Case Report 2: A 75-year-old Irishman presented with a week history of an inflamed thoracic and upper limb area, populated by fragile 3 cm fluid-filled vesicles and flaccid blisters. He had previously been in Dubai where he had seen two dermatologists who had prescribed steroids, anti-inflammatories and Aldara cream. The patient said that the bullae ruptured easily; leaving a reddened base but now they were turning browny black and causing the patient some distress. The patient was a newspaper magnate who was leaving to Toronto that evening. He was otherwise healthy and denied any history of recent infection or trauma. Apparently, recent full blood count and blood chemistry in Dubai was within normal range. He had no other medical problems, except mild diarrhea and was not taking any systemic medications. On physical examination, there was evidence of numerous bullae containing a clear, yellow fluid along his thorax and in his intertriginous areas. The chest area contained some cloudy and dark yellow bullae mostly the lesions appeared to have a brownish crust at the periphery. Removal of this crust in one instance revealed a moist, red base. There was no surrounding erythema or edema present between the lesions or evidence of regional adenopathy. There was no involvement of the buccal mucous membranes and no A punch biopsy was taken from the thoracic area to aid in the diagnosis. Histology showed skin with subcorneal bulla formation and overlying parakeratosis. The superficial and mid dermis contained a moderate inflammatory infiltrate composed predominantly of lymphocytes with occasional neutrophils. Gram stain highlighted gram-positive cocci in fragments of detached scale crust. Based on the clinical findings a provisional diagnosis of bullous impetigo was made. The diagnosis of impetigo is usually based solely on history and clinical appearance. Impetigo is an acute, highly contagious gram-positive bacterial infection of the superficial layers of the epidermis. Bacterial culture and sensitivity are recommended to identify possible methicillin-resistant Staphylococcus aureus (MRSA). Impetigo occurs most commonly in children, especially those who live in hot, humid climates. It presents in two forms: bullous and nonbullous. Nonbullous impetigo is the more common form, constituting approximately 70% of impetigo cases (1) It tends to affect skin on the face or extremities that has been disrupted by bites, cuts, abrasions, other trauma, or diseases such as varicella. (2) The rarer variant, bullous impetigo is commonly due to exfoliative toxins of S aureus termed exfoliatins A and B. These exotoxins cause a loss of cell adhesion in the superficial dermis, which, in turn, causes blisters and skin sloughing by cleaving of the granular cell layer of the epidermis.(3). It is characterized by fragile fluid-filled vesicles and flaccid blisters and is caused by pathogenic strains of Staphylococcus aureus

1. 37
CASE FILES
Aesthetic Medicine • May 2014
S K I N / D E R M AT O L O G Y
www.aestheticmed.co.uk
Dr Patrick Treacy shares some of his most challenging cases
Dr Treacy’s
CASEBOOK
DR PATRICK TREACY
is chairman of the Irish
Association of Cosmetic
Doctors and Irish regional
representative of the British
Collage of Aesthetic Medicine
(BCAM). He is European medical
advisor to Network Lipolysis
and Consulting Rooms and
holds higher qualifications in
dermatology, laser technology
and skin resurfacing. In 2012
and 2013 he won awards for
‘Best Innovative Techniques’
for his contributions to
facial aesthetics and hair
transplants. Dr Treacy also
sits on the editorial boards
of three international
journals and features regularly
on international television and
radio programmes. He was
Faculty IMCAS Paris 2013,
AMWC Monaco 2013, EAMWC
Moscow 2013 and keynote
speaker for the American
Academy of Anti-Ageing
Medicine in Mexico City
this year.
>>
SPONSORED BY
A
75-year-old Irishman presented with a week history of an inflamed
thoracic and upper limb area, populated by fragile 3cm fluid-filled vesicles
and flaccid blisters. He had previously been in Dubai where he had seen
two dermatologists who had prescribed steroids, anti-inflammatories
and Aldara cream. The patient said that the bullae ruptured easily; leaving
a reddened base but now they were turning browny black and causing the patient
some distress. The patient was a newspaper magnate who was leaving to Toronto
that evening. He was otherwise healthy and denied any history of recent infection or
trauma. Apparently, recent full blood count and blood chemistry in Dubai was within
normal range. He had no other medical problems, except mild diarrhea and was not
taking any systemic medications.
On physical examination, there was
evidence of numerous bullae containing
a clear, yellow fluid along his thorax
and in his intertriginous areas. The
chest area contained some cloudy
and dark yellow bullae mostly
the lesions appeared to have a
brownishcrustattheperiphery.
Removal of this crust in one
instance revealed a moist, red
base.Therewasnosurrounding
erythema or edema present
betweenthelesionsorevidence
of regional adenopathy. There
was no involvement of the buccal
mucous membranes and no ??
Sentance finishes strangely
A punch biopsy was taken
from the thoracic area to aid in the
diagnosis. Histology showed skin with >
“On physical
examination, there was
evidence of numerous bullae
containing a clear, yellow fluid
along his thorax and in his
intertriginous areas. The chest
area contained some cloudy
and dark yellow bullae.”
Will finalise layout once text is sorted

2. 38 Aesthetic Medicine • May 2014
S K I N / D E R M AT O L O G Y
CASE FILES SPONSORED BY
subcorneal bulla formation and
overlying parakeratosis. The
superficial and mid dermis
contained a moderate
inflammatory infiltrate
composed predominantly
of lymphocytes with
occasional neutrophils.
Gram stain highlighted
gram-positive cocci in
fragmentsofdetachedscale
crust.
COMMENT
Based on the clinical findings a
provisional diagnosis of bullous impetigo was made. The
diagnosis of impetigo is usually based solely on history and clinical
appearance. Impetigo is an acute, highly contagious gram-positive
bacterial infection of the superficial layers of the epidermis.
Bacterial culture and sensitivity are recommended to identify
possible methicillin-resistant Staphylococcus aureus (MRSA).
Impetigo occurs most commonly in children, especially those
who live in hot, humid climates. It presents in two forms: bullous
and nonbullous. Nonbullous impetigo is the more common form,
constituting approximately 70% of impetigo cases1
. It tends to
affect skin on the face or extremities that has been disrupted by
bites, cuts, abrasions, other trauma, or diseases such as varicella2
.
The rarer variant, bullous impetigo is commonly due to exfoliative
toxins of S aureus termed exfoliatins A and B. These exotoxins
cause a loss of cell adhesion in the superficial dermis, which, in
turn, causes blisters and skin sloughing by cleaving of the granular
cell layer of the epidermis3
. It is characterized by fragile fluid-filled
vesicles and flaccid blisters and is caused by pathogenic strains
of Staphylococcus aureus4
. Bullous impetigo is at the mild end of
a spectrum of blistering skin diseases caused by a staphylococcal
exfoliative toxin that, at the other extreme, is represented by
widespread painful blistering and superficial denudation (the
staphylococcal scalded skin syndrome).5
Impetigo has been associated crowded living conditions, poor
personal hygiene, or an unhygienic work environment encourages
contamination of the skin by pathogenic bacteria. It is also
associatedwithhothumidweatherandevenparticipationincontact
sports, such as rugby6
. Conditions such as HIV infection, post
transplantation, diabetes mellitus, hemodialysis, chemotherapy,
radiation therapy, or systemic corticosteroid treatment increase
susceptibility7
.
Topical therapy should constitute either fusidic acid (Fucidin,
Leo Pharma Ltd) as a first-line treatment or mupirocin (Bactroban,
GlaxoSmithKline) in proven cases of bacterial resistance. First-line
systemic therapy is oral or intravenous flucloxacillin (Floxapen,
GlaxoSmithKline). Nasal swabs from the patient and immediate
relatives should be performed to identify asymptomatic nasal
carriers of Staphylococcus aureus. In the case of outbreaks on
wards and in nurseries, healthcare professionals should also be
swabbed8, 9
. AM
REFERENCES
1. ColeC,GazewoodJ.Diagnosisandtreatmentofimpetigo.
AmFamPhysician.Mar152007;75(6):859-64.
2. MoulinF,QuinetB,RaymondJ,GilletY,CohenR.[Managing
childrenskinandsofttissueinfections].ArchPediatr.
Oct2008;15Suppl2:S62-7.
3. YamasakiO,TristanA,YamaguchiT,etal.Distributionofthe
exfoliativetoxinDgeneinclinicalStaphylococcusaureus
isolatesinFrance.ClinMicrobiolInfect.Jun2006;12(6):585-8.
4. AmagaiM,MatsuyoshiN,WangZH,AndlC,StanleyJR
(November2000).“Toxininbullousimpetigoandstaphylococcal
scalded-skinsyndrometargetsdesmoglein1”.Nat.Med.6(11):
1275–7.
5. Yasushi,Hanakawa.“Molecularmechanismsofblisterformation
inbullousimpetigoandstaphylococcalscaldedskinsyndrome.”
journalofClinicalInvestigation.110.1(2002):53-60.
6. LudlamH,CooksonB.Scrumkidney:epidemicpyodermacaused
byanephritogenicStreptococcuspyogenesinarugbyteam.
Lancet.Aug91986;2(8502):331-3.
7. ManciniAJ.Bacterialskininfectionsinchildren:thecommonand
thenotsocommon.PediatrAnn.Jan2000;29(1):26-35.
8. KoningS,VerhagenAP,vanSuijlekom-SmitLW,etal.
Interventionsforimpetigo.CochraneDatabaseSystRev.
2004;CD003261
9. GeorgeA,RubinG.Asystematicreviewandmeta-analysisof
treatmentsforimpetigo.BrJGenPract.Jun2003;53(491):480-7.
HISTOLOGY REPORT
Histology showed skin with subcorneal bulla
formation and overlying parakeratosis.
The superficial and mid dermis contained a
moderate inflammatory infiltrate composed
predominantly of lymphocytes with occasional
neutrophils. A Gram stain (not photographed)
highlighted gram-positive cocci in fragments
of detached scale crust. The histopathology
featuresareconsistentwithbullousimpetigo.
Prof.KieranSheahan,
ConsultantHistopathologist,
St.Vincent’sUniversityHospital,
ElmPark,Dublin4.
DrLindaMulligan,
PathologyRegistrar,
St.Vincent’sUniversityHospital,
ElmPark, Dublin4.
“Impetigo
has been associated with
crowded living conditions,
poor personal hygiene, or an
unhygienic work environment
encourages contamination of
the skin by pathogenic
bacteria.”
www.aestheticmed.co.uk