Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
This article have been viewed 2120 times
Miguel Sanchez
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Pinta (carate, azul, mal de pinto, empeines, lota, tina) and yaws (pian, frambesia, parangi, paru, buba) are non-venereal ‘endemic’ spirochetal infections caused respectively by Treponema carateum and Treponema pallidum subspecies pertenue. Pinta was almost exclusively found in inhabitants of rural, overcrowded, poverty-stricken regions of Mexico, the Caribbean, and the northern part of South America, and has been reported most recently from scattered areas in the Brazilian rainforest. Whereas yaws was prevalent in indigent persons living in tropical, rural, medically under-served areas with high humidity and rainfall within Central Africa, Southeast Asia, Central and northeast South America and some Pacific Islands, outbreaks have recently been reported from Papua New Guinea and Guyana. Most patients are children and young adults who acquire the infections by direct contact of abraded skin with another person’s exudative infected lesions.
Pinta and yaws are very rare, and familiarity with the types of lesion is essential to differentiate them from syphilis, psoriasis, leprosy, and leukodermas, in order to establish an appropriate treatment plan. As in syphilis, both infections have three distinct clinical stages. In pinta signs or symptoms are limited to the skin and lymph nodes, but yaws can also affect the skeletal system and mucous membranes. The primary stage of pinta develops after an incubation period of 15 days to months (usually 2 to 4 weeks). Following exposure, one to three erythematous papules erupt, usually on the face or extremities, and grow into erythematous scaly plaques that may become hypochromic or light blue in the center. Non-tender regional lymphadenopathy may appear. The secondary stage of pinta usually follows within 2 to 5 months (sometimes years later), with the appearance of erythematous papules (pintids) that enlarge to form psoriasiform plaques, which may remain for years. The plaques, which may be annular or circinate, progress through a range of colors from copper-brown to slate blue or black. Some may be hypochromic. Lymphadenopathy may be present. The tertiary stage is characterized by depigmented patches on the wrists, ankles, elbows, and within old lesions. These develop between 3 months and 10 years after the onset of the secondary stage. At this point patients have a combination of hyperpigmented, hypochromic, achromic, dyschromic, and polychromic patches of different sizes, imparting a mottled appearance to the skin. In 80% of cases serologic tests become reactive two to three months after the onset of the primary lesion, and are always reactive in late lesions.
In yaws the primary stage develops after an incubation period of 10 days to 3 months, with the appearance, usually on a lower extremity, of an erythematous, occasionally pruritic papulonodule (the ‘mother yaw’) that enlarges up to 5 cm in circumference and ulcerates with exuberant granulation tissue imparting a framboesiform appearance. The secondary stage usually ensues over 10 to 16 weeks, but may be as long as 2 years after the onset of the primary stage, with an eruption of reddish, weeping, crust-covered papules (‘daughter yaws’) similar to, but smaller than, the primary lesion. In some patients the clinical findings are similar to those of secondary syphilis, with scaly papules and plaques, hypertrophic condyloma lata resembling lesions on body folds, or mucous patches such as lesions on mucous membranes. Nodules around the joints are common. Some patients suffer with painful osteoperiostitis of the forearm or leg and polydactylitis of the hand or foot. In approximately 10% of infected patients the disease progresses to the tertiary stage with infiltrated plaques and nodules that ulcerate, leaving deep ulcers with raised granulomatous edges. Skeletal changes include chronic hypertrophic osteoperiostitis which most commonly affects the tibiae (saber shins) or the superior nasal processes of the maxillae. This latter process triggers disfiguring progressive exostosis of new bone (goundou) which, in 5 to 20 years, results in massive destruction and perforation of the nose and the palate (rhinopharyngitis mutilans or gangosa).
The recommended treatment of pinta and yaws is a single intramuscular injection of 1.2 million units of benzathine penicillin G in adults, adolescents, and older children, and 0.6 million units in children under 10 years of age. Patients cease to be infectious within 24 hours. In pinta primary and secondary lesions heal in 4 to 12 months, but achromic lesions persist indefinitely. Penicillin-allergic patients over 8 years of age are treated with a 15-day course of tetracycline 250 mg four times daily or doxycycline 50 mg twice daily. Erythromycin
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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