are generally harmless
 can be disfiguring and embarrassing
 higher incidence in children and young adults, warts may occur at any age

Causative Agent: Human papillomavirus (HPV) – group of more than 100 strains of viruses that cause
epithelial tumors of the skin and mucous membranes

** Rarely, a wart can become malignant when caused by a particular type of HPV. HPV 16 is associated
with carcinoma of the vulva, vagina, cervix, anus, and penis.

Risk Factors
 Children and young adults
 Impaired immune system - with HIV/AIDS or people who've had organ transplants
 Sharing of personal items
 Multiple sexual contacts at a young age

Mode of Transmission

The warts contain variable amounts of virus. Transmission occurs through direct contact, and often warts
are transmitted from one part of the body to another by autoinoculation. Because the virus is fairly stable in
the environment, warts can also be transmitted indirectly from towels or from a shower stall, where they
persist inside the protective covering of sloughed-off keratinized skin cells.

Incubation Period – 1-8 months

Signs & Symptoms

Many patients are asymptomatic. Clinical manifestations depend on the type of wart and its location. The
primary sign of wart infection is the well-defined growth of varying shapes and sizes- depending on the type
of wart – on the skin surface.

Common/Seed warts (Verruca vulgaris) – This type of wart occurs most commonly in children and
young adult. It is a raised wart with roughened surface, and the lesion can appear to have black dots
that look like seeds and can feel like rough bumps, appears most frequently on extremities, particularly
hands, although they maybe located on any skin surface or mucous membrane.

Flat warts (Verruca plana) – This type of wart is smaller and smoother and flattened than other types
of warts. It is skin/flesh colored, which can occur in large numbers- about 20-100 at a time. Children
most commonly have them on the face, trunk, neck, hands, wrists and knees or anywhere on the body.

Digitate warts - finger-like wart, horny projection arising from a pea-shaped base; occurs on scalp or
near hairline;

Filiform warts – This type of wart looks like a single thin threadlike projection, or thin fingers that stick
out on skin surface, most common on the face and neck, around mouth, eyes and nose. Filiform warts
often grow quickly.

Periungual warts – This type of wart is found around the nails. They appear rough, irregularly shaped,
elevated surface; occurs around edges of fingernails and toenails; when severe, may extend under nail
and lift it off nail bed, causing pain. As they grow within weeks or months, they become pea-sized,
rough, dirty brown, gray or black in color, and horny. Periungal wart also becomes fissured, inflamed,
and tender.

Plantar warts (Verruca pedis) – slightly elevated or flat, deep, painful lump, often with multiple black
specks in the center; usually only found on pressure points on the soles of the feet;
 Page |2

Mosaic warts - group of tightly clustered plantar-type warts, commonly found on the soles of the feet,
although they might also be found on the hands or other areas of the body;

Genital warts (venereal wart, Condyloma acuminatum, Verruca acuminata) – usually small, pink to
red, moist and soft; may occur singly or in large cauliflower-like clusters on the genitalia (penis,
scrotum, vulva, cervix, vagina, and anus); can also occur on oral mucosa following oral genital
exposure.

** Warts are painless with occasional itchiness or pain

Diagnostic Procedure

Warts caused by papillomaviruses are distinctive enough to permit reliable clinical diagnosis without much
difficulty. However, a biopsy and histological examination can help clarify ambiguous cases.
 Physical examination - Warts can generally be diagnosed simply by their location and appearance
 HPV DNA testing
 Tissue biopsy – confirms HPV infection
 Papanicolaou (Pap) smear – identifies abnormal cells, which may or may not be caused by HPV.
Further testing should be done to confirm HPV.
 Application of 5% acetic acid – warts will turn white when exposed to the acetic acid solution

Treatment/ Management
Warts are usually recurrent, so to reduce the chances of it coming back, it must be removed
completely. Listed below are the usual treatments being done to remove warts:
 Acid therapy – applies plaster patches impregnated with acid (40% salicylic acid plasters) or acid
drops (5%-16.7% salicylic acid in flexible collodion or trichloroacetic acid), every 12 to 24 hours for
2 to 4 weeks. It is used for common warts.

 25% podophyllin in compound with tincture of benzoin – This solution is used for venereal warts

 Cryotherapy - freezing the wart with liquid nitrogen, creating a blister between the wart and
epidermal layer, after which the wart and surrounding dead skin falls off by itself. An average of 3
to 4 treatments is required for warts of thin skin. Warts on calloused skin like plantar warts might
take dozens or more treatments.

 Medications for genital warts:

 Imiquimod cream is a topically active immune enhancer that stimulates production of interferon and
other cytokines. The drug is very expensive.
 Podofilox topical gel is an antimitotic drug that destroys warts, is relatively inexpensive, easy to
use, safe, and self-applied.

 Laser surgery - often with a pulse dye laser or carbon dioxide laser; pulse dye lasers (wavelength
582 nm) work by selective absorption by blood cells (specifically hemoglobin). CO2 lasers work by
selective absorption by water molecules. Pulse dye lasers are less destructive and more likely to
heal without scarring. CO2 laser works by vaporizing and destroying tissue and skin. Both laser
treatments can be painful, expensive, and can cause scarring. CO 2 lasers will require local
anesthetic, while pulse dye laser might need conscious sedation. It takes 1 to 4 treatments.

 Electrosurgery and curettage - destruction of tissue by dehydration (electrodesiccation), done by

means of a high-frequency electric current and is followed by surgical removal of dead tissue at the
base (use of curette) and application of an antibiotic ointment (polysporin), covered with a bandage
for 48 hours.

 Electrocautery - the application of a needle or snare heated by electric current for the destruction of
warts

 Surgical excision

 Special cushions are available at drugstores for plantar warts. These pads help relieve any
pressure and pain from the warts.
 Page |3

** OTC Treatment for common and plantar warts

 Adhesive Tape (Duct Tape) - Place adhesive tape over the wart. Do not remove the tape for 7
days. Then take off the tape and open the area to the air for 12 hours. Reapply the adhesive tape
for another 7 days. Adhesive tape works because the airtight, moist environment under the tape
will not allow the wart virus (HPV) to grow.
 Compound W. Freeze Off - This wart removal system enables you to easily and effectively
freeze and remove common and plantar warts in the convenience of your home. For years,
doctors have performed a simple “wart freezing” process that quickly removes warts. In the past,
this could only be done in a medical professional’s office. Compound W Freeze Off® Wart
Removal System has taken this type of treatment and made it available over-the-counter for use
at home. The product works by applying a foam applicator to the center of the wart for no more
than 40 seconds. The applicator tip is cooled to about -55° C. Typically the wart falls off within
two weeks’ time and new healthy looking skin grows in its place.

Notes:
 No treatment exists to eradicate HPV.
 Almost all nongenital warts are harmless, and they tend to resolve themselves over time.
Warts disappear on their own 60-70% of the time, usually over the course of 2-3 years.
 Some warts disappear readily with treatment; others necessitate more vigorous and prolonged
treatment.

Nursing Responsibilities

The following are nursing implications that can be done for people infected with warts:
 Reassure clients that warts are not caused by dirt or lack of hygiene
 Health education about wart’s mode of transmission and preventive measures

Complications

 Scarring
 Secondary infection
 Cervical CA – 70% is associated w/ HPV
 Urinary obstruction

When to contact a doctor

Call for an appointment with your doctor if:

 There are signs of infection (red streaking, pus, discharge, or fever) or bleeding. Warts can bleed a
little, but if bleeding is significant or not easily stopped by light pressure, see a doctor.
 The wart does not respond to self-care and you want it removed.
 You have pain associated with the wart.
 You have anal or genital warts.
 You have diabetes or a weakened immune system (for example, HIV) and have developed warts.
 There is any change in the color or appearance of the wart.

Prevention

 Avoid direct skin contact with a wart on someone else.

 After filing your wart, wash the file carefully since you can spread the virus to other parts of your
body.
 After touching any of your warts, wash your hands carefully.
 HPV vaccine – females ages 9 to 26 years old, to prevent cervical CA, genital warts, and
precancerous genital lesions; given in 3 doses and is most effective if given before the female
becomes sexually active. Cervarix vaccine (containing HPV types 16 & 18) and Gardasil vaccine
(containing HPV types 6, 11, 16, and 18).
 Use of condoms and abstinence.

ACNE (ACNE VULGARIS)

 Page |4

 Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin
cells. It often causes whiteheads, blackheads or pimples, and usually appears on the face,
forehead, chest, upper back and shoulders. Acne is most common among teenagers, though it
affects people of all ages.

 Effective treatments are available, but acne can be persistent. The pimples and bumps heal slowly,
and when one begins to go away, others seem to crop up.

 Depending on its severity, acne can cause emotional distress and scar the skin. The earlier you
start treatment, the lower your risk of such problems

 The term acne encompasses all follicle-associated lesions, from the isolated pimple to severe
widespread acne. Normally, the sebaceous glands associated with hair follicles are a self-
contained system for protecting, softening and lubricating the skin. As hair and skin grow, dead
epidermal cells and sebum work their way upward and are discharged from the pore to the skin
surface.
 Skin prone to pimples and acne has a structure that traps the mass of sebum and dead cells,
clogging the pores. An exaggerated process of keratinization occurs in skin cells and in around the
follicle, which also helps to block the pore. An added factor is overproduction of sebum when the
sebaceous gland is stimulated by hormones.

 The surface areas of the skin that contain the most amounts of sebaceous glands will be the areas
where acne vulgaris breakouts are most likely to occur. This includes the back, face, and upper
portion of the chest.

 Almost 100% of adolescents and young adults experience acne of some degree at some time in
their lives. More severe forms of adolescent acne are more common in males than females,
probably because male hormones, or androgens, aggravate the condition. Females produce male
hormones as well, but during adolescence males have a higher incidence of moderate to severe
acne. Evidence
exists that acne extending into adulthood, or beginning in adulthood, is more common in women.

Causative Agent

 Propionibacterium acnes is the bacterium associated with acne, but the cause is multifactorial,
requiring other conditions to be just right before the presence of this otherwise benign bacterium
results in acne. The bacterium is an anaerobic or aerotolerant gram positive rod arranged in short
chains or clumps. It releases a variety of enzymes that contribute to its virulence. The most
important of these appears to be lipase, although it also releases proteases, neuraminidase and
hyaluronidase. In addition, it secretes a low molecular weight protein that is a strong attractant for
white blood cells (contributing to inflammation).
This bacteria is largely commensal and part of the skin flora present on most people's skin; and lives
on fatty acids in the sebaceous glands on sebum secreted by pores. It may also be found throughout
the gastrointestinal tract in humans and many other animals. It is named after its ability to
generate propionic acid.

Predisposing factors: heredity, hormonal changes related to puberty, menstrual periods, pregnancy, birth
control pills, or stress, certain drugs (ex. corticosteroids, phenytoin, INH), exposure to heavy oils, greases,
or tars, androgen stimulation, trauma or rubbing from tight clothing, cosmetics, emotional stress, and
unfavorable climate (high levels of humidity and sweating).

Mode of Transmission

P. acnes are normal microbiota on human skin, so it is not a transmissible infection.

Endogenous
 Page |5

Pathophysiology of Acne

At least four factors are important in the development of acne: plugging of the hair follicle with abnormally
cohesive desquamated cells, sebaceous gland hyperactivity, proliferation of bacteria
(especially Propionibacterium acnes) within sebum and inflammation.

Earliest changes in the hair follicle occur when the follicular canal becomes blocked with abnormally
keratinized desquamating cells. This plug starts above the opening of the sebaceous gland into the
follicular canal and causes gradual expansion of cells and sebum within the canal. The plug becomes
visible at the skin surface as a white papule ("whitehead," or closed comedo). If the opening of the follicular
canal dilates, this plug protrudes from the canal and turns a dark color ("blackhead," or open comedo).

Although sebum production increases during adolescence (particularly in boys, because of androgen
stimulation), and increased sebum alone does not cause acne.

Propionibacterium acnes in the follicle release lipases to digest this surplus of oil. The combination of
digestive products (fatty acids) and bacterial antigens stimulates an intense local inflammation that
eventually can burst the follicle. In time, the lesions can erupt on the surface.

P. acnes, are present in increased numbers in persons who have acne. Much of the inflammation that
eventually occurs arises from the action of enzymes produced by the bacteria. These enzymes hydrolyze
sebum into free fatty acids, which stimulate the inflammatory process. Chemotactic factors are released by
this reaction, attracting neutrophils. As the follicular wall becomes inflamed, an erythematous papule
appears at the skin surface. With increased sebum production, obstruction and bacterial colonization, the
follicular unit ruptures, spilling its contents into the dermis. The inflow of neutrophils causes the formation of
pustules. Continuation of severe inflammation leads to formation of nodules and subsequent cysts.

Signs and Symptoms

 whitehead/closed comedo (doesn’t protrude from follicle and is covered by epidermis)

 blackhead/open comedo (protrude from follicle and not covered by epidermis) – black coloration is
caused by melanin or pigment of the follicle
 inflammation, papules, pustules, cyst or abscesses – due to rupture or leakage of an enlarged plug
into the dermis

Classifications of Acne

Acne can be classified into three categories for the purposes of treatment: comedonal, inflammatory and
nodulocystic.
a. Comedonal acne consists predominantly of open or closed comedones with little or no accompanying
inflammation. In closed comedones (whiteheads), a mass of desquamated cells plugs the follicular canal
above the opening of the sebaceous gland. Sebum accumulates within the follicular canal and results in a
white papule visible at the skin surface. In open comedones (blackheads), when the opening of the
follicular canal dilates, the plug protrudes from the canal and turns a dark color. This type of acne typically
responds to topical keratolytic agents that decrease the cohesiveness of the follicular cells.

b. Inflammatory acne – with erythematous papules and pustules, but comedones may also be
present.The follicular wall ruptures, releasing sebum, cells and bacteria into the surrounding tissue, causing
inflammation and redness. Topical agents alone may be insufficient to treat inflammatory acne, which may
benefit from systemic antibiotics.

c. Nodulocystic acne may consist of comedones and inflammatory lesions, as well as deeper nodules and
cysts. Extensive tissue inflammation results in the formation of nodules, cysts or abscesses. Although a six-
month course of systemic antibiotics may be effective, nodulocystic acne frequently requires treatment with
isotretinoin (Accutane). Before the initiation of isotretinoin therapy, however, patients should be evaluated
for other causes of antibiotic treatment failure. Unusual causes of recalcitrant acne include drug-induced
acne, tropical acne, acne conglobata and acne fulminans.

Diagnostic Test

 The diagnosis of acne is based on the history and physical examination. Lesions most commonly
develop in areas with the greatest concentration of sebaceous glands, which include the face,
neck, chest, upper arms, and back.
 Page |6

Treatment

 Topical retinoic acid (tretinoin) – treatment of choice for non-inflammatory acne

Consisting of open and closed comedones. It works by increasing skin cell turnover promoting the
extrusion of the plugged material in the follicle. It also prevents the formation of new comedones.
Tretinoin is also the only topical medication that has been proven to improve wrinkles.
 Benzoyl peroxide – antibacterial used primarily for inflammatory acne, pustule, papules and cysts
 Topical antibiotics (tetracycline, erythromycin, clindamycin, and benzamycin) – for mild pustular
and comedone acne
 Systemic antibiotics (tetracycline, minocycline, erythromycin, clindamycin, ampicillin,
cephalosporine, cotrimoxazole, and systemic retinoids)
 Oral contraceptive pills containing estrogens – to inhibit androgen activity
 Oral isotretinoin (accutane) – inhibits sebaceous gland function and keratinization, but it can have
severe side effects, including psychological depression and patients must be closely monitored.

Notes:
 Tetracycline is contraindicated during pregnancy because it discolors the teeth of the fetus.
 Acne takes a long time to clear even years for complete resolution.

Nursing Responsibilities

1. Administer prescribed medications, which may include acne products containing benzoyl peroxide
(explain that these products initially cause skin redness and scaling but that the skin adjusts quickly);
topical agents, such as vitamin A acid; and antibiotics such as tetracycline.
2. Provide client and family teaching
 Advise the client that heat, humidity, and perspiration exacerbate acne. Explain that
uncleanliness, dietary indiscretions, menstrual cycle, and other myths are not responsible for
acne.
 Explain that it will take 4 to 6 weeks of compliance with the treatment regimen to obtain
results.
 Instruct the client to wash his face gently (do not scrub) with mild soap twice daily.
 Instruct the client not to squeeze blackheads, not to prop hands on or rub the face, to wash hair
daily and keep it off the face, and to use cosmetics cautiously because some may exacerbate
acne.
 Instruct the female client to inform her health care provider if she is possibly pregnant.
Some medication, such as systemic retinoic acid, have teratogenic effects, therefore a
pregnancy test is required prior to treatment and strict birth-control measures are use throughout
pregnancy.

Complications

 Abscess formation
 Permanent scarring
 Secondary bacterial infection

Prevention

No effective prevention of acne; it is not a result of poor hygiene or even of eating the wrong foods.
 Try to identify predisposing factors that may be eliminated or modified
 Maintain a well balanced diet
 Adequate rest
 Manage stress
 Keep your hands and hair away from your face. Your hands and hair may contain oils and dirt. If
contacted on your face it can contaminate the pores and cause acne.
 Keep your face clean
 Never squeeze or prick your pimples (spots). We all know this maybe very tempting, but it would
only make matters much worse. Most spots will heal on its own. Picking at spots will just increase
the chance of it spreading the bacteria or even worst permanently scarring your skin. So remember
never to pick on it.
 Avoid heavy foundation makeup. Choose powder cosmetics over cream products because they're
less irritating.
 Page |7

 Remove makeup before going to bed. Going to sleep with cosmetics on your skin can clog tiny
openings of the hair follicles (pores). Also, be sure to throw out old makeup and clean your
cosmetic brushes and applicators regularly with soapy water.
 Wear loose-fitting clothing. Tight-fitting clothing traps heat and moisture and can irritate your skin.
Also, whenever possible, avoid tight-fitting straps, backpacks, helmets or sports equipment to
prevent friction against your skin.
 Shower after exercising or doing strenuous work. Oil and sweat on your skin can trap dirt and
bacteria.

BOIL

Boil (or furuncle) is a skin disease caused by the infection of hair follicles, resulting in the localized
accumulation of pus and dead tissue. Individual boils can cluster together and form an interconnected
network of boils called carbuncles.

Furuncles may occur in the hair follicles anywhere on the body, but they are most common on the face,
neck, armpit, buttocks, and thighs. Furuncles can be single or multiple. At first, the skin turns red in the area
of the infection, and a tender lump develops. After four to seven days, the lump starts turning white as pus
collects under the skin.

Chronic furunculosis is a recurrent staphylococcal abscess of the hair follicle. The boils can develop
continuously, or occur from time to time.

Causative Agent

Furuncles are very common. Furuncles are generally caused by Staphylococcus aureus, but they may be
caused by other bacteria or fungi found on the skin's surface. Damage to the hair follicle allows these
bacteria to enter deeper into the tissues of the follicle and the subcutaneous tissue.

Predisposing Factors

 Infected wound
 Poor hygiene
 Impaired immune system – DM, kidney failure, taking steroids, CA chemotherapy

Mode of Transmission

 Direct contact –purulent lesion or discharge

 Indirect contact - fomites

Signs and Symptoms

 A painful, red lump that starts out about the size of a pea
 Red, swollen skin around the lump
 An increase in the size of the lump over a few days as it fills with pus (can sometimes reach the
size of a golf ball)
 Development of a yellow-white tip that eventually ruptures and allows the pus to drain out.
 Sometimes boils will exude an unpleasant smell, particularly when drained or when discharge is
present, due to the presence of bacteria in the discharge.

*Once the boil drains, the pain usually subsides. Small boils usually heal without scarring, but a large boil
may leave a scar.

*In a severe infection, multiple boils may develop and the patient may experience fever and swollen lymph
nodes. In some people, itching may develop before the lumps begin to form.

Diagnostic Procedure

 Physical exam - based on the appearance of the skin

 Culture of drainage/pus may show staphylococcus or other bacteria
 Page |8

Treatment/ Management

Furuncles may heal on their own after an initial period of itching and mild pain. More often, they increase in
discomfort as pus collects. They finally burst, drain, and then heal on their own.

Furuncles usually must drain before they will heal. This most often occurs in less than 2 weeks. Treatment
by a health care provider is needed if a furuncle lasts longer than 2 weeks, returns, is located on the spine
or the middle of the face, or occurs with a fever or other symptoms because the infection may spread and
cause complications.

a. Apply warm moist compresses encourage furuncles to drain, which speeds healing. Gently soak the area
with a warm, moist cloth several times each day.

b. Incision and drainage of ripe lesions if the lesions don’t drain after the application of warm, wet
compresses. Deep or large lesions may need to be drained surgically by a health care provider. Never
squeeze a boil or attempt to cut it open it at home because this can spread the infection and make it worse.

c. When the boil starts draining, wash it with an antibacterial soap (chlorhexidine) until all the pus is gone.

d. Topical antibiotic after incision and drainage such as mupirocin ointment, clindamycin or erythromycin

e. Systemic antibiotic such as cephalosporin (cephalexin) or dicloxacillin - may help to control infection in
those with repeated furuncles

**Antibacterial soaps and topical antibiotics are of little benefit once a furuncle has formed.

Nursing responsibilities

1. Prevention of infection
 Resist the temptation to squeeze the boil.
 Wash the boil with antiseptic soap.
 Apply a hot compress for 10 minutes or so, three times daily, to encourage the

boil to come to a head.

 Cover a burst boil with a bandaid.

 Wash your hands thoroughly to prevent the spread of infection.
 Use fresh towels every time you wash and dry the infected areas.
 See your doctor if the boil isn’t improving after a few days.

Complications

 Permanent scarring
 Spread of infection that trigger secondary infection (cellulitis, septic arthritis, osteomyelitis,
endocarditis, septicemia, and brain abscess)

Prevention

The following may help prevent the spread of infection:

 Encourage the patient to take shower using antibacterial soap
 Meticulous hygiene is important to prevent the spread of infection. Draining lesions should be
cleaned frequently. You should wash your hands very well after touching a furuncle. Do not re-use
or share washcloths or towels. Clothing, washcloths, towels, and sheets or other items that contact
infected areas should be washed in very hot (preferably boiling) water. Dressings should be
changed frequently and discarded in a manner that contains the drainage, such as by placing them
in a bag that can be closed tightly before discarding.
 Clean and treat minor wounds
 Practice good personal hygiene
 Good nutrition

IMPETIGO
 Page |9

Impetigo is a superficial bacterial infection that causes the skin to flake or peel off. It is not a serious
disease but is highly contagious, and children are the primary victims, but all ages can acquire the disease.

The skin infection is marked by vesicles or bullae that become pustular, rupture, and form yellow crusts. It
appears most commonly on the face (around the nose & mouth) and other exposed areas.

Causative Agents

 Staphylococcus aureus (gram-positive)

 Streptococcus pyogenes (gram-positive)
 Methicillin resistant Staphylococcus aureus (MRSA) - becoming a common cause, that does not
get better with the first-line antibiotics that usually cure staph infections

**In some cases are probably caused by a mixture of the two (Staphylococcus aureus or Streptococcus
pyogenes). It has been suggested that S. pyogenes begins all cases of the disease, and in some cases, S.
aureus later takes over and becomes the predominant bacterium cultured from lesions. Because S. aureus
produces a bacteriocin (toxin) that can destroy S. pyogenes, it is possible that S. pyogenes is often missed
in culture-based diagnosis.

Predisposing Factors

 Poor hygiene
 Anemia
 Malnutrition
 Warm climate

Mode of Transmission

 Direct contact – most common

 Indirect contact via fomites
 Mechanical vector transmission

**Although it commonly occurs when bacteria enter the skin through cuts or insect bites, it can also develop
in skin that's perfectly healthy.

Incubation Period: 2-5 days

Signs and Symptoms

 Lesions of impetigo looks variously like peeling skin, crusty and flaky scabs, or honey-colored
crusts. Lesions are most often found around the mouth, face and extremities though they can occur
everywhere on the skin. It is very superficial and it itches.
 Painless, fluid-filled blisters
 In a more serious form, painful fluid- or pus-filled sores that turn into deep ulcers

Types/Forms
 Nonbullous impetigo (Impetigo contagiosa) -The most common form, which usually starts as a
small, red papule that has turned into vesicle, becoming pustular within a few hours on the child's
face, most often around the nose and mouth. The vesicle ruptures quickly, oozing either fluid or
pus that forms a honey-colored crust. Eventually the crust disappears, leaving a red mark that
heals without scarring. Impetigo sores may be itchy, but they aren't painful.

The child isn't likely to have a fever with this type of impetigo but may have swollen lymph nodes in
the affected area. And because it's highly contagious, just touching or scratching the lesion can
spread the infection to other parts of the body.

 Bullous impetigo - This type primarily affects infants and children younger than 2 years. It causes
painless, fluid-filled blisters — usually on the trunk, arms and legs. The skin around the blister is
usually red and itchy but not sore. The blisters, which break and scab over with a yellow-colored
crust, may be large or small, and may last longer than sores from other types of impetigo.
 P a g e | 10

These blisters are fragile and contain a clear yellow-colored fluid. A dark crust will commonly
develop during the final stages of development. With healing, this crust will resolve.

 Ecthyma - more serious form of impetigo in which the infection penetrates deeper into the skin's
second layer, the dermis. Signs and symptoms include:
o Painful fluid- or pus-filled sores that turn into deep ulcers, usually on the legs and feet
o A hard, thick, gray-yellow crust covering the sores
o Swollen lymph glands in the affected area
o Little holes the size of pinheads to the size of pennies appear after crust recedes
o Scars can remain after the ulcers heal

Causative Organism S. aureus S. pyogenes

Mode of transmission Direct & indirect contact Direct & indirect contact
Virulence factors Exfoliative toxin A, coagulase, Streptokinase, plasminogen-
other enzymes binding ability, hyaluronidase,m
protein
Culture/Diagnosis Based on clinical signs, culture Based on clinical signs, culture
and Gram stain, coagulase and and Gram stain, coagulase and
catalase tests, multitest systems catalase tests, multitest systems
Prevention Hygiene practices Hygiene practices
Treatment Topical mupirocin, oral cephalexin Topical mupirocin, oral cephalexin
Distinguishing features Seen more often in older children, Seen more often in newborns,
adults may have some involvement in all
impetigo (preceeding S. aureus in
staphylococcal impetigo)

Diagnostic Procedure
 P.E.
 Gram stain – reveals neutrophils w/ gram-positive cocci
 Culture and sensitivity testing of the lesions - reveals the causative agent and may indicate the
most appropriate antibiotic therapy

Treatment/Management

 Topical mupirocin (Bactroban) - a protein synthesis inhibitor, crust removal prior to each application
 oral antibiotics such as cephalexin may be used for widespread involvement
 removal of exudate – washing with soap and water; warm soaks or compresses of normal saline
solution
 antihistamine – help alleviate itching

Nursing Responsibilities

 Provide health teaching on the causative agents, modes of transmissions and prevention
 Advise client to prevent sharing of clothes, towels, or other articles that can be a possible indirect
contact for transmission
 Teach client about proper hygiene specifically proper handwashing techniques
 Administer and teach client how to properly take medication
 Provide follow up care to client

Complications

 Glomerulonephritis
 Meningitis
 Bacteremia
 Osteomyelitis
 Scarring

Prevention
 Good hygiene
 Avoiding contact with others who have impetigo.
 P a g e | 11

 Keep your skin clean, dry, and avoid scraping or injuring your skin.

If someone in your family already has impetigo, follow these measures to help keep the infection from
spreading to others:

 Gently wash the affected areas with mild soap and running water and then cover lightly with gauze.
 Wash an infected person's clothes, linens and towels every day and don't share them with anyone
else in your family.
 Wear gloves when applying any antibiotic ointment and wash your hands thoroughly afterward.
 Cut an infected child's nails short to prevent damage from scratching.
 Wash hands frequently.
 Keep your child home until your doctor says he or she isn't contagious.

CUTANEOUS MYCOSES (TINEA INFECTIONS

RINGWORM or DERMATOPHYTOSIS)

Dermatophytosis is a group of superficial fungal infections usually classified according to their anatomic
location. These mycoses are strictly confined to the nonliving epidermal tissues (stratum corneum) and
their derivatives (hair and nails). These disorders vary from mild inflammations to acute vesicular reactions.

Causative Agents

 Epidermophyton
 Trichophyton
 Microsporum

The dermatophytes have the ability to invade and digest keratin which is naturally abundant in the cells of
the stratum corneum. The fungi do not invade deeper epidermal layers. Important factors that promote
infection are the hardiness of the dermatophyte spores (that can last for years on fomites); presence of
abraded skin and intimate contact.

**Warm weather, humidity, and tight clothing encourage fungal growth.

Risk Factors
 Live in damp, humid or crowded conditions
 Have close contact with an infected person or animal
 Share clothing, bedding or towels with someone who has a fungal infection
 Sweat excessively
 Participate in contact sports, such as wrestling, football or rugby
 Wear tight or restricted clothing
 Have a weakened immune system

Mode of Transmission
 direct contact with infected lesions
 indirect contact through contaminated articles or surfaces, such as shoes, towels, or shower stalls
 contact with contaminated animals or soil
Classification of Tinea Infections and its Signs and Symptoms

Ringworm of the Scalp (Tinea Capitis) - This mycosis results from the fungal invasion of the scalp and
the hair of the head, eyebrows, and eyelashes. Very common in children, tinea capitis is acquired from
other children and adults or from domestic animals. Manifestations range from small scaly patches to a
severe inflammatory reaction to destruction of the hair follicle and temporary or permanent hair loss.

Ringworm of the Beard (Tinea Barbae) - This tinea, also called barber’s itch, affects the chin and beard
of adult males. Although once a common after effect of unhygienic barbering, it is now contracted mainly
from animals. It is most common among agricultural workers, as the transmission is more common from
animal-to-human than human-to-human. It appears as pustular folliculitis in the bearded area.

Ringworm of the Body (Tinea Corporis) – This extremely prevalent infection of humans can appear
nearly anywhere on the body’s glabrous (smooth and bare) skin. The principal sources are other humans,
animals and soil, and it is transmitted primarily by direct contact and fomites (clothing, bedding). The
infection usually appears as one or more scaly reddish rings on the trunk, hip, arm, neck or face. Lesions
 P a g e | 12

may be dry and scaly or moist and crusty and itchy. The ringed pattern is formed when the infection
radiates from the original site of invasion into surrounding skin. Depending on the causal species and the
health and hygiene of the patient, lesions vary from mild and diffuse to florid and pustular.

Ringworm of the Groin (Tinea Cruris) - Sometimes known as jock itch, crural ringworm occurs more
often in males on the groin, perianal skin, scrotum, and occasionally, the penis. It may extend to the
buttocks, inner thighs and external genitalia.The fungus thrives under conditions of moisture and humidity
created by sweating. It is transmitted primarily from human to human and is pervasive among athletes and
persons living in close quarters (ships, military installations). It is raised, sharply defined itchy lesions.

Ringworm of the Hands (Tinea Manuum) – Infection of the hand by dermatophytes is nearly always
associated with concurrent infection of the foot. Lesions usually occur on the fingers and palms of one
hand, and itchy. They vary from white and scaly patches to deep and fissured.

Ringworm of the Nail (Tinea Unguium/onychomycosis) - Fingernails and toenails, being masses of
keratin, are often sites for persistent fungus colonization. The first symptoms are usually superficial white
patches in the nail bed. A more invasive form causes thickening, distortion, and darkening of the nail. Nail
problems caused by dermatophytes are on the rise as more women wear artificial fingernails, which can
provide a portal of entry into the nail bed.

Ringworm of the Foot (Tinea Pedis) – T. pedis has more colorful names as well, including athlete’s foot
and jungle rot. The disease is clearly connected to wearing shoes because it is uncommon in cultures
where people customarily go barefoot. Conditions that encase the feet in a closed, warm, moist
environment increase the possibility of infection. Tinea pedis is a known hazard in shared facilities such as
shower stalls, public floors and locker rooms. Infections begin with blisters between the toes that burst,
crust over, scales and can spread to the rest of the foot and nails. There is extreme itching and pain on
walking.

Diagnostic Procedure

 P.E.
 KOH (potassium hydroxide) test coupled with microscopic examination of lesion
scrapings usually help confirm tinea infection
 Culture of the affected area may help to identify the causative agent

The presenting symptoms of a cutaneous mycosis occasionally are so dramatic and suggestive of these
genera that no further testing is necessary. In most cases, however, direct microscopic exam and culturing
are required. Diagnosis of tinea of the scalp caused by some species is aided by the use of a long-wave
ultraviolet lamp that causes infected hairs to fluoresce. Samples of hair, skin scrapings, and nail debris
treated with heated potassium hydroxide (KOH) show a thin, branching fungal mycelium if infection is
present.

Treatment
 Topical antifungal agent- Tolnaftate, Itraconazole, Terbinafine, Miconazole, Thiabendazine
 Oral griseofulvin – side effects: hepatotoxic, nephrotoxic
 Gentle debridement of skin

Nursing Responsibilities

It is generally agreed that simple advice can help people to improve healing and reduce the risk of
infection to others. For example, those with athlete's foot should wear open footwear if possible, if not they
should wear cotton socks and change them daily. It is also helpful to avoid walking barefoot in communal
changing rooms. For all fungal conditions avoid sharing towels and make sure that showers, baths and
floors are cleaned regularly at home, particularly if walking around barefoot. There is no need for children to
miss school when tinea capitis is diagnosed.

Complications

 Hair or nail loss

 Secondary bacterial or candidal infection

Prevention
 Hand washing
 P a g e | 13

 Keep the nails short & straight.

 Expose feet to air whenever possible.
 Wear sandals or leather shoes & clean cotton socks.
 Good hygiene
 Wearing loose-fitting clothing
 Educate about the risk of ringworm from infected persons or pets.
 Stay cool and dry. Don't wear thick clothing for long periods of time in warm, humid weather.
 Avoid infected animals - The infection often looks like a patch of skin where fur is missing. In some
cases, though, you may not notice any signs of the disease. Ask your veterinarian to check your pets
and domesticated animals for ringworm.
 Don't share personal items. Don't let others use your clothing, towels, hairbrushes or other personal
items. Refrain from borrowing these items from others as well.
 Contact precaution

CONJUNCTIVITIS/PINK EYE

Conjunctivitis is one of the most common and treatable eye infections in children and adults. It is an
inflammation or infection of the transparent membrane (conjunctiva) that lines your eyelid and covers the
white part of your eyeball. This tissue helps keep the eyelid and eyeball moist. When small blood vessels in
the conjunctiva become inflamed, they're more visible. This is what causes the whites of your eyes to
appear reddish or pink.

This disorder usually occurs as benign, self-limiting pinkeye; it may also be chronic, possibly indicating
degenerative changes or damage from repeated acute attacks.

Causative Agents

Most common causative organisms

 Bacterial – Staphylococcus aureus, Streptococcus pneumoniae, Neisseria gonorrheae, Neisseria
meningitidis, Chlamydia trachomatis
 Viral – adenovirus types 3,7, and 8; herpes simplex virus type 1
 Other causes – allergic reactions to pollens, grass, topical medications, air pollutants, smoke, or
unknown seasonal allergens, dust, occupational irritants (acids and alkali), and hypersensitivity to
contact lenses or solutions

Risk Factors
 Exposure to something for which you have an allergy (allergic conjunctivitis)
 Exposure to someone infected with viral or bacterial conjunctivitis
 Using contact lenses, especially extended-wear lenses

Mode of Transmission

 Direct contact with discharges from the conjunctivae or upper respiratory tract of infected persons.
Neonates may acquire infection during vaginal delivery.
 Indirect contact - contaminated fingers, clothing and other articles especially those coming in close
contact with the eyes (i.e. make-up applicators, multiple dose eye medication applicators).

** Swimmers can contract conjunctivitis when swimming in the contaminated water. Chlamydial
conjunctivitis, the disease can also be transmitted during sexual intercourse.

**Bacteria and viruses can spread easily from person to person, but is not a serious health risk if diagnosed
promptly.

Incubation Period

Bacterial 24–72 hours and in case of trachoma incubation is 5–12 days

Viral 12 hours – 3 days

Types of Conjunctivitis

Bacterial conjunctivitis
 P a g e | 14

Bacterial conjunctivitis is an infection caused by bacteria such as staphylococci, streptococci or

haemophilus. These organisms may come from the patient's own skin or upper respiratory tract or they
may be caught from another person with conjunctivitis. This is a condition that affects both eyelids. They
usually feel gritty with a sticky discharge. Both eyes are red. The eyelids may be stuck together particularly
in the mornings, and there may be discharge on the eyelashes.

Acute bacterial conjunctivitis usually last only for 2 weeks. The patient typically complaints of itching,
burning, and the sensation of a foreign body in his eye. The eyelids show a crust of sticky, mucopurulent
(whitish or yellowish) discharge. If the disorder is due to N. gonorrhoeae, the patient exhibits a profuse,
purulent discharge.

Ophthalmia Neonatorum (neonatal conjunctivitis) is a severe form of bacterial conjunctivitis that occurs in
newborn babies. This is a serious condition that could lead to permanent eye damage unless it is treated
immediately. Ophthalmia neonatorum occurs when an infant is exposed to Chlamydia or gonorrhea while
passing through the birth canal.

Chlamydial conjunctivitis

This type of conjunctivitis is caused by an organism called Chlamydia trachomatis. This organism may also
affect other parts of the body and can cause the venereal disease chlamydia. Both eyes will be red with a
sticky discharge. The cornea may also be involved in this condition.

Viral conjunctivitis

Viral conjunctivitis is often associated with the common cold. This may be caused by a virus called
'adenovirus'. This type of conjunctivitis can spread rapidly between people and may cause an epidemic of
conjunctivitis. The eyes are red and there may be a watery discharge. The eyes are uncomfortable and
there may also be symptoms of a cold. Sometimes there are tender lymph nodes around the ear or the
neck. This type of conjunctivitis may also spread to affect the cornea (keratitis) and it may persist for
several weeks.

Allergic Conjunctivitis

Allergic conjunctivitis is common in people who have other signs of allergic disease such as hay
fever, asthma and eczema. The conjunctivitis is often caused by antigens like pollen, dust mites or
cosmetics. Allergic conjunctivitis is usually associated with intense itching of the eyes. There may be a
stringy discharge and the eyes are usually intermittently red. This may occur at particular times of the year,
for instance during spring and summer when there is a lot of pollen in the air.

Vernal Conjunctivitis

Vernal conjunctivitis is a long-term (chronic) swelling (inflammation) of the outer lining of the eyes due to an
allergic reaction. Vernal conjunctivitis often occurs in people with a strong family history of allergies, such
as allergic rhinitis, asthma, and eczema. It is most common in young males, and most often occurs during
the spring and summer.

Is a severe form of IgE-mediated mast cell hypersensitivity reaction. This form of conjunctivitis is bilateral. It
usually begins at age 3-5 years and persists for 10 years

Reactive/Chemical Conjunctivitis
Some people are very susceptible to chemicals in swimming pools (chlorine) or to smoke or fumes and this
can cause an irritation of the conjunctiva with discomfort, redness and watering. In such cases these
irritants should be avoided.

Signs and Symptoms

 Pink or red color in the white of the eye(s) (often one eye for bacterial and often both eyes for viral
or allergic conjunctivitis)
 Swelling of the conjunctiva (the thin layer that lines the white part of the eye and the inside of the
eyelid) and/or eyelids
 Increased tearing
 Discharge of pus, especially yellow-green (more common in bacterial conjunctivitis). A discharge in
one or both eyes that forms a crust during the night that may prevent your eye or eyes from
opening in the morning
 P a g e | 15

 Itching, and irritation

 Burning sensation (if caused by irritants and chemicals)
 Slight blurring of vision due to secretions
 Feeling like a foreign body is in the eye(s) or an urge to rub the eye(s)
 Crusting of eyelids or lashes sometimes occurs, especially in the morning
 Cold, flu, or other respiratory infection may also be present
 Sensitivity to bright light sometimes occurs (photophobia)
 Enlargement and/or tenderness, in some cases, of the lymph node in front of the ear. This
enlargement may feel like a small lump when touched. (Lymph nodes act as filters in the body,
collecting and destroying viruses and bacteria.)
 Symptoms of allergy, such as an itchy nose, sneezing, a scratchy throat, or asthma may be
present in cases of allergic conjunctivitis

**Generally doesn’t affect vision, and usually begins in one eye and rapidly spreads to the other
eye by contamination of towels, washcloths, or patient’s own hand.

Diagnostic Procedure

 P.E.
 Culture and sensitivity test

Treatment

 Bacterial Conjunctivitis - Broad-spectrum topical antibiotic often ciprofloxacin

 Viral conjunctivitis - None, although broad-spectrum antibiotics sulfonamide eyedrops may
prevent a secondary infection
 Herpes simplex infection - Trifluridine drops or vidarabine ointment or oral acyclovir, may persist
for 2-3 weeks
 Vernal conjunctivitis – Corticosteroid drops followed by cromolyn sodium, cold compress and,
occasionally oral antihistamine
 Neonatal conjunctivitis - Topical erythromycin ointment and IV or IM third-generation
cephalosporin
 Chemical Conjunctivitis – Treatment for chemical conjunctivitis requires careful flushing of the
eyes with saline and may require topical steroids. The more acute chemical injuries are medical
emergencies, particularly alkali burns, which can lead to severe scarring, intraocular damage or
even loss of the eye.
 Allergic conjunctivitis - can be treated with a variety of medications, including topical
antihistamines, mast cell stabilizers, nonsteroidal anti-inflammatory drugs (NSAIDs), and
corticosteroids. Applying cold compresses can relieve discomforts.

Nursing Considerations

 Nurses must emphasize that treatment for conjunctivitis depends on the cause. Conjunctivitis may
go away on its own, but treatment can make the client feel better. Putting a cold compress against
the eye can help. Don't rub eyes and avoid touching it with hands.
 Allergy drops may help ease itching and redness for allergic conjunctivitis.
 Give health teachings on the proper administration of antibiotic drops or ointments prescribed by
the healthcare provider or eye care professional to treat bacterial conjunctivitis. Continue using the
drops or ointment for as long as prescribed, even if the infection seems to have cleared up,
because some bacteria might remain even after symptoms go away. After completing treatment,
throw away any remaining drops or ointment.
 Remind clients that the only thing that will help viral conjunctivitis go away is time. Soothing eye
drops can prevent discomfort.
 Provide health teachings in the prevention of the spread of infectious conjunctivitis to others:
* wash your hands frequently
* don't touch your eyes
* don't share eye makeup
* don't use the eye makeup testers at cosmetic counters
 P a g e | 16

* don't wear your contact lenses longer than recommended and always clean them properly
* don't share a facecloth, towel, or pillowcase with anyone.
 To prevent allergic conjunctivitis, instruct clients to avoid allergens that cause it. Stay in air-
conditioned places when pollen counts are high in the area. Don't hang clothes out on a
clothesline.
Complications

 Corneal infiltrates - Small hazy greyish areas (local or diffuse) composed of inflammatory cells,
proteins, and surrounded by edema
 Corneal ulceration
 Keratitis (inflamed cornea) – affect vision
 Blindness

Prevention

 Maintain good personal hygiene, particularly thorough hand washing before and after contact with
eyes.
 Avoid hand-eye contact.
 Do not share towels and toilet articles.
 Avoid sharing of eye droppers, eye medicines, eye make-up and other items that may come into
contact with the eyes.
 Crede’s prophylaxis - apply one dose of erythromycin ophthalmic ointment

OTITIS EXTERNA

Also known as external otitis, and swimmer’s ear; otitis externa is an inflammation of the skin of the
external ear canal and auricle. It may be acute, chronic, or invasive and it is most common in the summer
among children and young adults.

Causative Agents

 Bacteria (more common) – Pseudomonas aeruginosa, Proteus vulgaris, group A Streptococci, or

Staphylococcus aureus
 Fungi (less common) - Aspergillus niger, or Candida albicans ((fungal otitis externa, is most
common in the tropics)

Notes:

 Occasionally, chronic otitis externa results from dermatologic conditions, such as

seborrhea or psoriasis.
 Allergic reactions - nickel or chromium earrings, chemicals in hair spray, cosmetics,
hearing aids, and medications can also cause otitis externa.
 Like all skin, the external auditory canal has a normal bacterial flora and remains free of
infection unless its defenses are disrupted. When disruption occurs, a new pathogenic
flora develops that is dominated by Pseudomonas aeruginosa and Staphylococcus aureus.

Risk Factors

 swimming in contaminated water - cerumen creates a culture medium for the waterborne
microorganism
 cleaning the ear canal with a cotton swab, bobby pin, finger, or other foreign object – irritates the
ear canal and possibly introduces the infecting microorganism
 exposure to dust, hair care products, or other irritants – causes the client to scratch his ear,
excoriating the auricle and canal
 regular use of earphones, earplugs, or earmuffs – trap moisture in the ear, creating a culture
medium for infection
 chronic drainage from a perforated tympanic membrane
 perfumes or self-administered eardrops
 narrow ear canal — for example, in a child — that can more easily trap water
 P a g e | 17

Mode of Transmission

 indirect contact
**part of indigenous microflora
**cannot be spread from one person to another

Signs and Symptoms

** usually appear within a few days after swimming
 Itchiness inside the ear.
 Redness and swelling of the ear.
 Pain when the infected ear is tugged or when pressure is placed on the ear.
 Liquid or pus draining from the infected ear.
 some degree of temporary hearing loss
Notes:
 Hearing acuity is normal unless complete occlusion has occurred.
 Fungal otitis externa may be asymptomatic.
 With treatment, acute otitis externa usually subsides within 7 days (although it may
become chronic) and tends to recur.

Diagnostic Tests

 Physical examination - confirms otitis externa, otoscopy reveals a swollen ear canal (sometimes to
the point of complete closure), pericauricular lymphadenopathy (tender nodes in front of the tragus,
behind the ear, or in the upper neck) and, occasionally, regional cellulitis.
 Microscopic exam or culture and sensitivity test – identify the causative agent and determines the
antibiotic treatment

Treatment

Treatment varies, depending on the type of otitis externa.

 Heat therapy to the periauricular region (heat lamp; hot, damp compresses; heating pad) - To
relieve the pain of acute otitis externa
 Aspirin or acetaminophen, and codeine – for pain
 Instillation of antibiotic eardrops such as polymyxin (with or without hydrocortisone) follows
cleaning of the ear with alcohol-acetic acid mixtures and removal of debris.
 Systemic antibiotic - If fever persists or regional cellulitis develops
 Fungal otitis externa - necessitates careful cleaning of the ear. Application of a keratolytic or 2%
salicylic acid in cream containing nystatin may help treat otitis externa resulting from candidal
organisms
 Primary treatment of chronic otitis externa - cleaning the ear and removing debris. Supplemental
therapy includes instillation of antibiotic eardrops or application of antibiotic ointment or cream
(neomycin, bacitracin, or polymyxin, possibly combines with hydrocortisone). Another ointment
contains phenol, salicylic acid, precipitated sulfur, and petrolatum, and produces exfoliative and
antipruritic effects.
 Mild chronic otitis externa - instilling antibiotic eardrops once or twice weekly and wearing specially
fitted earplugs while showering, shampooing, or swimming.

Notes:
 Instillation of slightly acidic eardrops creates an unfavorable environment in the ear canal for most
fungi as well as Pseudomonas.
 During treatment, the following steps will help keep your ears dry and avoid further irritation:
- Don't swim or scuba dive.
- Avoid flying.
- Don't wear an earplug, hearing aid or headphones before pain or discharge has stopped.
- Avoid getting water in your ear canal when bathing. Use a cotton ball coated with
petroleum jelly to protect your ear during a bath.

Nursing Responsibilities
 P a g e | 18

 Monitor vital signs, particularly temperature. Watch for and record the type and amount of aural
drainage.
 Remove debris and gently clean the ear canal with mild Burrow’s solution (aluminum acetate).
Place a wisp of cotton soaked with solution into the ear, and apply a saturated compress directly to
the auricle. Afterward, dry the ear gently but thoroughly. (In severe otitis externa, cleaning may be
delayed until after initial treatment with antibiotic eardrops.)
 To instill eardrops in an adult, pull the pinna upward and backward to straighten the canal. For
children, pull the pinna downward and backward. To ensure that the drops reach the epithelium,
insert a wisp of cotton moistened with eardrops.
 If the patient has chronic otitis externa, clean the ear thoroughly. Use wet soaks intermittently on
oozing or infected skin. If the patient has chronic fungal infection, clean the ear canal well, then
apply an exfoliative ointment.

Complications:
Although complications associated with otitis externa are uncommon, there's a small risk of further
problems developing.

 Otitis media
 Hearing loss

 Inflamed or perforated eardrum -It's possible for any infection to spread to the eardrum. In some
cases, the infection may cause pus to build up inside the inner ear and may rupture (tear) the
eardrum.
 Cellulitis -a bacterial skin infection that can occur after otitis externa. It's what happens when
bacteria that normally live harmlessly on the surface of the skin enter skin's deeper layers through
damaged areas
 Abscesses - Abscesses are painful, pus-filled growths that can form in and around the affected
ear after an infection.

 Stenosis of the ear canal - For long-term (chronic) otitis externa, thick and dry skin can build up
inside the ear canal. This causes the ear canal to narrow (stenosis), which may affect hearing and,
in rare cases, can even cause deafness.

 Malignant otitis externa - serious but very rare complication of otitis externa, in which the infection
spreads to the bone that surrounds the ear canal. Malignant otitis externa usually affects adults
more than children. In particular, adults who are immunocompromised (have a weakened immune
system) have an increased risk of developing it. This includes people having chemotherapy
treatment or who have a chronic (long-term) health condition, such as diabetes, HIV or AIDS.

Prevention

 Use of lamb’s wool earplugs coated with petrolatum to keep water out of the ears when showering
or shampooing.
 Keep your ears dry and clean.

 Wear earplugs or to keep the head above water when swimming

 Instill two or three drops of 3% boric acid solution in 70% alcohol before and after swimming to
toughen the skin of the external ear canal.
 Avoiding irritants, such as hair-care products and earrings.
 Avoiding cotton tipped applicators or other objects when cleaning the ears.

OTITIS MEDIA

• An inflammation of the middle ear that may be suppurative or secretory, acute or chronic,
persistent, or unresponsive (treatment).
• An infection of the middle ear that causes inflammation (redness and swelling) and a build-
up of fluid behind the eardrum.
• A common sequela of the common cold. Viral infections of the URT lead to inflammation of
the Eustachian tubes and build-up of fluid in the middle ear, which can lead to bacterial
multiplication in those fluid.
 P a g e | 19

• Anyone can develop a middle ear infection but infants between six and 15 months old are
most commonly affected.
• Children are more likely than adults to get ear infections.
• Not communicable

Causative Agents

• Streptococcus pneumoniae
• Haemophilus influenzae – most common cause in children younger than 6 years old
• Moraxella catarrhalis
• Beta-hemolytic streptococci
• Staphylococcus aureus

** Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are considered

normal flora of the nasopharynx in children
**Bacteria or viruses reach the middle ear through the lining or the passageway of the Eustachian
tube; they can then produce infection. Infection causes swelling of the lining of the middle ear,
blocking of the Eustachian tube, and migration of white cells from the bloodstream to help fight the
infection. In this process, the white cells accumulate, often killing bacteria and dying themselves,
leading to the formation of pus (a thick yellowish-white fluid) in the middle ear.

Risk Factors

• Age - Children between the ages of 6 months and 2 years are more susceptible to ear infections
because of the size and shape of their eustachian tubes and because of their poorly developed
immune systems. Normally narrow, shorter, more horizontal Eustachian tube in children
• Increased lymphoid tissue in children
• Anatomic anomalies
• Gastroesophageal reflux
• Genetic predisposition
• Upper airway infections or allergies
• Seasonal factors. Ear infections are most common during the fall and winter when colds and flu are
prevalent. People with seasonal allergies may have a greater risk of ear infections during seasonal
high pollen counts.
• Day-care center attendance
• Bottle feeding - Babies who drink from a bottle, especially while lying down, tend to have more ear
infections than do babies who are breast-fed.
• Exposure to passive smoking - Passive smoking can increase the adherence of bacteria to the
respiratory epithelium, depress local immune function and decrease mucociliary action
• Use of pacifiers (high negative pressure that develops within the pharynx can prevent the
Eustachian tube from opening especially when nasal obstruction is present)

Mode of Transmission

 Direct contact
 Droplet
**sequela of URT

Incubation Period: No information

Signs and Symptoms

 Earache-most prominent symptom, because of inflammation and buildup of fluids in the middle ear
• Runny or stuffy nose
• Cough
• Headaches
• Fever
• Nausea & vomiting
• Tinnitus
• Dizziness
• Irritability
 P a g e | 20

• Sleep disturbance in infants and younger children

• Purulent drainage from tympanic membrane rupture
• Temporary hearing loss

**Many patients are asymptomatic.

Notes:

• Otitis media is another common sequel of rhinitis, or the common cold, and for reasons similar to
the ones described for sinusitis. Viral infections of the upper respiratory tract lead to inflammation
of the Eustachian tubes and the buildup of fluid in the middle ear, which can lead to bacterial
multiplication in those fluids. Although the middle ear normally has no biota, bacteria can migrate
along the eustachian tube from the upper respiratory tract. When bacteria encounter mucus and
fluid buildup in the middle ear, they multiply rapidly. Their presence increases the inflammatory
response, leading to pus production and continued fluid secretion called effusion.
• Otitis media results from disruption of eustachian tube patency.
• Suppurative form, bacterial infection is usually the cause; other causes include respiratory tract
infection, allergic reaction, nasotracheal intubation, or positional changes that allow flora to reflux
through the Eustachian tube and colonize the middle ear.
• Chronic suppurative otitis media results from inadequate treatment for acute otitis episodes or
from infection by resistant strains of bacteria or, rarely, tuberculosis.
• Secretory otitis media/ Otitis media with effusion results from obstruction of the Eustachian
tube. This causes a build-up of negative pressure in the middle ear that promotes transudation of
sterile serous fluid from blood vessels in the membrane of the middle ear. There is thick or sticky
fluid behind the eardrum in the middle ear, but there is no ear infection. When the Eustachian tube
is partially blocked, fluid builds up in the middle ear. Bacteria that are already inside the ear
become trapped and begin to grow. This may lead to an ear infection.
• Chronic secretory otitis media follows persistent Eustachian tube dysfunction from mechanical
obstruction (adenoidal tissue overgrowth or tumors), edema (allergic rhinitis or chronic sinus
infection), or inadequate treatment for acute suppurative otitis media.

Diagnostic Tests

 P.E.
 Otoscopy – reveals obscured or distorted bony landmarks of the tympanic membrane
 Culture and sensitivity testing of exudates
 Radiographic studies or computed tomography – shows mastoid involvement
 Tympanometry and audiometry – measure how well the tympanic membrane functions in order to
detect hearing loss and evaluate the condition of the middle ear

Treatment
• Amoxicillin plus Cefuroxime for S. pneumoniae and H. influenzae
• Azithromycin for other bacteria
• Decongestant
• Expectorant
• Analgesics and antipyretics
• Myringotomy

Myringotomy is a surgical procedure in which a tiny incision is created in the eardrum to relieve pressure
caused by excessive build-up of fluid, or to drain pus from the middle ear. A tympanostomy tube is a small
tube inserted into the eardrum in order to keep the middle ear aerated for a prolonged period of time, and to
prevent re-accumulation of fluid. Without the insertion of a tube, the incision will heal spontaneously in two
to three weeks. Depending on the type of tube used, it will be naturally extruded in six to 12 months or
alternatively removed by a doctor if needed. If a patient requires myringotomy for drainage or ventilation of
the middle ear, this generally implies that the Eustachian tube is either partially or completely obstructed
and is not able to perform drainage or ventilation in its usual physiologic fashion. Fluid in the middle ear can
be sucked out through the incision.

Nursing Responsibilities
 Positioning - Have the child sit up, raise head on pillows, or lie on unaffected ear.
 Heat application - Apply heating pad or a warm hot water bottle.
 Diet -Encourage breastfeeding of infants as breastfeeding affords natural immunity to infectious
agents; position bottle-fed infants upright when feeding.
 P a g e | 21

 Hygiene - Teach family members to cover mouths and noses when sneezing or coughing and to
wash hands frequently.
 Monitoring hearing loss - Assess hearing ability frequently.

Complications

• Spontaneous rupture of the tympanic membrane

• Mastoiditis
• Meningitis
• Septicemia, intracranial abscess
• Permanent hearing loss
• Suppurative labyrinthitis
• Facial paralysis
• Impaired hearing. Mild hearing loss that comes and goes is fairly common with an ear infection,
but it usually returns to what it was before the infection after the infection clears. Persistent
infection or persistent fluids in the middle ear may result in more significant hearing loss. If there is
some permanent damage to the eardrum or other middle ear structures, permanent hearing loss
may occur.
• Speech or developmental delays. If hearing is temporarily or permanently impaired in infants and
toddlers, they may experience delays in speech, social and developmental skills.

Prevention

• Reduce risk of having colds especially among children - Teach children to wash their hands
frequently and thoroughly and not to share eating and drinking utensils. Teach children to cough or
sneeze into their arm crook.
• Compliance to medication
• Proper positioning during feeding of the infant – if you bottle-feed, hold your baby in an upright
position (prevent reflux of nasopharyngeal flora)
• Avoid smoking or exposure to secondhand smoke.
• Avoid exposure to air pollution.
 Immunization - Pneumococcal conjugate vaccine (heptavalent) for Streptococcus pneumoniae, Hib
vaccine for Haemophilus influenzae
• Breastfeeding
• Avoid close contact with other children who are known to be infected

References (update):

Cowan, M.K. (2015). Microbiology: A systems Approach. 4th ed. New York: McGraw-Hill Education
Lippincott’s Guide to Infectious Diseases
Professional Guide to Diseases
http://www.cdc.gov/hpv/Prevention
http://microbewiki.kenyon.edu/index.php/Propionibacterium
http://www.mayoclinic.com/health/acne/DS00169/DSECTION=prevention
http://www.webmd.com/skin-problems-and-treatments/acne/10-tips-for-preventing-pimples
https://www.google.com/health/ref/Furuncle
http://www.mayoclinic.com/health/boils-and-carbuncles/DS00466/DSECTION=symptoms
http://www.medicinenet.com/impetigo/article.htm
http://www.mayoclinic.com/health/impetigo
http://en.wikipedia.org/wiki/Impetigo
http://my.clevelandclinic.org/disorders/Conjunctivitis/hic_Conjunctivitis.aspx
http://www.netdoctor.co.uk/diseases/facts/conjunctivitis.htm
http://www.cdc.gov/getsmart/antibiotic-use/uri/ear-infection.html
https://www.mayoclinic.org/diseases-conditions/swimmers-ear/symptoms-causes/syc-20351682
https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/otitis-externa
https://www.cdc.gov/healthywater/swimming/swimmers/rwi/ear-infections.html
https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/middle-ear-infection-otitis-media
https://www.medicinenet.com/script/main/art.asp?articlekey=8912
 P a g e | 22

https://www.webmd.com/skin-problems-and-treatments/guide/boils#1
https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/boils
www.nursinginpractice.com/article/superficial-fungal-skin-infections
https://www.nursingtimes.net/clinical-archive/womens-health/diagnosis-and-management-of-candidiasis-
vaginitis/205831.article