Cutaneous infections in the elderly: diagnosis and management

Abstract

Over the past several years there have been many advances in the diagnosis and treatment of cutaneous infectious diseases. This review focuses on the three major topics of interest in the geriatric population: herpes zoster and postherpetic neuralgia (PHN), onychomycosis, and recent advances in antibacterial therapy. Herpes zoster in adults is caused by reactivation of the varicella-zoster virus (VZV) that causes chickenpox in children. For many years acyclovir was the gold standard of antiviral therapy for the treatment of patients with herpes zoster. Famciclovir and valacyclovir, newer antivirals for herpes zoster, offer less frequent dosing. PHN refers to pain lasting > or = 2 months after an acute attack of herpes zoster. The pain may be constant or intermittent and may occur spontaneously or be caused by seemingly innocuous stimuli such as a light touch. Treatment of established PHN through pharmacologic and nonpharmacologic therapy will be discussed. In addition, therapeutic strategies to prevent PHN will be reviewed. These include the use of oral corticosteroids, nerve blocks, and treatment with standard antiviral therapy. Onychomycosis, or tinea unguium, is caused by dermatophytes in the majority of cases, but can also be caused by Candida and nondermatophyte molds. Onychomycosis is found more frequently in the elderly and in more males than females. There are four types of onychomycosis: distal subungual onychomycosis, proximal subungual onychomycosis, white superficial onychomycosis, and candidal onychomycosis. Over the past several years, new treatments for this disorder have emerged which offer shorter courses of therapy and greater efficacy than previous therapies. The treatment of bacterial skin and skin structure infections in the elderly is an important issue. There has been an alarming increase in the incidence of gram-positive infections, including resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and drug-resistant pneumococci. While vancomycin has been considered the drug of last defense against gram-positive multidrug-resistant bacteria, the late 1980s saw an increase in vancomycin-resistant bacteria, including vancomycin-resistant enterococci (VRE). More recently, strains of vancomycin-intermediate resistant S. aureus (VISA) have been isolated. Gram-positive bacteria, such as S. aureus and Streptococcus pyogenes are often the cause of skin and skin structure infections, ranging from mild pyodermas to complicated infections including postsurgical wound infections, severe carbunculosis, and erysipelas. With limited treatment options, it has become critical to identify antibiotics with novel mechanisms of activity. Several new drugs have emerged as possible therapeutic alternatives, including linezolid and quinupristin/dalfopristin.

A retrospective study on the microbiology in patients with oral complaints and oral mucosal lesions

“…The latter species is more commonly developing resistance for vancomycin (Linden, 2002). The presence of VRE strains in the clinic is of a general medical concern as vancomycin is regarded as the drug of last resistance for MRSA (Weinberg and Scheinfeld, 2003). A spread of this resistance between Gram‐positive bacteria must therefore be prevented.…”

Bacterial infections of the oral mucosa

“…Vancomycin‐resistant enterococcal isolates are rare in the oral cavity (20). As vancomycin should be restricted to treatment of the most severe gram‐positive bacterial infections, the risk of developing multiresistant, including vancomycin‐resistant, strains of E. faecalis and E. faecium should be a concern in every antibiotic treatment of enterococcal infections (180). The potential risk is the subsequent transfer of vancomycin resistance to S. aureus or other virulent gram‐positive bacteria.…”

The efficacy of time-based short-course acyclovir therapy in treatment of post-herpetic pain

“…During the acute illness, the rash is often accompanied by pain, and the most frequent complication of HZ infection is post-herpetic neuralgia (PHN), defined as debilitating pain, the pathogenesis of which remains unclear [2,3]. The true incidence of post-herpetic neuralgia is difficult to establish and depends partly on the definition being used.…”