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Erythrasma

Erythrasma is a chronic skin infection caused by Corynebacterium minutissimum. The infection usually appears on interdigital spaces of toes as well as body folds. The clinical presentation is typically benign, but more severe manifestations can occur with increased body involvement.  


Presentation

There are two forms of erythrasma: 1) interdigital and 2) generalized.

Interdigital erythrasma is more common than the generalized variant. It frequently appears on the 3rd and 4th web spaces of the foot, especially the 4th interdigital space [5]. The main characteristics of the lesions are maceration, scaling, and fissuring. These patients usually remain overall asymptomatic. Erythrasma may affect other areas such as the axillae, groin, and perineum. Furthermore, it targets moist regions such as infra breast, abdominal and intergluteal folds. Diabetics and obese women are particularly prone to infection in these areas.

At the onset of erythrasma, skin lesions are well demarcated pink-red scaly patches giving a wrinkled characteristic. They transform into brown-red macular patches and hence, this discoloration is observed in moist body folds. While the infection does not usually manifest in other symptoms, pruritus can occur. Erythrasma lasts from months to years. Some cases involve body-wide distribution such as the trunk and extremities.

Generalized erythrasma is more frequently observed in type 2 diabetics but can also occur in nondiabetics. Lesions extend beyond body folds. They are described as well-circumscribed erythematous patches that may be scaly or smooth. This type of infection is usually pruritic. Since these lesions may be confused with cutaneous dermatophytosis, potassium hydroxide preparation is used to differentiate these two.

Patients with recurrent episodes should be evaluated for diabetes. In fact, identifying and modifying this risk factor is important to prevent recurrence. Of importance, immunosuppressed individuals are susceptible to complications. Patients with erythrasma can also have concomitant infections with other organisms. These must be treated as well. Atypical cases are common and tend to appear with color variations. 

A careful exam of both feet and all body folds can differentiate erythrasma from other corynebacterial skin infections such as pitted keratolysis and trichomycosis axillaris. The clinical presentation of erythrasma is similar to that of tinea and intertrigo. An appropriate work up is key. 

Turkish
  • 14 Exogenous coproporphyrin III production by Corynebacterium aurimucosum and Microbacterium oxydans in erythrasma lesions. ( 21393451 ) Yasuma A....Handa H. 2011 15 Antibiotic susceptibility of Corynebacterium minutissimum isolated from lesions of Turkish[malacards.org]
  • 12 Exogenous coproporphyrin III production by Corynebacterium aurimucosum and Microbacterium oxydans in erythrasma lesions. ( 21393451 ) Yasuma A....Handa H. 2011 13 Antibiotic susceptibility of Corynebacterium minutissimum isolated from lesions of Turkish[malacards.org]
  • Antibiotic susceptibility of Corynebacterium minutissimum isolated from lesions of Turkish patients with erythrasma. J Am Acad Dermatol. 2011 Dec. 65(6):1230-1. [Medline]. Clayton YM, Connor BL.[emedicine.medscape.com]
  • Antibiotic susceptibility of Corynebacterium minutissimum isolated from lesions of Turkish patients with erythrasma. J Am Acad Dermatol . 2011 Dec. 65(6):1230-1. [Medline] . Clayton YM, Connor BL.[emedicine.medscape.com]
Weight Loss
  • First of all, modification of risk factors should be addressed through improvement of glycemic control as well as weight loss.[symptoma.com]
  • Risk Factors Obesity Diabetes Occlusive clothing/shoes Hyperhidrosis Immunocompromised state Advanced age Living in a subtropical or tropical region General Prevention Nonocclusive clothing and footwear Good hygiene Weight loss Good blood sugar control[unboundmedicine.com]
  • Other options include a short course of either erythromycin or a tetracycline In recurrent cases give advice on weight loss if appropriate, keeping the skin dry, and provide an antiseptic wash[pcds.org.uk]
  • Weight loss should also be explored if you are not at a healthy weight.[dermatology.about.com]
Heart Disease
  • One patient presented simultaneously with all the three conditions. [18] References Complications Note the following possible complications: Fatal septicemia in immunocompromised patients with erythrasma Infective endocarditis in valvular heart disease[misc.medscape.com]
Intertrigo
  • Treatment Uncomplicated intertrigo If secondary infection is present: Treatment depends on the organism. Candida : e.g., miconazole , clotrimazole , fluconazole Erythrasma: See “Treatment” below.[amboss.com]
  • Risk Factors Similar to risks associated with Intertrigo III. Symptoms Usually asymptomatic May be pruritic in some cases IV.[fpnotebook.com]
  • Compare intertrigo, tinea cruris. erythrasma infectious disease A patchy red-brown rash in the axilla and inguinal region, due to the presence of Corynebacterium minutissimum in the stratum corneum er·y·thras·ma ( er'i-thraz'mă ) An eruption of well-circumscribed[medical-dictionary.thefreedictionary.com]
  • Codes ICD10CM: L08.1 – Erythrasma SNOMEDCT: 238418005 – Erythrasma Look For Subscription Required Diagnostic Pearls Subscription Required Differential Diagnosis & Pitfalls Inverse psoriasis Seborrheic dermatitis Tinea corporis Acanthosis nigricans Intertrigo[visualdx.com]
Skin Patch
  • These tests can help diagnose erythrasma: Lab tests of scrapings from the skin patch Examination under a special lamp called a Wood lamp A skin biopsy Your provider may suggest the following: Gentle scrubbing of the skin patches with antibacterial soap[medlineplus.gov]
  • These tests can help diagnose erythrasma: Lab tests of scrapings from the skin patch Examination under a special lamp called a Wood lamp A skin biopsy Treatment Your provider may suggest the following: Gentle scrubbing of the skin patches with antibacterial[m.ufhealth.org]
Eczema
  • Essentials of Diseases of the Skin Including the Syphilodermata Arranged in the Form of Questions and Answers Prepared Especially for Students of Medicine (1822-64, eczema marginatum, erythrasma caused by fungus, and herpes zoster) and his successor,[wordnik.com]
  • […] usually causes no other symptoms apart from change of skin colour. ( sciencephoto.com ) If the patient has diabetes, obesity, or hyperhidrosis, erythrasma takes over complicated with secondary infection of the lesion, the occurrence of diaper rash and eczema[lookformedical.com]
  • […] atopicum (dermatitis atopica) Subacute and chronic (eczem) dermatitis Microbial eczema Granuloma gluteale infantum Toxic contact (irritative) dermatitis, acute Toxic contact (irritative) dermatitis, chronic Seborrhoic dermatitis Pityriasis amiantacea[atlases.muni.cz]
  • GENERALS - DIABETES MELLITUS - accompanied by – eczema ins. GENERALS - DIABETES MELLITUS abrom-a. acet-ac. adren. aether alf. all-s. allox. aloe alumn. am-act. anthraco. apoc. arg-met. arg-n. arist-m. Ars-br. ars. asc-c. aspar. aur-m-n. aur. bar-m.[homeopathyworldcommunity.ning.com]
Lichenification
  • It can be complicated by contact dermatitis, lichenification, postinflammatory pigmentation, and coinfection with other bacteria, yeasts, and dermatophytes. Serious complications are very rare.[dermnetnz.org]
  • It can be complicated by contact dermatitis , lichenification , postinflammatory pigmentation , and coinfection with other bacteria , yeasts , and dermatophytes . Serious complications are very rare.[dermnetnz.org]
  • Lichenification and hyperpigmentation are common. The skin occasionally has a wrinkled appearance with scales. KOH test results are negative. Courtesy of Michael Bryan, MD.[misc.medscape.com]
  • Secondary lesions Fine branny gray-white or brown scale gives a dry, velvety appearance Lichenification in rare pruritic lesions Post inflammatory hyperpigmentation The appearance of erythrasma is often typical.[homeopathyworldcommunity.ning.com]
Meningism
  • Corynebacterium minutissimum bacteremia and meningitis: a case report and review of literature. J Infect. 2008 Jan. 56(1):77-9. PubMed.[dermnetnz.org]
  • Corynebacterium minutissimum bacteremia and meningitis: a case report and review of literature. J Infect . 2008 Jan. 56(1):77-9. PubMed .[dermnetnz.org]
  • Corynebacterium minutissimum bacteremia and meningitis: a case report and review of literature. J Infect. 2008 Jan. 56(1):77-9. [Medline]. Shin JY, Lee WK, Seo YH, Park YS. Postoperative Abdominal Infection Caused by Corynebacterium minutissimum.[emedicine.medscape.com]

Workup

The workup will include a detailed history and identification of predisposing factors as well as a thorough physical exam of both feet and all body folds. 

Microscopy and culture are both methods to diagnose erythrasma. Scrapings are used for evaluation. Under ultraviolet radiation from Wood light examination, erythrasma will fluoresce a coral red color. This is a characteristic finding of these lesions since corynebacteria produce excess porphyrins that accumulate under the skin [6]. Furthermore, hyphae are not found in skin scrapings unlike in tinea. It must be noted that if the patient has bathed prior to this examination, the characteristic finding may not be present [7].

Specific culture media can be utilized as well. Gram staining is also useful. Erythrasma lesions appear as gram positive filamentous rods. Methylene blue stain can reveal both the curved rods of C minutissimum and fungal spores of pityriasis versicolor in cases where both organisms exist [8]. Of important note, patients with recurrence should raise suspicion for underlying diabetes and a workup may be appropriate.  

Trichophyton Mentagrophytes
  • The commonest dermatophyte isolated was Trichophyton mentagrophytes var interdigitale. There was a significant rise in the incidence of both types of infection with age.[ncbi.nlm.nih.gov]
  • Of those infected at the first visit 41% had persistent infection mainly due to Trichophyton rubrum, whereas new infections were largely caused by Trichophyton mentagrophytes.[ncbi.nlm.nih.gov]
Trichophyton Rubrum
  • Of those infected at the first visit 41% had persistent infection mainly due to Trichophyton rubrum, whereas new infections were largely caused by Trichophyton mentagrophytes.[ncbi.nlm.nih.gov]
  • Abstract Four patients are reported with concomitant erythrasma and trichophyton rubrum dermatophytosis of the groin. The recognition and diagnosis of these associated infections is emphasized.[ncbi.nlm.nih.gov]
Malassezia Furfur
  • A single method to stain Malassezia furfur and Corynebacterium minutissimum in scales. Rev Inst Med Trop Sao Paulo 1996; 38: 299–302 PubMed CrossRef Google Scholar 23. Montes LF, Black SH. The fine structure of diphtheroids of erythrasma.[doi.org]

Treatment

There are various treatment options available. Eliminating the infection, along with preventing complications and recurrence are the therapeutic goals for these patients.

Antibiotic treatment

One regimen consists of erythromycin (drug of choice) or tetracycline: 250mg taken orally 4 times daily for a duration of 14 days (these are effective for extensive infection). Oral erythromycin is very effective and has cure rates up to 100%. This is more efficient than tetracycline in patients with erythrasma affecting axillae, groin, and interdigital lesions. Chloramphenicol can also be used, but this is associated with potentially severe side effects. To assess the usability of clarithromycin further studies need to be conducted. While C minutissimum is susceptible to numerous antibiotics such as erythromycin, tetracycline, penicillins, cephalosporins, and others, multidrug resistance has emerged [9] [10] [11] [12]. 

Medication particularly effective for interdigital infection and prophylaxis

  • Topical erythromycin or clindamycin 
  • Fusidic acid cream
  • Whitfield ointment
  • Antibacterial soap 

Phototherapy

Photodynamic therapy using red light (broadband, peak at 635 nm) is another method to treat erythrasma. In one study investigating the effects of phototherapy on erythrasma in 13 patients, 23% experienced complete clearance, and the remaining patients showed improvement [13]. 

A thorough clinical evaluation is pertinent to identify all organisms as there could be coexisting infections. The clinician should establish treatment to target all of these. Antifungals are used in concomitant yeast infections. It is important to keep the lesions dry since these bacteria flourish in moist environments. The area should be washed with antibacterial soap and topical aluminum chloride. As always when developing a treatment regimen, the clinician should be aware of drug interactions and side effects especially in pregnant women, women on oral contraceptives, and patients with contraindications. Many antibiotics have drug interactions and side effects. 

Prognosis

Erythrasma is typically benign. While the prognosis is very good, there is a possibility for recurrence as long as there are risk factors present. In immunocompromised patients, it may become widespread and invasive, but this is rare. C minutissimum can cause other diseases in these high-risk cases. 

Etiology

Corynebacterium minutissimum, which is present in the normal skin flora, is the organism responsible for erythrasma. This skin infection can affect anyone but is especially present in individuals with diabetes mellitus, obesity or other underlying diseases [1] [2]. Those residing in warm damp climates are also at higher risk due to production of body moisture. Additional risk factors for erythrasma include hyperhidrosis, poor hygiene, older age, and sensitive skin. Immunocompromised hosts are also susceptible.

Epidemiology

The incidence of erythrasma is approximately 4%. While its occurrence is reported globally, it has a higher prevalence in tropical and subtropical regions [3]. One study emerging from Turkey reports that erythrasma was the cause of interdigital foot lesions in 46.7% of patients with this presentation [4]. 

As for patient demographics, this infection is more common in black and dark skinned individuals but can affect anyone. Furthermore, both genders are affected equally (except for crural lesions which are more common in men). However, one particular study reports interdigital erythrasma was more commonly observed in women than men [5]. Finally, erythrasma is found in all ages, but incidence increases with age. Reports indicate that it was even diagnosed in a 1-year-old child. 

Sex distribution
Age distribution

Pathophysiology

When in warm and humid climates, C minutissimum proliferates in the stratum corneum (which is the outermost layer of the epidermis). Hence, this layer becomes thick. Furthermore, the bacteria enter the cells and intercellular spaces subsequently causing break down of the keratin fibrils. This organism is also responsible for porphyrin synthesis, which results in the red fluorescence of scales that appear under examination of Wood light.

Prevention

Prevention can be achieved through numerous recommendations. First of all, modification of risk factors should be addressed through improvement of glycemic control as well as weight loss. Additionally, patients should maintain good hygiene, use antibiotic soap, wear clean clothing, avoid humid and hot weather if possible, and keep the skin and especially skin folds dry. Prevention of recurrence is also achieved through these measures. The clinician may prescribe prophylactic treatment as well. 

Summary

Erythrasma, caused by Corynebacterium minutissimum, is an intertriginous infection usually found in individuals with predisposing factors such as diabetes, obesity, and darker skin. It is most prevalent in tropical or subtropical regions due to humidity and dampness. The culprit of this infection is a component of the normal skin flora. Favorable risk factors allow for this organism to multiply under the skin.

The clinical presentation of erythrasma can be confused with infections such as tinea versicolor and cutaneous dermatophytosis, which are due to other organisms. Therefore, a detailed exam of the body folds and feet is necessary.

This is typically a benign condition. Most patients will have an interdigital infection of the feet but remain asymptomatic. However, diabetics, immunocompromised individuals, and others may also have systemic involvement as the disease is targeting groin, axilla, and other moist folds.

Ultraviolet light is utilized to diagnose erythrasma. It reveals a characteristic coral red emission due to the porphyria produced by this organism. Treatment aims to eradicate the infection and prevent complications and recurrences. Therapy consists of antibiotics and/or antifungals as well, depending on the presence of coexisting organisms. Recognizing and modifying risk factors such as implementing better glycemic control and weight loss are also important in the treatment and prevention of this infection.

Patient Information

Erythrasma is an infection of the skin due to the bacterium Corynebacterium minutissimum. It usually appears as scaling and cracking in the skin between the 4th and 5th toes. The infection can also occur in areas of the body where there are skin folds such as the armpits, the skin below the breasts, or the abdomen. In women, it can appear on the vaginal/anal skin and in men it can be seen on the scrotum.

Erythrasma is common in diabetic and obese patients. Also, there are other factors increasing the risk of infection, for example as excessive sweating in addition to living in hot and humid environments such as tropical regions. 

This mild infection does not usually produce symptoms. Also, there are other skin infections that look very similar. Your doctor will examine your feet and skin carefully. Examination of the infected skin or scrapings from the skin with ultraviolet light will confirm the diagnosis.       

Treatment includes antibiotics such as erythromycin or tetracycline. There are other medications that can be applied to the infected skin. Good results are achieved with the available drugs. Also, it is recommended that some patients use preventative treatment. If there is yeast found on the infected skin, then your doctor will prescribe antifungal treatment in addition. 

Treatment and prevention of future episodes is important. Preventative measures are as follows: wash the skin with antibacterial soap and dry the skin well, practice good hygiene, avoid hot, humid weather if possible, and keep your body dry. Since the risk of infection is higher in patients with diabetes and obesity, improving glucose control and weight loss are also advised. 

References

Article

  1. Hodson S, Henslee T, Tachibana D, Harvey C. Interdigital erythrasma. Part I: A review of the literature. Journal of the American Podiatric Medical Association. 1988;78(11):551-558. doi:10.7547/87507315-78-11-551.
  2. Sindhuphak W, MacDonald E, Smith EB. Erythrasma overlooked or misdiagnosed? International Journal of Dermatology. 1985; 24(2):2495- 96
  3. Sarkany I, Taplin D, Blank H. Incidence and bacteriology of erythrasma. Arch Dermatol Archives of Dermatology. 1962;85(5):578. 
  4. Inci, M, Serarslan, G, Ozer, B, et al. The prevalence of interdigital erythrasma in southern region of Turkey. Journal of the European Academy of Dermatology and Venereology. 2011;26(11):1372–1376.
  5. Morales-Trujillo, M, Arenas, R, Arroyo, S. Interdigital Erythrasma: Clinical, Epidemiologic, and Microbiologic Findings. Actas Dermo-Sifiliográficas (English Edition). 2008;99(6):469–473.
  6. Yasuma, A, Ochiai, T, Azuma, M, et al. Exogenous coproporphyrin III production by Corynebacterium aurimucosum and Microbacterium oxydans in erythrasma lesions. Journal of Medical Microbiology. 2011;60(7):1038–1042.
  7. Mattox TF, Rutgers J, Yoshimori RN, Bhatia NN. Nonfluorescent erythrasma of the vulva. Obstetrics and Gynecology. 1993; 81(5 (Pt 2)):862-4.
  8. Karakatsanis G, Vakirlis E, Kastoridou C, Devliotou-Panagiotidou D. Coexistence of pityriasis versicolor and erythrasma. Mycoses. 2004; 47(7):343-5.
  9. Clayton YM, Connor BL. Comparison of clotrimazole cream, Whitfield's ointment and Nystatin ointment for the topical treatment of ringworm infections, pityriasis versicolor, erythrasma and candidiasis. British Journal of Dermatology. 1973; 89(3):297-303
  10. Hamann K, Thorn P. Systemic or local treatment of erythrasma? A comparison between erythromycin tablets and Fucidin cream in general practice. Scandinavian Journal of Primary Health Care. 1991; 9(1):35-9.
  11. Holdiness MR. Management of cutaneous erythrasma. Drugs. 2002; 62(8):1131-41.
  12. Wharton JR, Wilson PL, Kincannon JM. Erythrasma treated with single-dose clarithromycin. Archives in Dermatology. 1998; 134(6):671-2.
  13. Darras-Vercambre S, Carpentier O, Vincent P, Bonnevalle A, Thomas P. Photodynamic action of red light for treatment of erythrasma: preliminary results. Photodermatology, Photoimmunology & Photomed. 2006; 22(3):153-6.

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Last updated: 2019-07-11 22:37