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Erythema induratum from tuberculosis is seen on the posterior surfaces of the legs and may ulcerate Lupus panniculitis presents as tender nodules on the buttocks and posterior arms that heal with depressed scars Polyarteritis nodosa is less inflammatory, and the subcutaneous nodules are often associated with a fixed livedo In the late stages, erythema nodosum must be distinguished from simple bruises and contusions
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Pain and tenderness may be prominent The abscess is either rounded or conical It gradually enlarges, becomes fluctuant, and then softens and opens spontaneously after a few days to 1 2 weeks to discharge a core of necrotic tissue and pus The inflammation occasionally subsides before necrosis occurs Infection of the soft tissue around the nails (paronychia) may be due to staphylococci when it is acute or candida when chronic
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First, the underlying cause should be identified and treated Primary therapy is with NSAIDs in usual doses Saturated solution of potassium iodide, 5 15 drops
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There may be slight leukocytosis, but a white blood cell count is rarely required Pus should be cultured to rule out MRSA or other bacteria Culture of the anterior nares may identify chronic staphylococcal carriage in cases of recurrent cutaneous infection
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Differential Diagnosis
The most common entity in the differential is an inflamed epidermal inclusion cyst that suddenly becomes red, tender, and expands greatly in size over one to a few days The history of a prior cyst in the same location, the presence of a clearly visible cyst orifice, and the extrusion of malodorous cheesy rather than purulent material helps in the diagnosis Tinea profunda (deep dermatophyte infection of the hair follicle) may simulate recurrent furunculosis Furuncle is also to be distinguished from deep mycotic infections, such as sporotrichosis (often in gardeners); from other bacterial infections, such as anthrax and tularemia (rare); from atypical mycobacterial infections; and from acne cysts Hidradenitis suppurativa presents with recurrent tender sterile abscesses in the axillae and groin, on the buttocks, or below the breasts The presence of old scars or sinus tracts plus negative cultures suggests this diagnosis
localize Use surgical incision and debridement after the lesions are mature To incise and drain an acute staphylococcal paronychia, insert a flat metal spatula or sharpened hardwood stick into the nail fold where it adjoins the nail This will release pus from a mature lesion Inflamed epidermal cysts may be treated in the initial stages with intralesional injections of triamcinolone acetonide into the borders of the lesions Drainage of fluctuant lesions results in rapid resolution and reduction of pain
Prognosis
Recurrent crops may harass the patient for months or years
Embil JM et al A man with recurrent furunculosis CMAJ 2006 Jul 18;175(2):143 [PMID: 16804121] Zetola N et al Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat Lancet Infect Dis 2005 May;5(5):275 86 [PMID: 15854883]
EPIDERMAL INCLUSION CYST
ESSENTIALS OF DIAGNOSIS
Firm dermal papule or nodule Overlying black comedone or punctum Expressable foul-smelling cheesy material May become red and drain, mimicking an abscess
Complications
Serious and sometimes fatal complications of staphylococcal infection such as septicemia can occur
Treatment
A Specific Measures
Incision and drainage is recommended for all loculated suppurations and is the mainstay of therapy Systemic antibiotics are usually given, although they offer little beyond adequate incision and drainage Sodium dicloxacillin or cephalexin, 1 g daily in divided doses by mouth for 10 days, is usually effective Doxycycline 100 mg twice daily, trimethoprim-sulfamethoxazole DS one tablet twice daily, and clindamycin 150 300 mg twice daily are effective in treating MRSA Recurrent furunculosis may be effectively treated with a combination of cephalexin, 250 500 mg four times daily for 2 4 weeks, and rifampin, 300 mg twice daily for 5 days during this period Chronic clindamycin, 150 300 mg daily for 1 2 months, may also cure recurrent furunculosis Family members and intimate contacts may need evaluation for staphylococcal carrier state and perhaps concomitant treatment Applications of topical 2% mupirocin to the nares, axillae, and anogenital areas twice daily for 5 days may eliminate the staphylococcal carrier state
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