Skin Infection: from trivial to fatal

2015, March/April Adirondac Adirondoc

Today’s topic is a reminder of a couple of important facts. First, we all live in a veritable cesspool of bacteria, covering every inch of our body and most surfaces we touch. Fortunately, healthy folks seem to have no difficulty with this. Second, some seemingly minor health issues can simply be “watched” in civilization, but in the backcountry must be taken very seriously. Skin infections go by a variety of names, but for simplicity we will classify them as abscesses and cellulitis. Abscesses are more localized. They can be thought of as walled-off collections of pus, which sometimes drain spontaneously. Often, drainage is all that is required to treat an abscess.

Cellulitis is a bit more complicated, and potentially much more serious. These are infections under the skin tha spread throughout tissues, sometimes with dramatic speed. They are not localized like abscesses, and therefore there is nothing to drain.

Cellulitis generally begins with a small break in the skin, which allows bacteria to enter. Rarely, the infection may be blood-borne and not associated with any obvious breach in the skin. The first sign of the infection is an area of redness that is often quite tender, warm, and hard to the touch. Most often, our body’s intricate defense mechanisms fight off the infection, and it gradually recedes on its own.

Here is where the approach to possible cellulitis in the backcountry differs from home. When care by one’s physician or urgent care center is a few moments away, watchful waiting may be appropriate. The last time I visited, however, there was no urgent care center in the Five Ponds Wilderness! Waiting too long in the wilderness could be a prescription for disaster.

Some findings with cellulitis demand immediate exit from the backcountry. Anyone who has fever, chills, or other “systemic” symptoms associated with a skin infection needs to get to definitive care rapidly. What seems like a trivial skin infection at one point can progress to overwhelming disease and organ failure within hours.

Another warning sign is the presence of streaks of redness extending from the local infection upward toward the center of the body. This is evidence that the infection is entering the body’s lymph system.

Does this mean that anyone with a little skin redness needs to hike out immediately? Of course not. It means that the individual merits close watching. One very useful technique is to use a pen to outline the margins of redness. Cellulitis that is moving beyond its inked boundary every few hours probably merits an end to the trek If the individual is otherwise feeling well, and the lesion is not spreading, continued careful watching is appropriate.

As with many wilderness problems, hygiene is an important preventive measure for cellulitis. Breaks in the skin should be washed with soap and water, and protected with an over-the-counter antibiotic ointment. Once an infection is established, however, such ointments have no value.

There is little first aid for cellulitis. Warm compresses increase the flow of infection-fighting blood cells, but this is rarely practical in a campsite. Definitive treatment requires oral or intravenous antibiotics. I am not a proponent of non-professionals bringing prescription medications into the wilderness. However, folks entering areas from which medical care is a day or two away may wish to consult with their personal physician about bringing an appropriate drug with them. If this is done, remember that the antibiotic is only to be used during evacuation, not to replace it.

~Tom Welch, MD, is professor and chair of pediatrics at Upstate Medical University in Syracuse and an active member of the Wilderness Medical Society. He is a licensed professional guide and certifying instructor for the Wilderness Education Association, and has guided groups in the Adirondacks, Montana, 4nd Alaska. More information is available at his website and blog: Infectious disease specialist Jana Shaw, MD, MPH, reviewed this column and provided helpful comments.

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Topics: Skin