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A furuncle is a deep-seated inflammatory nodule with a pustular center that develops around a hair follicle [see Figure 10]. Figure 10 A furuncle, or boil, occurs as an acute, painful, localized staphylococcal abscess surrounding a hair follicle. The normal cutaneous flora helps prevent infection by other organisms through the mechanisms mentioned above: occupying available sites of residence, competition for nutrients, establishment of a low pH, and the elaboration of antibacterial substances.
Cutaneous abscesses usually cause a painful, fluctuant, red, tender swelling, on which may rest a pustule. Porphyrin-producing coryneform bacteria, which are gram-positive bacilli that constitute part of the normal cutaneous flora, cause a superficial, usually asymptomatic, skin disorder called erythrasma. Trichomycosis axillaris is characterized by colored concretions of axillary hair that result from infection of the hair shafts by large colonies of various species of Corynebacterium.
These infections typically begin with fever, systemic toxicity, severe pain in the affected site, and the development of a  painful, red swelling that rapidly progresses to necrosis of the subcutaneous tissue and overlying skin. Folliculitis is an inflammation at the opening of the hair follicle that causes erythematous papules and pustules surrounding individual hairs [see Figure 11]. Occasionally, Pseudomonas aeruginosa is responsible, as a consequence of inadequate disinfection of hot tubs, swimming pools, or whirlpools.30 This gram-negative bacillus grows well in hot water.
Figure 11 Folliculitis is a superficial or deep inflammation of the hair follicles, appearing at follicular openings as small pustules surrounded by erythema (a). Spores of Bacillus anthracis sent through the mail in the fall of 2001 as an act of bioterrorism caused cases of inhalational and cutaneous anthrax in several states. Except for cases associated with bioterrorism [see 8:V Bioter-rorism], humans usually develop anthrax from exposure to affected animals or their products, such as hides.
Warts, or verrucae, are caused by human papillomaviruses (HPVs), a subgroup of DNA-containing papovaviruses, of which there are more than 70 types.
The common wart consists of single or multiple skin-colored papules, which often have a hyperkeratotic, papillary surface.
The flat wart is a skin-colored or light-brown, slightly elevated, smooth papule commonly seen on the face and the dorsum of the hand.
Anogenital warts consist of skin-colored or gray, discrete or confluent cauliflower-like excrescences that may cause no symptoms or produce itching, burning, pain, or tenderness [see Figure 13]. Anogenital warts may be difficult to eradicate, and several treatments are often necessary.33 Therapies administered by clinicians include liquid nitrogen, podophyllin resin, trichloro-acetic or bichloroacetic acid, surgical removal, laser therapy, or intralesional interferon. Figure 14 Benign lesions of bowenoid papulosis, as seen on the shaft of the penis, may histologically resemble carcinoma in situ.
Bowenoid papulosis consists of benign-appearing erythem-atous or pigmented papules in the anogenital area that histo-logically resemble Bowen disease (squamous cell carcinoma in situ) [see Figure 14].
With involvement of several adjacent follicles, a mass called a carbuncle may form, with pus discharging from multiple follicular orifices. Although a few patients have definable abnormalities in host defenses, such as neutrophil disorders, most are otherwise healthy people who, like 20% to 40% of the population, carry S.
Occasionally, however, the resident skin flora causes cutaneous infections, especially with trauma or alterations in the stratum corneum. One particular species, corynebacterium minutissimum, has often been cited as the sole cause of this infection, but its precise role, if any, remains unclear. The nodules may be yellow, black, or red; and because the organisms may invade the cuticle, the hair can become brittle.
Outbreaks occur an average of 48 hours after exposure, with a range of several hours to several days.
Humans are the only known reservoir; transmission probably occurs from close contact with infected people or possibly from exposure to sloughed, infected epidermal cells. Administered with a cotton-tipped applicator or cryospray device, liquid nitrogen freezes the lesion, causing it to blister and subsequently dissolve.
These may be difficult to treat, but freezing with liquid nitrogen, application of trichloroacetic acid, or painting the lesions with 10% salicylic acid and 10% lactic acid in flexible collodion may be effective. A mosaic wart, a variant of verruca plantaris, consists of multiple discrete or confluent superficial lesions and is often difficult to treat. The incidence is highest in young adults; most often, it is a sexually transmitted disease, though some anogenital warts may develop from autoinoculation or may be acquired in other ways.
Most cases of squamous carcinoma of the cervix are caused by HPV, especially HPV-16 and HPV-18, but fortunately, these types represent only a small percentage of the isolates from anogenital warts.
Patient-applied treatments are podo-phyllotoxin, which the patient applies twice daily for 3 days, or imiquimod cream, used at bedtime three times a week for up to 16 weeks.

Its course, however, is not aggressive, and the papules should be treated as anogenital warts (see above).
This infection typically develops on the back of the neck and appears more commonly in patients with diabetes than in the general population.
Examples are erythrasma, pitted keratolysis, trichomycosis axillaris, and most cases of cutaneous abscesses. Sites of trauma associated with cutaneous abscesses may be apparent, as with sites of injections in illicit-drug users,23 or they may be minor and unnoticed. Gram stain and culture of the pus are ordinarily unnecessary, as are topical antimicrobials.
The most common site of erythrasma is between the toes, especially in the fourth interdigital space, where it causes fissuring, maceration, and scaling, resembling tinea pedis.
This infection occurs with increased moisture, such as caused by excessive sweating, occlusive footwear, or frequent contact with water.
The same process occasionally affects the facial or pubic hair.27 Excessive sweating, poor hygiene, and failure to use an axillary deodorant are predisposing factors.
The injury is typically deep, but sometimes, infection occurs after apparently trivial trauma, such as abrasions or lacerations. Erythem-atous, pruritic papules, often with a pinpoint central pustule, appear in areas exposed to the contaminated water; lesions are particularly numerous in regions occluded by tight-fitting swimming suits. Ordinarily, this bacterium resides in the soil, where it forms spores that can persist for years. The cutaneous form develops when spores enter the skin through abrasions and then transform into bacilli, which produce toxins that cause local tissue edema and necrosis. A histologic feature that distinguishes a wart from other papillomas is the presence in the upper epidermis of large, vacuolated cells that contain numerous viral particles. More than one application at 2- to 3-week intervals may be necessary for large or periun-gual warts. A plantar wart that is covered by a callus can be distinguished from an ordinary callus by paring off the surface keratin; multiple, pinpoint dots, representing thrombosed vessels, or bleeding points from surface capillaries will become apparent if it is a wart. Genital verrucous carcinoma, also called giant condyloma acuminatum of Buschke-Lowenstein, is a low-grade genital malignancy caused by HPV-6 and HPV-11. Another approach involves fluorouracil (5-FU) cream administered twice daily for 1 to 3 weeks. HPV-16 is a common cause, however, and malignancy does occasionally develop, especially in women.
From this site or occasionally from the perineum or axilla, organisms can spread and enter the skin, presumably through minor, usually inapparent, trauma. Systemic antibiotics are reserved for patients with extensive surrounding cellulitis, neutropenia, cutaneous gangrene, or systemic manifestations of infection, such as high fever. Other locations are in-tertriginous areas, such as the axillae, groin, submammary area, and intergluteal cleft. Shaving the hair is effective treatment; other options include topical erythromycin or clindamycin.
The necrotizing process may develop from extension of an adjacent infection, especially in the second most common location, the anogenital area.
Subsequently, inflammation develops, which may be provoked by bacteria, yeast, or other nonmicrobial substances trapped beneath the occluded ostium. In these patients, oral eryth-romycin or doxycycline may be effective in eradicating the lesions.
The lesions disappear spontaneously over several days, leaving no scars; ordinarily, no topical or systemic therapy is necessary.
When ingested— primarily by herbivores (cattle, horses, sheep, and goats) grazing on contaminated land—these spores may cause infection. The warts may be filiform, with a small base and a thin projection of several millimeters, especially on the face.
Electrodesiccation and curettage or laser surgery are effective for persistent or recurrent lesions. Paring of the wart can be followed by immediate treatment with liquid nitrogen, the application of strong acid (50% trichloroacetic acid), or the nightly administration of salicylic acid in plasters, an acrylic vehicle, or collodion. This medication is particularly suitable for large wart plaques and warts of the ure-thral meatus, but side effects, including discomfort and painful erosions, are common.
Incision and drainage are appropriate for large or multiple furuncles and for all carbuncles.

Successful prevention of recurrent infection requires eradication of these bacteria from their site of residence, but most sys-temic antibiotics do not achieve adequate levels of drug in the anterior nares. In these regions, the lesions are usually scaly, brownish-red, sharply circumscribed patches. An impressive malodor of the feet is often apparent, and although the disorder may cause no symptoms, some patients complain of itching, tenderness, or sliminess of the feet. When anaerobes or certain aerobic gram-negative bacilli cause the infection, gas may form in tissues, evident as crepitus on physical examination or visible on radiographic studies. Some patients have sore throat, rhinitis, earache, and headache, but fever or bacteremia is very rare. This veterinary disease is most frequent in tropical and subtropical areas, but extensive vaccination can markedly diminish its frequency. After an incubation period of about 1 to 7 days, a painless, pruritic papule forms at the entry site, most commonly the head, neck, and extremities.
Organisms are demonstrable with tissue Gram stain or immunohistochemical staining for the bacteria’s cell wall antigen. Systemic antibiotics are unnecessary unless there is fever or substantial surrounding cellulitis.
Anaerobes occur either alone or in the mixture of anaerobes and aerobes that constitutes the normal regional flora; they are sometimes accompanied by microbes from adjacent mucous membranes.
As in erythras-ma, topical azoles, such as clotrimazole and miconazole, are effective, as are topical erythromycin and clindamycin. Because it requires acute and convalescent blood specimens, serologic testing for antibodies to B.
Antibiotic therapy does not alter the course of eschar formation and healing, but it does decrease the risk of systemic disease.
Cell-mediated immunity appears important in controlling these infections, which can be very extensive and refractory to treatment in immunocompromised patients. In anogenital infections, such as scrotal, inguinal, vaginal, buttock, and perirectal abscesses, the organisms are commonly fecal bacteria, including streptococci, anaerobic gram-positive cocci, and anaerobic gram-negative bacilli, such as Bacteroides fragilis.
The definitive diagnostic technique is examination of the skin with a Wood light, which, because the organisms produce por-phyrins, reveals a coral-red fluorescence. Computed tomography or magnetic resonance imaging may be helpful in some cases in detecting the infection and defining its extent.
In other patients, the avoidance of oily substances on the skin or tight clothing leads to resolution of the problem.
In 1 to 2 days, vesicles appear, surrounding the papule and containing numerous bacteria but few neutrophils. On the extremities, trunk, neck, and head, the usual microbes include co-agulase-negative staphylococci, anaerobic gram-positive cocci, and Propionibacterium acnes, an anaerobic gram-positive bacillus. Aspiration of the affected tissue may yield purulent fluid, which on Gram stain demonstrates only gram-positive cocci in chains when S. Painless, gelatinous, nonpitting edema then encircles the lesion, often spreading extensively to adjacent skin and soft tissue [see Figure 12].
These organisms ordinarily possess little virulence, but when introduced into the dermis or subcutaneous tissue by trauma or through a disrupted cutaneous surface, they may become pathogenic. Because they possess some activity against gram-positive bacteria, topical azoles, such as miconazole and clotrimazole, are effective in the treatment of this infection. The findings on Gram stain and culture of pus should dictate antibiotic choice, but a good initial program is gentamicin in combination with clindamycin. Most important is incision and drainage of the affected area, which should include removal of any necrotic tissue. In the depressed center of the lesion, a black eschar forms and sloughs within 1 to 2 weeks, leaving a shallow ulcer that heals with minimal, if any, scarring.
Often, the amount of disease revealed at surgery is much greater than was apparent on the preoperative clinical examination, because the infection typically extends far beyond the borders of cutaneous inflammation.
Repeat operation after 24 hours is typically prudent to detect new areas of infection and necrotic tissue.

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