Federal guidelines for the management of patients with pyoderma

RUSSIAN SOCIETY DERMATOVENEREOLOGY and cosmetology

FEDERAL clinical guidelines

On the management of pyoderma

Moscow 2013

Personal composition of the working group on preparation of the federal guideline for profile "Dermatology", "pyoderma" section:

Klemenova Irina - director of the Nizhny Novgorod branch of State Organization "State Scientific Center of dermatology and cosmetology» Russian Ministry of Health, MD.

METHODOLOGY

The methods used for the collection / selection of evidence:

search in electronic databases.

Description of the methods used for the collection / selection of evidence:

evidence base for recommendations are publications included in the Cochrane Library, EMBASE and MEDLINE databases.

The methods used to assess the quality of evidence and strength:

• The consensus of experts;
• Assessment of significance according to the rating scheme (scheme attached).

The rating scheme to assess the strength of recommendations:

levels of evidence	Description
1++	Meta-analyzes of high-quality systematic reviews of randomized controlled trials (RCTs), or RCTs with a very low risk of bias
1+	Well-conducted meta-analyzes, systematic, or RCTs with a low risk of bias
1-	Meta-analyzes, systematic, or RCTs with a high risk of bias
2++	High-quality systematic reviews of case-control or cohort studies. High-quality reviews case-control or cohort studies with a very low risk of mixing effects or systematic errors and the average probability of a causal relationship
2+	Well-conducted case-control or cohort studies with an average risk of mixing effects or systematic errors and the average probability of a causal relationship
2-	Case-control or cohort studies with a high risk of mixing effects or systematic errors and the average probability of a causal relationship
3	Non-analytic studies (for example case reports, case series)
4	expert opinion

The methods used for the analysis of the evidence:

• A review of published meta-analyzes;
• Systematic reviews of the evidence from the tables.

The methods used for formulating the recommendations:

The consensus of experts.

The rating scheme to assess the strength of recommendations:

Force	Description
BUT	At least one meta-analysis, systematic review or RCT evaluated as ++ 1 is directly applicable to the target population and demonstrate the robustness of the results or group of evidence, including the results of studies evaluated as 1+, directly applicable to the target population and the results demonstrate the overall stability
AT	Evidence Unit, which includes the results of studies rated as 2 ++, directly applicable to the target population and demonstrating overall stability results or Extrapolated evidence from studies rated as 1 ++ or 1+
FROM	Group of evidence, including the results of studies rated as 2+, directly applicable to the target population and demonstrating overall sustainability of results; or Extrapolated evidence from studies rated as 2 ++
D	Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

Indicators benign practices (GoodPracticePoints – GPPs):

Recommended benign practice is based on the clinical experience of the working group to develop recommendations.

Economic analysis:

value not analyzed and publications pharmacoeconomics not analyzed.

Method validation guidelines:

• External peer review;
• Internal expert judgment.

Description of the method validation guidelines:

These recommendations are in the preliminary version reviewed by independent experts.

Comments received from experts, systematized and discussed by the working group. Introduced as a result of this change in the recommendation were recorded. If changes were not made, the reasons for refusal registered by the change.

Consultation and expert assessment:

A preliminary version was put up for discussion at the site FGBU "State Scientific Center of dermatology and cosmetology" the Ministry of Health Russia to persons who are not involved in the development of recommendations, were able to participate in the discussion and improvement recommendations.

Working group:

For the final version of the recommendations and quality control re-analyzed by the working group.

Key recommendations:

The strength of the recommendation (A-D) is in presenting text recommendations.

pyoderma

Identifier in International Classification of Diseases, ICD-10: L 00-08, L39.4, L46, L66, L73, L74.8, L88, L98.4, R02

DETERMINATION

Pyoderma - a group of dermatoses, which are based on a purulent inflammation of the skin and its appendages, as well as subcutaneous fat.

Etiology and epidemiology

Disease pathogens often are representatives Micrococcaceae family: staphylococci (Gram-positive facultative anaerobic bacteria) and Streptococci (Gram-positive aerobic and facultative anaerobic bacteria) The most common etiological Agneta pyoderma is Staphylococcus aureus, S. haemolyticus, S. epidermidis, β-hemolytic streptococcus. Pathogenic properties of microorganisms is determined by their ability to develop during the life toxins, enzymes and other biologically active substances. Toxic skin lesions accompanied by exfoliation cause fagogruppy II staphylococci, lysed phage 3A, 3B, 3C, 55, 71.

Etiological agents may be pyoderma and other organisms - Proteus vulgaris, pneumococci, Pseudomonas aeruginosa, etc., protruding usually in associations with and staphylococci. streptococci. The epidemiology of staphylococcal infection attaches great importance to stafilokokkonositelstvu.

Exogenous factors contribute to the development of pyoderma and their recurrence, include violation of the integrity of the epidermis (microtrauma, maceration of the skin), skin contamination, increased sweating, skin pH shift to the alkaline side, the high and low action temperatures.

Endogenous factors of disease risk include a variety of endocrinopathies, and above all, a violation of carbohydrate metabolism (diabetes), Insufficient intake of proteins in the organism, the presence of severe somatic diseases, vitamin deficiencies, chronic toxicity, the presence of staphylococcal infection foci in various organs and tissues. All pathological changes in macroorganism cause the failure of the immune system.

CLASSIFICATION

Depending on the pathogen, and the depth of destruction of pyoderma are divided into the following types:

1. Stafilodermii

surface

• ostiofollikulit
• folliculitis
• sycosis
• vezikulopustulez
• epidemic pemphigus newborns
• exfoliative dermatitis (Ritter disease)
• syndrome staphylococcal burned skin (SSSS)
• staphylococcal toxic shock syndrome (TSS)

deep

• furuncle
• furunculosis
• carbuncle
• abscess
• psevdofurunkulez
• hydradenitis

2. streptoderma

surface

• impetigo strep
• slit impetigo
• paronychia
• papules erosive streptoderma
• intertriginoznoy streptoderma
• mug
• streptococcal toxic shock syndrome (STSS)
• streptoderma acute diffuse

deep

• cellulitis
• ecthyma vulgar

3. streptostafilodermii

surface

• impetigo vulgar

deep

• chronic deep ulcerative pyoderma vegetans
• pyoderma gangrenosum
• pyoderma vegetans Allopo
• Acne keloidea (sclerosing folliculitis neck) 2.5. folliculitis scarring
• folliculitis and perifolliculitis head abscessed undermining Hoffmann
• shankriformnaya pyoderma
• vegetating piostomatit
• gangrene of the penis and scrotum.

CLINICAL PICTURE

Stafilodermii.

Ostiofollikulit (impetigo Bockhart) (L73) - pathogen is S. aureus, more rarely S. epidermidis. It is characterized by the appearance of a pointed yellowish-white pustules the size of a pinhead, imbued hair. It is the result of inflammation of the mouth of the hair follicle. The most frequent localization on the face in the beard, mustache, chest, limbs in areas of hair. 3-4 day pustule shrinks to form a yellowish crust, after falling off which is a pink spot.

Folliculitis (L73) – purulent inflammation of the entire hair follicle. The causative agent is S. aureus. The disease is characterized by the occurrence of a limited inflammatory infiltrate in the form of nodules of bright red, painful on palpation. 2-3 day formed pustule filled with yellowish-green contents, which can be seen in the center of the hair follicle or mouth. After 5-7 days pustule shrinks to form a yellowish crust.

Sycosis vulgaris (Sycosis staphylococcal, Sycosis nonparasitic) (L73) - chronic relapsing inflammation of the follicles in the area of ​​bristly hair growth (beard, mustache, eyebrows, pubic area, armpits). Pathogen - S. aureus or associations of different staphylococcal strains. The disease is characterized by the appearance of foci with marked infiltration of the skin bluish-brown color, on which there is a pustule, erosion, serosuppurative peel. After allowing ostifollikulitov folliculitis and scarring is formed.

Vezikulopustulez (periporit, osteoporit) (L74.8) - purulent inflammation of the mouth of merokrinnyh sweat glands. The causative agent is S. aureus. The disease is common in newborns. Vezikulopustuleza appearance precedes sudamen. Initially, there is a red prickly heat in the form of multi-point red spots, then on the surface of bubbles appear milky-white contents. Localized rash on the trunk, in the folds of skin on the scalp.

epidemic pemphigus Newborn (pyococcus pemphigoid, pemphigus pyococcus) (L00) - a superficial purulent skin lesions, appears in 3-5 day, at least - at 8-15 days after birth. Characterized by the appearance of disseminated "flaccid" bubbles (phlyctenas) the size of a pea to hazelnut with muddy contents on neinfiltrirovannoy skin. At the site revealed the bubbles are still wet erosion remnants of tires exfoliating epidermis, are not formed on the surface of the crust. Period blistering rash lasts from a few days to 2-3 weeks. Localized rashes on the skin in the area of ​​the navel, lower abdomen, genital area, region natural folds, with extensive lesions - skin chest, back, legs, rarely - on the palms and soles. The disease occurs with fever. Epidemic pemphigus highly contagious for infants. neonatal infection occurs from mothers and health care workers with pyoderma.

Exfoliative dermatitis Ritter (epidermolysis neonatal acute) (L00) is the most severe stafilodermii form newborn and is regarded as a severe variant of epidemic pemphigus newborns. Called Staphylococcus phage group II, phage type 71 or 55/71. The disease develops in weak, premature infants, severe in children 2-4 days of life than children in the 2-3 weeks after birth. There are three stages of the disease - erythematous, exfoliative and regenerative. The disease begins with redness, cracking, exfoliating the upper layers of the epidermis around the mouth or around the umbilicus. Then there is serous skin soaking and there epidermolysis reminiscent of II degree burns, positive Nikolsky sign. In different parts of the skin appear flabby bubbles. Process for 6-12 hours extends from the head across the skin surface. Within 8-15 days the rash resolved with subsequent desquamation. Rubtsov not formed. The general condition of patients with severe, the disease occurs with a high body temperature to 40-41S may develop toxic-septic conditions and sepsis.

Syndrome staphylococcal burned skin (Staphylococcal Scalded Skin Syndrome) (L00) - skin lesions similar exfoliative dermatitis in children aged 1 month to 5 years. The disease is associated with staphylococcal infection related to phage group II, which causes production of the toxin (eksfoliatin A or B). It causes the detachment of the epidermis directly below the granular layer. Clinically characterized by the appearance of common spotted erythematous rash, often after purulent conjunctivitis, otitis media or infections of the upper respiratory tract. In the inguinal and axillary folds marked foci of maceration. Around the orifices accumulate impetiginoznye peel. The skin lesion progresses within 24-48 hours from rash to Scarlatiniform spontaneous large bubbles. There is a positive sign of Nikolsky. Within 5-7 days, says epithelialization of erosions followed by exfoliation.

Staphylococcal toxic shock syndrome (TSS) (L00) is characterized by a sudden increase in fever, hypotension, reddening of the skin and mucous membranes and multiple organ insufficiency. The causative agent is S. aureus (fagogruppa I, types 16, 29, 35, 36, 52) which produces a toxin TSST-1. The risk factors are the use of tampons during menstruation, infections of surgical wounds, burns, ulcers, skin injuries, postnatal infection. The disease is characterized by the appearance of punctate spotty rash all over the skin, more pronounced around the foci of infection, rarely seen petechiae, blisters. There dense edema, more pronounced on the face, hands, feet, in a subsequent (after 10-21 days of onset) - peeling and sloughing of the epidermis on the palms and soles. Language crimson color, there is a violation of general condition in the form of muscle weakness, muscle pain, headaches, cramps, profuse diarrhea, vomiting, shortness of breath. Possible death (5% of patients).

Boil (L02) - necrotic inflammation of the hair follicle and the surrounding subcutaneous fat. Characterized by formation of pustules tapered rod to form necrotic area and inflammation, swelling, pain on palpation of the skin around the hearth. In place of the separated rod formed necrotic ulcer.

Abrasions (L02) is characterized by the appearance of multiple boils in confined spaces can be disseminated in nature. Possible relapse over a few weeks to several years.

Bacteremia (L02) - boils conglomerate combined overall infiltrate. It is a dense assembly of dark red or purple color with a diameter of 5-10 cm, clearly delimited from the surrounding tissue, the surface of which has several pustules. After opening these pustules formed deep necrosis of underlying tissues to form extensive deep ulcers.

Abscess (L02) - demarcated purulent inflammation accompanied by necrosis. The causative agent is S. aureus. It is localized in the dermis, subcutaneous tissue and muscles. Characterized by the appearance of painful site, followed by the formation in the center of the cavity element filled with pus. For the formed abscess is characterized by fluctuation.

Psevdofurunkulez (multiple abscesses newborn) (P39.4) in children after the first few months of life, often in the background of malnutrition, with associated severe illness (pneumonia, anemia). The causative agent of the disease is S. aureus, or its association with other pathogens. Characterized by the occurrence of subcutaneous nodes size from pea to hazelnut purplish-red to bluish tint. Favorite localization - neck, back, buttocks, back of the thighs. The central floating node is formed, at the opening of which is allocated creamy yellow-green pus. Necrotizing rod is formed. After the resolution process remain scars, as all affected ekkrinnaya sweat glands.

Hidradenitis (L73.2) - purulent inflammation of the apocrine glands. Hidradenitis often localized in the armpit, around the nipples, navel, genitals and anus. The thicker the skin produces small infiltrates the size of a pea, which gradually increase, soldered each other and with the surrounding tissues, forming a continuous painful inflammatory infiltrate bluish-purple colors. After 4-5 days there is a fluctuation, units opened with the formation of fistulas and the appearance of purulent discharge. For disease characterized by a chronic relapsing course torpid.

Streptoderma.

Characterized streptoderma more superficial lesions of the skin smooth and wrinkle prone to peripheral growth of lesions. Skin appendages are not affected.

Strep impetigo (L01) observed in children of different age groups. It is a highly contagious disease. Characterized by the formation phlyctenas with serous or serous, purulent content. As a result, bubbles formed erosion opening. Purulent contents shrinks to form a yellowish crust, disappears in 3-4 days. Scarring and atrophy is not formed. Preferential localization - the skin of the face (the region around the nose, mouth).

Bullous impetigo (L01) is characterized by cystic rashes, filled with serous-purulent contents and surrounded by pink corolla. After opening the bubbles formed erosion thin leaf-covered crusts. The preferential localization - the lower limbs, back of the hand.

Slot impetigo (perleche) (L01) is characterized by rapidly dissected phlyctenas to form shallow slit-like linear fissures and erosions and macerated epidermis circumferentially. Localized in the corners of the mouth, outer corners of eye region slits base of the nose wings.

Paronychia (surface felon) (L01) is based on inflamed fliktenu localized around the nail plate.

Papules erosive streptoderma (P39.4) is characteristic of infants. It is localized on the skin of the buttocks, rear and inner thighs, perineum, the scrotum. Characterized by the presence of dense bluish-red papules surrounded ostrovospalitelnym whisk. On the surface of the papules formed phlyctenas, which quickly opened with the formation of erosions and crusts. Predisposing factors for the development of papules, erosive streptoderma are irritating urine, mechanical irritation diapers, detergents.

Intertriginoznoy streptoderma (P39.4) is localized at the contacting surfaces of the large folds: groin, armpits, neck, gluteal region, behind auricles. Characterized by the presence of rapidly reveals phlyctenas to form a moist erosions with sharp scalloped borders and pyococcus Screenings at the periphery. This form of streptococcal common in children with hypertrophy, overweight, diabetes, increased sweating.

mug(A46) is an acute inflammation of the skin. Activators are group A streptococci (Streptococcus pyogenes), as well as Staphylococcus aureus, Haemophilus influenzae, pneumococci. More common in children under 3 years of age and older people. The preferential localization in adults - shin, upper limbs, trunk (where operating RAS), face (complications of rhinitis and conjunctivitis) in children - cheeks, periorbital region, head, neck, limbs. Gateway for infection are various skin lesions, and mucosal membranes, mainly in children skin the navel and the anogenital area. Inflammation presented erythema with raised edges, sharp edges, irregular shapes, different sizes. The focus of inflammation swollen, shiny, hot to the touch, painful on palpation. Sometimes on the surface of bubbles formed, subcutaneous abscesses, necrosis.

Streptococcal toxic shock syndrome (STSS) is characterized by the acute development of shock and multisystem organ failure. The causative agent is Streptococcus pyogenes. Are pathogenic group A streptococci strain No. 1, 3, 12, and 28 types that produce streptococcal exotoxin A and B (SPE-A, SPE-B). The disease can occur in healthy people, often at the site of injury to the skin, which are the gateway for infection. risk factors - diabetes, peripheral vascular disease. The patient rapidly develops hypotensive shock with renal insufficiency. soft tissue infection develops in 80% of patients and in most cases (70% of patients) proceeds as heavy subcutaneous infections (necrotizing fasciitis, myositis). Vesicles and blisters on the surface of inflammatory center appear later in 5% of cases, and are a poor prognostic sign. Patients without soft tissue infections are pockets of focal infections: osteomyelitis, myositis, pneumonia, peritonitis, myocarditis, and sepsis. Early symptoms of STSS may be redness of the conjunctiva and mucosa of the oropharynx, strawberry tongue. Other symptoms include petechial skin, maculopapular and diffuse scarlatiniform rash. The rash may appear as early in the disease, and in 1-2 weeks (20-30% of patients) after the end of the disease, along with desquamation. Mortality reached 30%.

Streptoderma acute diffuse - acute diffuse skin lesions. More common in adults. Characterized by the presence phlyctenas prone to peripheral growth and merging to form large superficial erosions, bordered rim exfoliating horny layer of the epidermis with scalloped outlines. There pronounced edema, hyperaemia, plenty moknutie, serous crust. The process is localized mainly in the lower extremities, as well as around infected wounds, fistulae, burns.

Cellulite - an acute infectious inflammation of the dermis and subcutaneous fat. Pathogens are Streptococcus pyogenes group A and Staphylococcus aureus. Most people prone to infection, suffering from diabetes, liver cirrhosis, renal failure, cancer pathology. Cellulite develops in the field of skin damage, close surgical wounds, as well as the apparently healthy skin. Inflammatory foci of bright red color, with indistinct contours, swollen, infiltrated, hot and painful on palpation. Within the inflammatory focus could be vesicles, blisters, hemorrhage, abscess. Cellulite can occur in any part of the skin, but more frequent localization - the lower limbs, face. Marked malaise, fever. cellulitis complications may be abscesses, osteomyelitis, septic arthritis, thrombophlebitis, bacteremia, necrotizing fasciitis, and lymphangitis and glomerulonephritis. Recurrent infections of the lower extremities may be complicated by the development of fibrosis of the dermis, limfootekom and thickening of the epidermis.

Ecthyma (streptoderma ulcer) (L98.4) - deep tissue damage with ulceration in a limited area. The causative agent is Streptococcus pyogenes. Development of the disease begins with the appearance phlyctenas with purulent contents which within a few days of shrinking in the crust, beneath which revealed a deep ulcer with swollen inflamed soft edges and bottom. Bottom is covered with necrotic, purulent and mucoid plaque. Within 2-4 weeks, the ulcer scar. The process is most often localized on the skin of the lower extremities. risk factors are chronic diseases, pruritic dermatoses.

Streptostafilodermii.

Streptostafilokokkovoe impetigo (L01.0) is shown fliktenami, located on an erythematous background. Content phlyctenas shrinks to form a loose crusts honey-yellow color. There is a growing element of the periphery. Rashes are usually disseminated, captured large swathes of skin. The duration of a single element impetigo on average 7 days. The disease is highly contagious. Streptostafilokokkovoe impetigo often complicates pruritic skin diseases (eczema, scabies, atopic dermatitis and etc.).

Chronic peptic vegetans pyoderma (L98.4) - profound form streptostafilodermii. It characterized by irregularly shaped ulcer formations with jagged edges podrytymi with vegetations and sero-purulent discharge in the area of ​​the edges and the bottom. The skin around the ulcer is inflamed, infiltrated. Healing occurs to form uneven scarring. The process is most often localized on the scalp, upper extremities, pubic, axillary and inguinal region, on the shins. Characterized by chronic course with periodic exacerbations. More common in people aged 40-60 years. The disease often develops in patients with immunodeficiency.

Pyoderma gangrenosum (L88) occurs in people suffering from various systemic diseases aged 30-50 or older than 60 years. The disease is characterized by the appearance of pustules, which quickly opened with the formation of extensive ulcers with jagged edges raised podrytymi lividno pink with overhanging fragments epidermis. The bottom of the ulcers performed juicy granulations, copious discharge, purulent of bloody character with an unpleasant putrid odor. Ulcers increase in size by an eccentric growth. The typical localization - the lower limbs, at least - the torso, upper extremities, face. For chronic diseases, there is a tendency to relapse.

Pyoderma vegetans Allopo (L98.4) common in adults, rare in children. The disease begins with the appearance of multiple grouped pustules, which are formed after opening warty vegetation with purulent discharge, shrinking in the crust. Foci grow on the periphery, merge with neighboring centers and form large plaques with clear contours, surrounded by an erythematous halo. Favorite localization - the scalp, forehead, mouth, armpit, genitals, the mucous membrane of the cheeks, nose. Weather favorable for therapy lesions resolved within a few weeks or months.

Acne keloidea (sclerosing folliculitis occiput) (L73.0) is found only in men. Characterized by the eruption of small, dense, painful papules coalescing into plaques bluish-red color. Hair within inflammatory lesions arranged brushes 10-15 Hair of one follicle. The process is localized on the scalp in the neck with the transition to a rear surface of the neck. The disease is characterized by a prolonged course and ends with sclerotherapy affected areas.

Folliculitis scarring (L66) is characterized by inflammation of the hair follicle, with subsequent destruction and reception alopecia. It is noted the appearance of scalp, less foci in the axillary region of scar alopecia of various size and shape. The disease is characterized by a long torpid course with periods of exacerbation.

Folliculitis and perifolliculitis head abscessed undermining Hoffmann (L66.3) is characterized by the appearance on the scalp parietal and occipital areas tubercles yellowish or bluish-red color with a soft texture with a stretched, thinned, hairless skin. Foci merge in winding strands resembling gyrus, while squeezing the pus from which fistular moves.

Shankriformnaya pyoderma (L98.4) - form of chronic ulcer streptostafilodermii clinical manifestations similar to chancre. Sick, both adults and children. Inflammatory lesions localized in the genital or extra-genital. The disease begins with the appearance of the bubble, after the opening of which is the erosion or ulcer rounded shape with dense base flat bottom pinkish-red color, with a slight purulent discharge, and elevated edges. The most common lesion is solitary, rarely multiple.

Vegetative piostomatit (L01.0) - inflammatory disease of the oral mucosa, characterized by the appearance on an erythematous background small vegetations with purulent discharge.

Gangrene of the penis and scrotum (Fournier gangrene lightning) (R02) is characterized by the sudden development of swelling of the penis and scrotum accompanied by increased body temperature. After a few days of developing superficial necrosis, exciting the entire surface of the penis and scrotum. The disease progresses over 2-3 weeks, causing tissue destruction.

DIAGNOSTICS

Diagnosis pyoderma conducted on the basis of clinical manifestations of disease.

Laboratory research:

• bacteriological examination of purulent discharge with definition of sensitivity to antibiotics;
• the study of blood glucose levels;
• clinical blood test.

According to the testimony of other experts appointed by the consultation: therapist, endocrinologist

DIFFERENTIAL DIAGNOSIS

pyoderma	differential diagnosis
Diseases associated with the action of toxins produced by strains of Staphylococcus and Streptococcus (epidemic pemphigus newborns exfoliative dermatitis, staphylococcal syndromes burnt skin, staphylococcal and streptococcal toxic shock syndrome toxic shock)	Syphilitic pemphigus - early manifestation of syphilis in the newborn. Is characterized by a polymorphic rash, blisters are localized mainly in the palms and soles, along with pustules are papules, papular infiltrates. Syphilitic pustules hemispherical, have a "hard" fat tire, thick pus, of almost no increase. The contents of pustules and other syphilides reveal pale treponemu. It notes the presence of other symptoms of congenital syphilis. Positive serological tests for syphilis in the child and the mother.
Epidermolysis bullosa - characterized by the appearance of bubbles with serous, serous-hemorrhagic content in the field, injury-prone - knees, elbows, buttocks, calves, brushes (simple EB) or occurring spontaneously (dystrophic BE). Bubbles appear on the non-inflamed background, the site revealed the bubbles formed erosion serosanguineous crusts. Erosion epiteliziruyutsya quickly without scarring (simple EB) or characterized by slow wound to form the hyper- or atrophic scarring (recessive dystrophic EB).
Erythema multiforme - an acute, relapsing disease of the mucous membranes and skin. Caused by infectious agents, drugs, vaccines, is observed in diseases of connective tissue, and others. Eruptions are located symmetrically and presented swollen bluish-red spots with a papule or vesicle in the center.
Stevens-Johnson syndrome is a severe form of erythema multiforme exudative. It begins acutely with high fever, artirta, arthralgia, myalgia. The process involves the skin, mucous membranes, internal organs. Enanthesises are limited and are presented maculopapular elements vesicles, pustules, hemorrhages. On oral mucosa appear bubbles erosion. eye disease is characterized by severe catarrhal and purulent conjunctivitis with the development of vesicles and erosions. disease continues within about 6 weeks. Without treatment, death occurs in 5-10% of cases.
Toxic epidermal necrolysis Lyell due mainly to drugs. The first symptoms appear within a few hours or 2-3 days after ingestion of the drug. Total patient critical condition. Skin rashes such as erythema multiforme, painful diffuse erythema with a brownish tinge. On the background of the inflamed and apparently healthy skin showing signs of detachment of the epidermis (the symptom of "wet bulb laundry"), later appearing with bubbles sagging tire, epidermis torn away to form a large, painful erosions (usually in the form of gloves and socks), scalded skin takes the form boiling water. Symptom Nikolsky sharply positive. Perioral desquamation of the epidermis absent. Lethal outcome is noted in 20-30% of cases.
Kawasaki disease - acute mucocutaneous syndrome with lymph node and coronary arteries. They get sick more often than infants and children under the age of 5 years. The disease is characterized by fever, lasts 5 days or more, conjunctival hyperemia, erythema, dryness cracks, scabs on the lips, redness of the oral mucosa and pharynx, acute inflammation cervical lymph nodes. Polymorphic rash - morbilliform, the type of exudative erythema multiforme, maculopapular, urticaria occurs in 85-90% of patients, localized on the trunk and extremities. After 2-5 days after the onset of the disease appear erythema and edema in the palms and soles followed epidermal desquamation terminal phalanges. Characterized by vascular aneurysm, thrombocytosis, increased CRP, Erythrocyte sedimentation rate.
Scarlet fever - an infectious disease caused by Streptococcus pyogenes. It is most common in children aged 4 to 8 years. Rash occurs after 1-4 hours after the onset of symptoms of fever and pharyngitis. On the face, then on the neck and torso appear red spotty rash, nasolabial triangle, pale, hands and feet are not affected. The skin folds - petechiae. After a week of onset appears melkoplastinchatoe peeling skin.
Impetigo	Herpes simplex is characterized by grouped vesicles with clear, then cloudy content on edematous erythematous background. At the site revealed the bubbles formed erosion with polycyclic margins, accompanied by itching and burning. The preferential localization of - mouth, the genital area. Molecular-biological methods detect the herpes virus.
Dyshydrosis - rashes on the hands and feet in the form of bubbles with a dense cap rock, resembling sago grain, there are long-term.
Felon	Chancroid-felon - a manifestation of primary syphilis, often as a result of occupational exposure among obstetricians and gynecologists, surgeons. The finger has a club-shape, bluish-red color. At the base of the ulcer is palpated dense infiltration. Positive specific serological tests for syphilis.
Candidiasis nail ridges is more common in women and children. Marked hyperemia nail ridges and pincushion swelling, pus from the nail shaft is not allocated, the nail plate brownish brown striations transversely striped. In the discharge from under the nail ridges detect yeast-like fungi.
ecthyma	Erythema induratum Bazin - a form of skin tuberculosis. Characterized by the formation of a dense, adherent to the skin site maloboleznennogo bluish-red color. Subsequently node regresses to form scar atrophy. Sometimes nodes ulcerate in the central part (Hutchinson form) and heal with scarring. Diagnosis is by history, the results of tuberculin tests, histology (granulomas of epithelioid cells surrounded by lymphocytes, the presence of Langhans giant cells and caseous necrosis in the center tubercle).
Syphiloma - deep knotted syphilide size of a walnut, plotnoelasticheskoy consistency, with sharp edges, purple-red, limited mobility. Subsequently marked softening and disintegration gummas to form deep ulcers with characteristic valikoobraznymi thick plotnoelasticheskoy, bluish-red edges. The ulcer heals with scar formation depigmented. During a long gummy ulcers. Positive specific serological tests for syphilis.
chronic pyoderma	strumoderma begins with dense painless nodules that grow in size and become cyanotic node adherent to the underlying tissues. Subsequently assembly is opened with the release of purulent content. On-site assembly is formed ulcer with a soft-edged, yellowish coating and granulation at the bottom. After its healing are "torn" scars of irregular shape, covered with papillate skin appendages. The preferential localization - the neck, limbs less. Positive tuberculin reaction.
Warty lupus is characterized by painless nodules in red with a bluish tint, which merge into infiltrative elements, warty surface which appear growths coated horny masses peripheral zone free from growths and looks reddish rim. The rash usually located on the fingers, the back and the palm of the hands, soles. Positive tuberculin reaction.
Paracoccidioidomycosis - deep, often systemic, chronic mycosis characterized by lesions of the mucous membranes and internal organs with formation of granulomas and ulcers. Pathogen - dimorphic fungus Paracoccidioidis braziliensis. There mucous membranes of the mouth, nose, nasal, anal area. Clinically, granulomatous inflammation is presented, ulcerative lesions, easily ulcerated subcutaneous infiltration. Characterized ostrovospalitelnye lymphangitis and lymphadenitis in the nose, mouth, neck, followed by the formation of fistulas. The diagnosis is based on clinical findings, detection of the pathogen in the pathological material.
Sporotrichosis - deep mycosis subacute and chronic course with skin lesions, subcutaneous tissue, mucous membranes, lymphatic system, rarely - bones and viscera. Pathogen - Sporotrichum schenckii, aerobic refers to hyphomycetes. At the site of the introduction of the fungus, most often in the skin of the upper and lower extremities, there are thick, reddish-brown lumps that are soldered to the surrounding tissues, ulcerate and form "sporotrihoznye chancre" - superficial ulcers with an irregular bottom and papillomatous or podrytymi edges. The bumps and gummy nodes are also located along the lymphatic vessels. Diagnosis is based on anamnesis data, clinical manifestations, detection of the pathogen in the pathological material.
Actinomycosis characterized by the appearance on the neck, the cheeks or below the lower jaw assemblies deep woody density nonhealing fistula formation. In purulent discharge of bloody detect drusen actinomycetes.
Pemphigus vegetans - a kind of vulgar pemphigus differs predominance of vegetative cells and benign course. Bubbles are localized on the oral mucosa, in skin folds and around the orifices. When opening the bubbles formed on the surface erosions juicy vegetation pink-red color, soft texture, covered with gray bloom purulent discharge, offensive odor. Subsequently vegetating erosion coalesce into large pockets, surface becomes dry and hyperkeratotic coated cracks. Subjectively, there is soreness and itching of the skin. Symptom positive Nikolsky near foci.

TREATMENT

Indications for treatment:

established diagnosis of pyoderma

The goals of treatment:

• resolution elements;
• epithelialization of erosions;
• decrease in frequency of relapses of chronic forms of pyoderma.

General comments on the therapy.

In superficial pyoderma forms recommended use of topical antiseptics, aniline dyes, antibacterials external action.

Antibacterial agents systemic action prescribed for common, deep, chronic, relapsing pyoderma, with no effect on external therapy, there are common events (fever, malaise) and regional complications (lymphadenitis, lymphangitis), localization of deep pyoderma face.

Glucocorticosteroid for systemic use prescribed for high activity of the pathological process in chronic ulcerative vegetating and pyoderma gangrenosum.

Systemic retinoids are administered in the case of keloid acne, folliculitis, and abscessed perifollikulita head.

Immunobiological means prescribed in cases of recurrent, hard occurring forms of pyoderma.

patient pyoderma mode assumes rational care of the skin in the lesion, and outside of it. It is forbidden to wash in metastatic process. The hair in the area of ​​location piodermicheskih elements recommended cut off. It is forbidden to hair removal by shaving them.

When the duration of the current processes, as well as multiple rashes particular attention should be given a diet: diet should be high-grade, rich in vitamins, severely limit the amount of salt and carbohydrates; completely eliminated the alcohol.

treatment regimens.

Drug therapy.

Outdoor therapy

Antiseptic external preparations (D) (1,2,3):

solution of brilliant green, alcohol 1% topically on rash area 2-3 times a day for 7-14 days
or
fukortsin, alcoholic solution externally to the eruption area 2-3 times a day for 7-14 days
or
Methylene blue, 1% aqueous solution, externally to the eruption area 2-3 times a day for 7-14 days
or

• potassium permanganate, aqueous solution of 0.01-0.1% topically on rash area 2-3 times a day for 7-14 days
• Hydrogen peroxide solution 3.1% topically on rash area 2-3 times a day for 7-14 days
• chlorhexidine, rastvor0,5% alcohol; aqueous solution of 0.05-1% topically on rash area 2-3 times a day for 7-14 days
• povidone-iodine solution 10%, externally to the eruption area 2-3 times a day for 7-14 days

Antibacterial drugs for external application:

neomycin sulfate (5000ME / 5mg) + bacitracin zinc (250ME), powder, ointment (A) externally to the eruption area 2-3 times a day for 7-14 days (5)
or
gentamicin sulfate, ointment or cream 0,1% (D) externally to the eruption area 3-4 times a day for 7-14 days (5)
or
fusidic acid cream or ointment 2% (A) externally to the eruption area 3-4 times a day for 7-14 days (4,5,7,14
or
mupirocin ointment 2% (A) externally to the eruption area 2-3 times a day for 7-14 days (4,5,7,8,14)
or
Erythromycin ointment (10000ED / g) (D) externally to the eruption area 2-3 times a day for 7-14 days (5)
or
lincomycin hydrochloride, Ointment 2% (D) externally to the eruption area 2-3 times a day for 7-14 days (1)
or
sulfathiazole silver, 1% cream (C) externally to the eruption area 1-2 times a day for 7-10 days, for 7-14 days (1)

Glucocorticosteroid topical means, combined with antibacterial drugs

administered in case of acute inflammation accompanied by erythema, swelling, itching, and often in the presence of pruritic dermatoses complicated with secondary pyoderma.

+ tetracycline hydrochloride, triamcinolone acetonide, aerosol (B) externally to the eruption area 2-4 times a day for 5-10 days (5)
or
+ oksiteratsiklina hydrocortisone acetate hydrochloride, an ointment, an aerosol (B) externally to the eruption area 1-3 times a day for 5-10 days (5)
or
fusidic acid + betamethasone cream (B) externally to the eruption area 2-3 times a day for 7-14 days (5)
or
fusidic acid + hydrocortisone cream (B) externally to the area of ​​lesions three times daily for 7-14 days (5)
or

• betamethasone valerate + gentamicin sulfate, cream, ointment (B) externally to the eruption area 1-2 times a day for 7-14 days (5).
• betamethasone dipropionate + gentamicin sulfate, cream, ointment (B) externally to the eruption area 2 times a day for 7-14 days (5).

Systemic therapy.

Antibacterial drugs penicillin group

benzylpenicillin sodium salt (A): children - 25 000 - 50 000 units per kg body weight per day intramuscularly to adults - 2 000 000-12 000 000 IU per day by intramuscular injection. The drug is administered every 4-6 hours for 7-10 days (6.8)
or
amoxycillin trihydrate tablets 250; 500 mg of (A): for children aged 2 - 20 mg per kg of body weight per day orally, to children aged from 2 to 5 years - 125 mg 3 times per day orally, for children aged 5 to 10 years - 250 mg 3 times a day orally, for children over the age of 10 years and adults - 500 mg 3 times a day orally. The course of treatment 7-10 days (5,7,8)
or
amoxicillin, tablets 125; 250; 500 mg of (A): children under 3 years - 30 mg per kg of body weight per day orally in 2-3 divided doses, for children aged 3 to 10 years - 375 mg 2 times a day orally, for children over the age of 10 years and adults - 500-750 mg 2 times a day orally. The course of treatment 7-10 days (5.7)
or
amoxicillin trihydrate + clavulanic acid tablets 250 mg + 125; 500 + 125 mg; slurry 125 + 31 mg (5ml); forte slurry 62,5mg 250+ (5ml) (A): children aged between 3 months to 1 year 2.5 ml suspension of 3 times a day orally and children aged 1 year to 7 years - 5 ml of the suspension 3 times a day orally, for children 7 to 14 years - 10 ml of the suspension or slurry 5 ml forte 3 times per day orally, children older than 14 years and adults - 1 tablet (250 + 125 mg) 3 times daily or 1 tablet (500 + 125 mg), 2 times a day orally. The course of treatment 7-10 days (5,7).

Antibacterials cephalosporin group

cephalexin, capsules of 250 mg; 500 mg; powder for suspezii (A): for children weighing less than 40 kg - 25-50 mg per kg body weight per day orally, adults and children over the age of 10 years - 250 - 500 mg 4 times a day orally. The course of treatment 7-14 days (5,6,8)
or
cefadroxil, tablets, 250 mg; granules for suspension (A): for children weighing less than 40 kg - 25-50 mg per kg body weight per day orally, for children weighing more than 40 kg and adults - 1-2 g 1-2 times daily orally. The course of treatment - 7-14 days (5,6,8)
or
cefazolin, powder for solution for intramuscular or intravenous administration of 500 mg; 1.0 g of (A): children - 20-40 mg per kg body weight per day, intramuscularly or intravenously to adults - 1 g per day intramuscularly or intravenously. The frequency of administration 2-4 times per day. The course of treatment 7-10 days (5,6,8)
or
cefaclor 125 mg capsules; 250 mg; 500 mg; slurry (A): for children aged 6 to 30 mg per kg body weight per day orally in 3 doses, to children aged from 6 to 10 years - 250 mg 3 times a day orally, for children over the age of 10 years and adults - 500 mg 3 times a day orally. The course of treatment 7-10 days (5,6,8)
or
cefuroxime powder for solution for intramuscular or intravenous administration in vials of 125 mg, 250 mg; 750 mg, 1.5 g; granules for oral suspension, tablet (A): children - 125 - 250 mg 2 times a day orally to adults - 250-500 mg 2 times a day orally. For parenteral administration: for children up to 3 months - 30 mg per kg body weight (daily dose) 2-3 times a day for children over the age of 3 months - 60 mg per kg body weight (daily dose) 3-4 times a day, to adults - 750 mg-1.5 g 3 times day. The course of treatment 7-10 days (5,6,8)
or
Cefixime 100 mg (5 ml) to prepare granules for oral suspension; tablets, capsules, 200 mg; 400 mg (V): for children up to 12 years - 8 mg per kg of body weight 1 time per day orally, for children over the age of 12 years and adults - 400 mg 1 time per day orally. The course of treatment 7-10 days (6.8)
or
cefotaxime, powder for solution for intramuscular or intravenous administration 1.0 g (B): for children weighing less than 50 kg - 50-100 mg per kg body weight per day intravenous or intramuscular injection with an interval of 6-8 hours, for children weighing more than 50 kg and adults - 2.0-6.0 g per day intravenously or intramuscularly administration interval 8-12 hours. The course of treatment is 5-10 days (5,6,8)
or
ceftriaxone, powder for solution for intramuscular or intravenous administration, 250 mg; 1.0 g; 2.0 g (B): for children up to 12 years - 50-75 mg per 1 kg body weight once a day intramuscularly to children in the age of 12 years and adults - 1.0-2.0 g 1 day intramuscularly. The course of treatment 7-10 days (6.8)
or
cefepime dihydrochloride monohydrate powder for solution for intramuscular or intravenous administration of 500 mg; 1.0 g (B): for children weighing less than 40 kg - 100 mg per kg of body weight per day, intramuscularly, for children weighing more than 40 kg and adults - 2.0 g per day by intramuscular injection. The frequency of administration - 2 times a day at 12 hours apart. The course of treatment 7-10 days (6.8).

Antibacterials macrolide

erythromycin tablets 100, 250, 500 mg (A): children under 3mesyatsa - 20-40 mg per kg body weight per day, children from 3 months to 18 years - 30-50 mg per kg body weight per day, for adults - 1.0-4.0 g per day in 4 divided doses orally. The course of treatment - 5-14 days (5.8)
or
azithromycin powder for oral suspension 125 (5ml); capsules, tablets, 250; 500 mg of (A): children - 10 mg per 1 kg body weight once a day orally for 3 days to adults - 1 500 mg once a day orally for 3 days (5)
or
clarithromycin granules for oral suspension to 125 (5 ml); capsules, tablets, 250; 500 mg of (A): children - 7.5 mg per kg of body weight per day orally, for an adult - 500-1000 mg per day orally. Multiplicity receiving 2 times per day. The course of treatment - 7-10 days (5).

Antibacterials tetracycline

Doxycycline hydrochloride monohydrate capsules, tablets, 100 mg (A) for children older than 12 years of age and / or weight a body less than 50 kg - 4 mg per 1 kg body weight once a day in Day 1, 2mg per kg of body weight one time a day in the subsequent days; children over the age of 12 years old and / or weighing more than 50 kg and adults - 200 mg 1 time per day in the first day, then 100 mg 1 time per day in the following days. The course of treatment - 10-14 days (7.10).

Antibacterials fluoroquinolone

Ciprofloxacin tablets 250; 500; 750 mg (V); solution for infusion of 2 mg (1 mL): 250-500 mg 2 times a day for 5-15 days (17)
or
levofloxacin tablets 250; 500 mg; (A): 250-500 mg 1-2 times a day orally for 7-14 days (17)
or
ofloxacin 200 mg tablets; solution for infusion of 2 mg (1 mL) (B): 200-400 mg 2 times a day, or intravenously at 200 mg 2 times a day for 7-10 days (17).

Antibacterials aminoglycoside

gentamicin sulfate solution for injection 40 mg (1 ml) (A): for children up to 2 years - 2-5 mg per kg of body weight per day for children over the age of 2 years - 3-5 mg per kg body weight day; frequency of administration 3 times a day. Adults - 3-5 mg per kg of body weight per day, frequency of administration 2-4 times per day. The course of treatment 7-10 days (5).

Antibacterials group lincosamides

Clindamycin 150mg capsule solution for intramuscular or intravenous administration, 300 mg / 2 ml (A): children - 3-6 mg per kg body weight orally 4 times a day, for adults 150-450 mg orally 4 times day; when administered parenterally to children 15-40 mg per kg body weight per day, for adults - 600 mg-2.7 g per day, frequency of administration 3-4 times per day. The course of treatment - 10 days (5,7,9,10).

Antibacterial sulfa drugs

trimethoprim + sulphamethoxazole + 400 tablets 80 mg; 100 + 20 mg of (A): children aged 3 to 5 years - 240 mg 2 times a day orally; children aged 6 to 12 years - 480 mg 2 times a day orally; adults and children over the age of 12 years - 960 mg 2 times a day orally. course of treatment for 5 to 14 days. (7,10)

Glucocorticosteroid for systemic use (in ulcer, ulcerative vegetating pyoderma) (C) (1)

prednisolone 5 mg tablets, injection of 25, 30 mg (1 ml) was 25-30 mg daily intramuscularly for 5-7 days with a gradual reduction in the dose until canceled
or
dexamethasone phosphate injection solution 4 mg (1 mL) was 4-6 mg daily intramuscularly for 5-7 days with a gradual reduction in the dose until canceled
or
betamethasone disodium phosphate + betamethasone dipropionate, injection of 2 mg + 5 mg (1 ml) 1-2 ml intramuscularly once, repeated administration of 10 days if necessary.

systemic retinoids

isotretinoin (D) 0,5-1,0 mg per kg of body weight per day for 3-4 months (1).

immunobiological agents

staphylococcal toxoid in 1 ml of the purified liquid 12 ± 2 EU staphylococcal toxoid (D): in increasing doses: 0.1, 0.3, 0.5, 0.7, 0.9, 1.2 and 1.5 mL subcutaneously every 2 days; per course of treatment - 7 injections. Preparation is not used simultaneously with the treatment of whey antistaphylococcal drugs (immunoglobulin and plasma) (1).
or
staphylococcal vaccine therapeutic liquid (antifagin staphylococcal), 1 ml (D): children aged 6 months to 7 years - 0.1 ml s.c. daily; children over the age of 7 years, initial dose - 0.2 ml subcutaneously daily thereafter increasing the dose of 0.1 ml for 8 days. Repeated treatment after 10-15 days in the case extensive lesions of the skin with relapses (1).
or
antistaphylococcal human immunoglobulin liquid, 100 IU (D): 100 IU per day in mild forms of pyoderma intramuscularly, with generalized infection of 5 IU per kg body weight per day by intramuscular injection, a course of treatment - 3-5 injections daily or every other day (1)

In the treatment of staphylococcal disease etiology accompanied by bacteremia and sepsis are used:

antistaphylococcal human immunoglobulin for intravenous injection, 10, 25 and 50 mL vials, 1 mL of not less than 20 IU (C): children 5-7 IU per kg body weight, less than 25 IU (single dose) intravenous infusion at a rate of 8-10 drops per 1 min. On a course of 10 infusions, who spend 24-72 hours. Adults: 5-7 IU per kg body weight (single dose) intravenous infusion at a rate not more than 40 drops per 1 min. On a course of 10 infusions, who spend 24-72 hours. The product is compatible with other drugs (1).
or
Human normal immunoglobulin for intravenous injection, 10, 25 and 50 mL vials (C). Children: 3-4 ml per kg body weight, less than 25 IU (single dose) intravenous infusion at a rate of 8-10 drops per 1 min for 3-5 days. Adults: 25-50 ml of intravenously at a rate no more than 40 drops per 1 minute after 1-3 days of treatment - 3-10 infusion. The product is compatible with other drugs (1).

Non-pharmacological therapy.

UHF - therapy - used in the forms of pyoderma deep (D). The treatment procedures for 5-10 (1)

The criteria for the effectiveness of treatment

Resolution pustular elements, epithelialization, scarring ulcers. Reducing the frequency of relapses in chronic forms of pyoderma.

Indications for hospitalization

Diseases related to the action of a toxin produced by the strains of staphylococcus and streptococcus.

Common rash, accompanied by violation of general condition.

PREVENTION

Primary prevention is timely pyoderma antiseptic treatment microtraumas, cracks, wound surfaces. It is common to treat the identified diseases against which may develop pustular skin lesions (diabetes, diseases of the digestive tract, upper respiratory organs, etc.).

Secondary prevention of pyoderma include periodic medical examinations, if necessary, carrying out preventive treatment (general UV irradiation, skin care, sanitation focal infections).

Bibliography

1. Dermatology. National leadership. (Ed. JK Skripkin, YS Butov, OL Ivanova) M.: GEOTAR Media 2011. - 1024.
2. European guidelines for the treatment of dermatological diseases (Ed. HELL. Katsambasa, TM Lottie) Publishing house "MEDpress-Inform", 2009, 736 pp.
3. Rodionov AN Dermatology. Complete guide for physicians. - St. Petersburg: Science and Technology, 2012. - 1200.
4. Belkova, Y. BUT. Pyoderma in ambulatory practice / Yu BUT. Belkova // Clinical Microbiology and Antimicrobial Chemotherapy. 2005. T. 7. № 3. FROM. 255 – 270.
5. Interventions for impetigo. Cochrane Database Syst Rev. 2012 Jan 18; 1: CD003261.
6. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 16 JUN 2010. CD004299.
7. Stevens, D. L. Practice Guidelines for the Diagnosis and Management of Skin and Soft_Tissue Infections / D. L. Stevens (et al.) // Clinical Infectious Diseases 2005; 41 (15 November): 1373 - 406.
8. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clinical Practice Guidelines d CID 2011: 52
9. Williams D.J., Cooper W.O., Kaltenbach L.A., Comparative Effectiveness of Antibiotic Treatment Strategies for Pediatric Skin and Soft-Tissue Infections. Pediatrics. 2011 Aug 15.
10. Dellit TN, Duchin J. Guidelines for Evaluation & Management of Community-Associated MRSA SSTI in Outpatient Settings. December, 2007.
11. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clinical Practice Guidelines d CID 2011: 52
12. Garau, J. Management of methicillin_resistant Staphylococcus aureus infections / J. Garau (et al.) // Clinical Microbiology and Infection, Volume 15, Number 2, February 2009; 125 – 126.
13. Gosbell, I. B. Epidemiology, clinical features and management of infections due to community methicillin resistant Staphylococcus aureus / I. B. Gosbell // Internal Medicine Journal 2005; 35: S120 - S135.
14. Cunha, B. A. Methicillin_resistant Staphylococcus aureus: clinical manifestations and antimicrobial therapy / B. A. Cunha // Clin Microbiol Infect 2005; 11 (Suppl. 4): 33 – 42.
15. Bryan L. Love, PharmD, BCPS. Management of Complicated Skin and Soft Tissue Infections in Hospitalized Patients // US Pharm. – 2007. – № 32(4). - R. 5–12.
16. Guidelines on the management of cellulites in adults, 2005. Clinical Resorce Efficiency Support Team (CREST).
17. Graham D.R., Talan D.A. et al. Once-daily, high-dose levofloxacin versus ticarcillin-clavulanate alone or followed by amoxicillin-clavulanate for complicated skin and skin-structure infections: a randomized, open-label trial. Clin Infect Dis. 2002 Aug 15; 35 (4): 381-9.