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The stiff paste prevented spread onto perilesional skin, which can become irritated by dithranol. However, other organisms that can cause skin disease include Aspergillus [1,2], Trichosporon [3] and Fusarium [4]; all of these may affect the neutropenic patient. In this classification the tuberculids would sit at the extreme end of the paucibacillary spectrum [19]. It is important to ask concerning the involvement by psoriasis of specific sites that may not be volunteered by the patient, for instance the anogenital region [5]. Infections of the dorsal surface present no specific features and are considered as ringworm of the glabrous skin under tinea corporis. The process of fusion and inward passage of the genetic material of the virus is accomplished by the transmembrane envelope protein gp41 coming into contact with the cell surface. The mycobacterial infection caused by Mycobacterium marinum (fishtank granuloma) may closely resemble lymphangitic sporotrichosis. Causative organisms these organisms are widely distributed in the environment in soil and water and may also be commensal organisms of human skin. In classical scabies, the combination of topical therapy and oral ivermectin has never been compared with either treatment alone. Many unusual localizations have been recorded, including digital and interdigital forms. It can be effective in eradicating some difficult warts, such as periungual and subungual warts which have been unresponsive to other treatments. Other extragenital chancres may follow from nibbling or biting the nipple, ear, neck or arm. As increasing numbers of new species are identified, it is becoming clear that each is associated with its own complex of reservoir hosts and vector sandflies. This binding inhibits the antibodies from fixing complement or direct ing macrophages which results in disruption of opsonisation and phagocytosis. A small number of cases have been described in heterosexuals, including women, in Europe [5,6] Introduction and general description Lymphogranuloma venereum was rare in industrialized countries prior to 2003. It is useful to consider treatment in two phases: induction of remission, and subsequent maintenance of remission. In soil, they may either moult into infective filariform larvae, or set up a freeliving cycle, with the production of more infective larvae. They can occur at any site including the conjunctiva, and may enlarge rapidly to reach a diameter of 10 cm or more. Presentation Acute eczema presents as an eruption that is typically oedematous, vesicular and may be exudative. Caterpillar dermatitis is quite frequent in children, but the reasons for this elevated frequency remain unknown, and may be due to parental concern and increased reporting [12,17]. The most common sources of error are the bluish or purplish fluorescence produced by ointments containing Superficial mycoses 32. Less severe histological grades may be impossible to differentiate from druginduced reactions. Classification of severity In severe cases, features may include diarrhoea, leading to hypovolaemia, renal damage with proteinuria, central nervous system Causative organisms the natural host of this virus has not yet been identified. Mammals, such as possums and koalas, as well as mosquitoes [23,24] have been proposed as hosts of M. In the skin and mucous membranes, there is pseudoepitheliomatous hyperplasia with severe granulomatous inflammation; intraepithelial abscesses occur and these frequently communicate with the surface. The staphylococci produce exotoxins with superantigenic prop erties, which cause Tcell activation, cytokine release and mast cell degranulation [1,7]. Introduction and general description Primary genital herpes infection or active recurrent infection in the mother at the time of delivery makes the risk of transmission to the baby during vaginal delivery very high.

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Compliance and convenience is enhanced by combination formulations and less frequent dosing with singletablet once daily regimen the ideal. A list of synonyms of sexual and asexual names is included for reference (Table 32. All are slender, nonmotile, aerobic, nonsporing rods with a waxy coating that makes them resistant to most stains. Chlamydia in pregnancy may be associated with pre mature labour and preterm birth. Trombiculid mite bites have provided evidence to implicate a suspect in a murder investigation [11]. Systemic symptoms such as fever, chills, malaise, anorexia, weight loss, myalgia and arthralgia may feature. Erythema multiforme has been reported immediately prior to or coincidental with the eruption of chickenpox or zoster [183,184]. Topical antibiotics were superior to disinfectants alone, although the latter can be a useful adjuvant. Lesions described include violaceous papules, nodules and ulcers and simulating histoid leprosy [76,77]. A comparative study of singledose treatment of chancroid using thiamphenicol versus azithromycin. White piedra Definition and nomenclature this is a fungal infection confined to the hair shafts and resulting in the formation of soft, white, grey or brown superficial nodules caused by Trichosporon species. Part 3: InfectIons & InfestatIons epidemiology perianal streptococcal cellulitis 26. Crusted scabies is a rare and severely debilitating form of the disease, characterized by the infestation of up to millions of mites and the development of hyperkeratotic skin crust. The clothing louse and its eggs will not survive hightemperature washing and ironing, and it is intolerant of temperature changes in its environment. The biting midges of the family Ceratopogonidae generally cause small, papular lesions on exposed parts of the skin, but wealing and bulla formation may occur in sensitized individuals. The invasion occurs from the top surface, but penetrates deeply into the nail plate. Alternatively, material may be obtained through a needle or with a dental broach [28]. Carbuncle Definition A carbuncle is a deep infection of a group of contiguous follicles with S. The efficacy of ciclosporin confirmed the primacy of immunological abnormalities and led to a large body of research suggesting that psoriasis is an immunemediated disease. Lupus vulgaris Definition this is a chronic, progressive, paucibacillary form of cutaneous tuberculosis, occurring in a previously sensitized individual with a high degree of immunity to tuberculin. Any part of the body that has been immersed may be affected, but often the worst areas are those in contact with bathing costumes. Topical imiquimod, topical and systemic cidofovir [55,70,71], electron beam therapy [72] and diphencyprone [73] have been used. Certolizumab improved all aspects of the disease including physical function and radiographic progression. The few figures available on the prevalence of trichomy cosis show it to be common. The later complications are a serious cause of morbidity and mortality, and can adversely affect reproductive health in women. Sun exposure is possibly more important in the causation of nonmelanoma skin cancer than immunosuppression [1,14]. They are asso ciated with papules and comedones, and are usually confined to the face and trunk. The choice of concentration of test substance and suitable vehicle are very important [34] (see also Chapter 128 for details of patch testing). Reports on the possibility of impairment of neutrophil function are conflicting [10,11].

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There is now a considerable literature on the microbiology of human skin of which these references are some of the most impor tant texts [5,6,7]. Epidemiology Incidence and prevalence Eczematous dermatoses account for a large proportion of all skin disease. Yaws is usually acquired by children living in poor rural conditions in the tropics. Finally, tick bites can cause nondermatological disease such as anaphylaxis, paralysis and other systemic symptoms [33]. Complications and comorbidities Patients with genital warts frequently have other sexually transmitted genital infections [256,257]. Essentially, the features are of generalized pustular psoriasis, usually of flexural onset and with a marked tendency to symmetry, and sometimes grouping of areas of pustulation. It should be given to neonates whose mothers develop varicella within the period from 7 days before to 7 days after delivery [203,204,205]. Oral lesions are not infrequently present [116] and can consist of illdefined red patches with some desquamation or with punctate haemorrhages, or bullae. This fly occurs throughout tropical Africa, where it lives in native huts and lays its eggs in the soil of the floor. Eggs are not laid on the host, but on sand or soil, especially if contaminated by urine or faeces. Moreover, there are also problems of crossreactivity amongst different Leishmania spp. It is a sharply defined, erythematous, round or oval plaque, soon covered by fine scale. In cases where the diagnosis of tuberculosis seems unlikely, testing for chronic hepatitis C viral infection and other infections is recommended. Multiple gummata tend to coalesce, the bridges of skin between them gradually undergoing necrosis. Available formulations include 1% permethrin and pyrethrins plus piperonyl butoxide. Clustering of pathology the histological appearances are variable and depend on the stage of disease [3]. For the treatment of superficial benign lesions such as syringomas, topical anaesthesia may be adequate. Currently, there is still controversy concerning the pathogenesis of the tuberculids and their association with M. The larvae subsequently form cocoons, and under suitable conditions of temperature and humidity the life cycle may be completed in a few weeks. The disease may begin in the first few weeks of life and two cases of congenital generalized pustular psoriasis have been described [6]. Tinea of the chin and upper lip in females and children are considered to be tinea faciei (ringworm of the glabrous skin of the face). In grain handlers, they are usually on the forearms and neck, but they may be profuse around the waist and in the groin area. The concept of a candidide remains largely unsubstantiated in that the cutaneous reactions are often ascribed to Management In proven Candida onychomycosis, fluconazole or itraconazole produce the best reponses [6]. The burrow is not confined to the stratum corneum, but is inclined downwards into the epidermis. They are important vectors of diseases such as tick borne relapsing fever, and in a number of viral, rickettsial (Chapter 26) and Borrelia (Chapter 26) infections (Lyme disease). Part 3: InfectIons & InfestatIons the inflammation seen in type 1 reactions is due to Tcell activity, with enhanced Tcell proliferation towards M. Another report from northern Canada has stressed the persis tence of diphtheria in spite of high immunization rates, and the more frequent isolation of C. Characteristics of such a lichenoid syphilide include small conical or spinular elements, which tend to be arranged in groups of varying size over the body. It is reasonable to try topical methods of treatment for simple sores, and to reserve the systemic use of pentavalent antimonials for problematic sores: these include sores where scarring would be disabling or severely disfiguring; sores that will not heal easily, for example on the lower leg or over a joint; sores involving mucosa or cartilage; or sores that might be due to parasites of the L.

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Incidence, however, remains sta ble at around 250 000 new cases annually, with high rates of child hood cases [3]. It is thought that the majority of head louse infections are acquired by direct head to head contact, optimal conditions for transfer being when hairs are parallel and slow moving [24]. Clinical variants Toe cleft infections are often asymptomatic; the scaling, fissuring and maceration that may be present are not necessarily caused by the corynebacteria. Because trauma favours infection, most lesions are on the foot and lower leg, but they may occur anywhere on the body [13]. Isolated swellings may simulate inflammatory or neoplastic disease of other internal organs. Thus, primary infection, including nonspecific dermatological reaction patterns, may go unnoticed, unreported or undiagnosed. Clinically, the lesions can assume a more nodular consistency with an insidious onset; they may last for several years and can also migrate. Associated diseases Herpangina commonly occurs together with hand, foot and mouth disease. In leishmaniasis, one must rely on finding the causative organism; similarly with blastomycosis and chromoblastomycosis. The detection of intrathecal antibody is useful in the diagnosis of Lyme neuroborreliosis [23]. Sex the disease occurs predominantly in females, and in three published series women accounted for between 78% and 90% of the cases [2,12,17]. They initially present with erythematous hyperkeratotic perifollicular papules which tend to coalesce into plaques but may progress to erythroderma, particularly in adults. This tape method is simple and may be useful for diagnosis of severe scabies infestation in longterm nursing units [50]. Miltefosine is an additional approved oral agent for the treatment of viscercal leishmaniasis in adult patients infected with L. The administration schedule of ivermectin should be based on the severity of infection [40]; between three and seven doses have been proposed [27]. The toxin produced by other strains is not neutralized, hence second attacks, although rare, can occur. More serious infections with a meningitic or glandular feverlike illness are well known, and in immunocompromised patients meningitis or pneumonia may dominate the picture. In a variant of the papular form, more common in Africans than Europeans, small lichenoid papules are thickly set in the edges of the lesions [123]. Erythema multiforme (herpesassociated erythema multiforme) [65] (see Chapter 47) In 65% of patients with recurrent erythema multiforme, there is a history of herpes labialis, usually preceding the erythema multiforme by several days to 2 weeks, but occasionally seeming to coincide with it. Lichen simplex can resemble psoriasis closely, particularly on the scalp and near the elbow. Animal inoculation (intraperitoneally into mice or guinea pigs) is necessary as culture on artificial media cannot be achieved. If it is difficult to obtain sufficient material for culture in cases of dermatophytosis, transport swabs are a good backup, as is usual with candidosis. Unfortunately it is usually not practicable to take deep samples from the proximal advancing edge without discomfort to the patient. Papulovesicular, vesicular, purpuric, erythema multiformelike lesions, follicular and pustular forms may rarely occur [121,122].

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Conical pits are then formed perpendicular to the surface of the hair as penetration of the keratinized hair cortex occurs. In older age groups, psoriasis that starts for the first time after the age of 65 years tends to be less extensive than earlyonset disease [9]. At the opposite end of the spectrum is the more common form in which an obvious family history may be lacking. If the primary lesion remains acutely inflamed, the eruption increases in severity and may become generalized. The pustule subsequently ruptures, forming a crust, and after several days the lesions heal, frequently leaving small scars. These lasers have recently been modified to perform fractional ablative resurfacing (see the section on non ablative fractional modalities). As well as damaging cells, cryotherapy may lead to clearance by stimulating the development of an immune response [107]. Atypical forms of psoriasis In a disease as common and variable as psoriasis, atypical forms are frequent. Infection It has long been known that patients with psoriasis may carry staphylococci on their plaques [1] and using modern Plaque psoriasis 35. The vesicles are followed by ragged ulcers and may be accompanied by pain and oedema. Clinical variants Very rarely, infection can cause illness without skin lesions [21]. Most authors regard the data as consistent with a polygenic or multifactorial pattern. Ross River virus infection is the most common arbovirus infection in Australia [74]. Management Surgical removal resulting in complete eradication of the disease is the treatment of choice. Side effects are not common and mainly consist of nausea and abdominal discomfort. However, it is likely that tinea manuum will continue to occur sporadically and a greater awareness of this condition, so that it may be recognized promptly, is of prime importance. A wide variety of unusual cutaneous histopahlogical findings have been described [41]. Prophylactic doses of aciclovir vary between 200 and 1000 mg daily; a typical regimen is 400 mg twice daily, gradually reduced to find the minimum effective dose for the individual patient. Similarly, erythema nodosum can be considered a facultative tuberculid with tuberculosis being just one of many causes [8]. Complications and comorbidities Motor involvement [230] this occurs overall in 5% of cases and is commoner in older patients and in those with malignancy, and in cranial compared with spinal nerve involvement. Indeed, nail clippings may reveal fungus mycelium in nails that appear completely normal [10]. Each category scores a maximum of 1 point, except category 1, which scores 2 points for current psoriasis. Differential diagnosis Part 3: InfectIons & InfestatIons Hand warts Conditions that may be confused with hand warts include epidermal naevus, Bowen disease, actinic keratosis and callus. Although the original classification of Moll and Wright remains valid, several alternative classifications have been proposed [8]. National Institutes of Health consensus development project on criteria for clinical trials in chronic graftversushost disease: I. It is rare in Native Americans [3] and one study found 0% prevalence in Latin American Indians [4]. The mechanism of immune activation in psoriasis is not understood although several mechanisms have been suggested. Guttate psoriasis is more frequent in children than adults, particularly under the age of 12 years [7]. Differential diagnosis this infection must be distinguished from acute rubella and other arbovirus infections.

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Strong fluorinated steroids seem most likely to produce this syndrome, but even 1% hydrocortisone cream can, on occasions, modify tinea to a confusing extent. Introduction and general description Pinta is a disease exclusively of the skin caused by T. History the prime reason for separating tinea faciei from tinea corporis in this account is to draw attention to the frequency of misdiagnosis in facial ringworm [1]. Although a form of flexural dermatitis associated with Pseudomonas seen mainly in atopics has been described where the organism causes a painful and fissured exacerbation of the underlying condion [19]. This is a common presentation of generalized pustular psoriasis in infancy and early childhood. Polymorphic lesions, consisting of weals, papules, vesicles, pustules and scabs, occur predominantly on exposed parts of the body [24]. Necrosis of the dermis extends laterally, leading to the characteristic undermining of the ulcer edge [34]. However, despite this there are important differences between the two morphological forms in their epidemiology and clinical manifestations. The edges of the lesions are usually well defined, unless secondary infection or medicament dermatitis, both quite common events, have occurred. Ova work their way out of the veins into the tissues, where they cause the formation of granulomas in which there is a pseudotubercle arrangement of inflammatory cells rich in eosinophils Part 3: InfectIons & InfestatIons 33. The observation of families over a period of years showed that the same phage type may be responsible for irregular episodes of infection between long inter vals of clinical quiescence [4]. Vitamin D and its analogues all have the potential to affect systemic calcium homeostasis with hypercalciuria and hypercalcaemia [15]. The infecting organism is usually present in the upper layers of the stratum corneum, and on electron microscopy may be seen to invade not only between but within the keratinized cells. It can be challenging to differentiate histologically from eosinophilic folliculitis but immunohistochemistry may be helpful [11]. The typical changes are those of wellmarked tubercle formation with epithelioid nodules embedded in sheets of lymphocytes. Trypanosomes are seen undulating between the lymphocytes in the wet preparation, or well defined in a Giemsa stained preparation. Bacterial infection and the underlying eczema or other dermatosis should be treated in the usual way, except that if aciclovir is being withheld, more cautious use of steroid therapy may be advisable until the viral lesions have healed. The dermis contains a dense inflammatory infiltrate of lymphoid cells and histiocytes, with an admixture of eosinophils and plasma cells, and the presence of atypical mononuclear cells with hyperchromatic nuclei. The gastrointesti nal type may follow ingestion of endosporecontaminated meat from infected animals. Skin involvement has also been described in a variety of invasive infections affecting the paranasal sinuses such as those caused by Exophiala dermatidis. Herbivorous and fungivorous, they subsist on fungi and are pests of stored food products with high moisture content. An examination of the yeast colony should include the recording of colour and texture. The initial lesion is a small, reddish brown, flat plaque of soft, almost gelatinous, consistency. Prognosis the cure rates with initial treatment of early syphilis are better than 95%. Increasingly, the cost of treatment is a significant consideration in planning a treatment strategy. The cysticerci form nodules in the subcutaneous tissue of the muscles (rarely with widespread muscular enlargement), eye [1], eyelid [2], lungs and brain and other organs, which may seriously interfere with function depending on their position. Pathology Histology shows necrotizing tuberculous granulomas with multiple acidfast bacilli.

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As a practical guide, to help differentiate the organism from others like it, there are about seven to eight coils per diameter of a red blood corpuscle. In the opportunistic systemic mycoses, serology is also useful but may be more difficult to interpret. Differential diagnosis Typical lesions are easily recognized by their pinkpurple colour, friable consistency and the presence of the white sporangia within the polyp itself. Plain Xrays of the hands and feet may be useful in detecting erosive disease but plain Xrays have a low diagnostic sensitivity in early disease. Mitotic figures in keratinocytes, and leukocytic infiltration in spongiotic foci, are seen in the lower half of the epidermis. The wall also contains mannans, glycoproteins and enzymes, some of which are secreted into the surrounding environment and break down Fungi reproduce both sexually and asexually, sometimes simultaneously. The organism has never been isolated in vitro, but through genetic studies its taxonomic position is now clearer, and it is now considered an aquatic member of the Protista rather than a fungus. Intrapilary hyphae fragment into arthroconidia up to 8 m in diameter, which are entirely contained within and completely fill the hair shaft. At the time of writing, phase 3 clinical trials of these three agents have been completed but only published for secukinumab. Human papillomavirus transmission has been most closely studied in the case of anogenital warts. In older children and adults, clinical infections occur mainly in patients with debilitating diseases. On the trunk and limbs, it can resemble circinate psoriasis, leukaemic infiltrations and mycosis fungoides. Occasionally, lesions are grouped adjacent to areas of tight clothing around the waistline. Introduction and general description Gonorrhoea results in a number of clinical syndromes including urethritis, cervicitis, epididymoorchitis, pelvic inflammatory syndrome, disseminated gonococcal infection and ophthalmia neonatorum. Despite these modifications, the use of dithranol as an outpatient therapy for psoriasis has declined [17]. Compartment syndrome caused by streptococcal cellulitis complicating an insect bite has been described [10]. High rates of infection have occurred in areas in which there had been recent large expansion in tick numbers [3]. Gangrenous stomatitis, due to opportunistic anaerobic organisms and Candida, Pseudomonas and Staphylococcus, causes severely symptomatic perioral ulceration complicated by pain, bleeding and inability to feed [11]. Given this lack of evidence and lack of clinical experience outside a few centres, it is used infrequently. This suggests that an abnormal cellmediated immune response against autologous skin antigens could be occurring [31,32]. It has extreme nutritional requirements due to deficiencies in biosynthetic pathways, and has a narrow equilibrium between oxygen dependence and toxicity. Mobile genetic elements and bacterial toxinoses: the superantigen encoding pathogenicity islands of Staphylococcus aureus. Introduction and general description this infection is originally localized in the nasal fossae, and invades the upper respiratory tract and lacrimal apparatus, where it pro duces an infiltrating granuloma with a marked tendency to scle rosis and subsequent obstruction. In other parts of the world, the most common organism is a eumycetoma agent, Madurella mycetomatis. The extent of the erythroderma and the warty plaques varies greatly, and either may predominate. Pityriasis versicolor may be localized to the groin but is usually noninflammatory and asymptomatic, as is erythrasma. It has also been isolated Management There are currently no standardized guidelines for the treatment of M. A lowgrade folliculitis is also often seen, while sometimes a frank kerion may develop. Ethnicity Several authors have noted a low incidence of head louse infection in black Americans [14,15], although infection rates in black Africans are high [5]. The appearance and evolution of the lesions is typically slow and mild, when compared with that of L.

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Bunyaviruses Basic biology Most of these viruses cause zoonotic infections, the human being an accidental host, but person to person transmission also occurs. Investigations In endemic areas, or in travellers returned from endemic areas, the clinical diagnosis is not difficult in the case of typical sores. Larvae, nymphs or adults may be discovered attached to the skin, and humans usually become accidental hosts when walking through, or sitting in, an area that contains ticks [21]. The procedure is increasingly being considered for other lifethreatening conditions such as multiple sclerosis, Crohn disease, systemic lupus erythematosus and systemic sclerosis [3,4]. Management Prophylaxis Active immunization by inoculation with live attenuated rubella virus is employed in many countries. Ulnar and median nerve lesions are usually low, causing small muscle but not deep flexor weakness, and anaesthesia of the two halves of the hand. The absence of activated lymphocytes and macrophages means that nerve dam age is slow and gradual in onset. The introduction of vaccination against measles is extending worldwide, with impressive reduction in mortality [2], but the prospect of global eradication of the disease is some time away. Clothing/body lice (pediculus corporis) epidemiology [22] Incidence and prevalence Because body lice are associated with poor socioeconomic conditions, with infestation occurring only when clothes are not changed or washed regularly (pediculosis vestimenti), indigent, homeless and refugeecamp populations are predominantly affected. These studies all demonstrate that reactions are difficult to prevent and to switch off once established. The hyphae are narrow and regularly septate, but the passage of cytoplasm and even nuclei from one cell to the next is made possible by the presence of a pore in the centre of each septum. It was also demonstrated that approximately 10% of individuals with latent tuberculosis in the study had a similar profile to those with active tuberculosis. During feeding, the bedbug injects saliva containing an anticoagulant and anaesthetic. In some cases, hypersensitivity produces only a more intense local reaction manifest as increased oedema, usually developing within the first half hour, but occasionally delayed for several hours. Adding azathioprine to prednisolone did not improve nerve function or reduce recurrence rate [135]. In advanced cases, destruction of bone within an infected area may be almost complete, and gross deformity may result [15,16]. FranciSella tularenSiS Francisella tularensis is a Gramnegative bacteria responsible for tularaemia, a zoonotic infection. The risk of depression in those with severe psoriasis (defined as prescribed phototherapy or systemic treatment) was higher still, affecting 32% of patients, and was more frequent in younger people [6]. Even in such cases, the organism is not limited to the lungs but is disseminated throughout all parts of the reticuloendothelial system. Microfilariae are demonstrated in the blood especially in acute cases, either in a thick blood film or by passing heparinized blood through a millipore filter, which retains the microfilariae, which can then be seen easily under the microscope. There are several species of vector, each occupying a particular zoogeographical zone. Human disease therefore includes the expected vaccination infection and its complications. Although the virus is widespread in these animals, it is the young that most commonly show features of the disease. In SouthEast Asia, Australia and the Pacific Islands, trombidiosis is commonly caused by E. For instance, 1 week of topical terbinafine was found to be more effective than 4 weeks of clotrimazole in tinea pedis. Part 3: InfectIons & InfestatIons Pathophysiology Pathology [3,4] Mature worms and microfilariae are found in granulomatous dermal nodules (onchocercal nodules), often situated on the scalp of their hosts in Central America, but in Africa near bony prominences on the trunk and limbs or in the natal cleft. They may take the form of macules, plaques, annular lesions or bizarreshaped bands. These compound formulations should only be used when there is an indication for each constituent, in order to avoid unnecessary exposure to the risks of sensitization and emergence of bacterial resistance. There are complex interrelationships between the metabolic syndrome and chronic inflammation. In the immunocompetent host, a traumatic injury (including tattooing and surgical procedures) is followed by the development of localized abscess formation [9]. Disease course and prognosis the clinical picture varies with the virulence of the strain.