trunk and neck of adolescents Systemic steroids and chemotherapy (EGFR inhibitors) patients who are immunodeficient can have folliculitis caused by gram-negative bacteria or fungi Performing a culture of the pus expressed from an intact pustule establishes the diagnosis and guides therapy It is very important to recognize that vesicular eruption of herpes simplex virus (HSV) or varicella zoster virus (VZV) can also look pustular if the eruption has been present for a few days Neutrophils infiltrate the vesicles and make them look pustular Therefore, in neonates with pustular eruptions, and any child with recurrent localized areas of grouped pustules, HSV should be considered Disseminated Gonococcal Infections (See also Chapter 94 Infectious Disease Emergencies ) Localized genitourinary or oral infection with Neisseria gonorrhoeae can rarely disseminate to the skin, presenting with erythematous papules, petechiae, or vesicle-pustules on a hemorrhagic base These cutaneous lesions usually develop on the trunk but may occur anywhere on the extremities Disseminated N gonorrhoeae should be considered in sexually active or sexually abused children, especially if the partner has a history of vaginal or penile discharge Diagnosis can be made by culture of vesiculopustular skin lesions, blood culture, or positive culture of oral or genital sites Gram stains of pustules show gram-negative diplococci and can help support the clinical diagnosis, although Neisseria meningitidis may have the same appearance on Gram stain Based on resistance patterns, recommended current therapy is ceftriaxone until clinical improvement is seen, at which point it can be changed to an oral antibiotic, such as cefixime, ciprofloxacin, ofloxacin, or levofloxacin, for a total of a 7-day course Quinolones should not be used for infections in men who have intercourse with men or in those with a history of recent foreign travel or partners’ travel, or infections acquired in other areas with increased resistance Concomitant sexually transmitted diseases should be tested for and treated empirically Furunculosis Furunculosis is an acute purulent abscess extending from the dermis into the subcutis Furuncles manifest as painful red or purple fluctuant nodules with or without a pustule on top ( Fig 66.2 ) Furunculosis is most commonly caused by SA and can be methicillin-sensitive or resistant (MRSA) Diagnosis is clinical but can be aided by ultrasound if it is unclear if there is fluctuance Therapy is with incision and drainage and adding antibiotic coverage is controversial The literature suggests antibiotics are not necessary for simple abscesses except in young children unless there is associated cellulitis, the lesion has failed incision and drainage previously, the patient is immunosuppressed or showing signs of sepsis, or the lesion is particularly difficult to drain Cultures can be sent from the purulent drainage in order to confirm the diagnosis and measure the antibiotic sensitivities Empiric therapy should be guided by local resistance patterns but is usually with clindamycin, trimethoprim-sulfamethoxazole, or doxycycline (if age appropriate) in order to cover for MRSA Recurrence of furunculosis is common Reinfection from the patient’s local environment can come from sources such as close contacts, pets, athletic equipment, or stuffed animals Reinfection may occur because of reinoculation from the patient’s own nares Decolonization is challenging but nasal decolonization may be effective with intranasal mupirocin two times daily for days for the patient and any close contacts Four percent chlorhexidine washes or dilute sodium hypochlorite (¼ cup in 20 to 40 gallons of water for 15 minutes) baths can be used to decolonize the skin FIGURE 66.1 Folliculitis (Reprinted with permission from Burkhart C, Morrell D, Goldsmith LA, et al VisualDx: Essential Pediatric Dermatology Philadelphia, PA: Lippincott Williams & Wilkins; 2009.) Bullous Impetigo Bullous impetigo is caused by a localized staphylococcal infection that produces an exfoliative toxin that cleaves the skin connection desmoglein (DGS1) This allows fluid to build up within the epidermis and forms bullae ( Fig 66.3 ) When the bullae rupture, the roof of the bulla and the fluid dries to the skin giving the classic “honey-colored” crusting SA colonization is most common in the nares and perianal areas and thus impetigo is more common on the face and perineum Culture of the blister fluid will yield the pathogen and establish sensitivities for therapy Localized bullous impetigo can often be treated with topical antibiotics such as mupirocin, bacitracin, or retapamulin Systemic antibiotics should be used for more widespread or severe infections or those in immunosuppressed hosts, including neonates FIGURE 66.2 Furuncle Note pustule with surrounding erythema and induration (Image courtesy of Lee R In: Elder DE, ed Lever’s Histopathology of the Skin 11th ed Philadelphia, PA: Wolters Kluwer; 2014 With permission.) ... (Reprinted with permission from Burkhart C, Morrell D, Goldsmith LA, et al VisualDx: Essential Pediatric Dermatology Philadelphia, PA: Lippincott Williams & Wilkins; 2009.) Bullous Impetigo