emergency dermatology
DESCRIPTION
Emergency DermatologyTRANSCRIPT
ED Dermatology
Aims
Review terminology of skin conditions
Identify common non-serious ED presentations
Discuss serious but rare skin disorders
Definitions
Macule
Impalpable coloured lesion <1cm, circumscribed alteration of skin colour
Patch
Impalpable coloured lesion >1cm.
Papule
Palpable lump <1cm diameter.
Nodule
Palpable lump >1cm.
Vesicle
Palpable fluid filled lesion <1cm.
Bulla
Palpable fluid-filled lesion >1cm
Petechiae
red, non blanching spots <5mm
Purpura
red, non blanching spots >5mm
Plaque = Palpable disc shaped lesion
Wheal = Area of dermal oedema
Descriptive Terms
Annular : Ring shaped, hollow centre Arcuate : Curved Circinate : Circular Confluent : Lesions that run together Discoid : Circular without hollow centre Eczematous : Inflammed and crusted Keratotic: Thickened Lichenified: Thickened and roughed with accentuated
skin markings Zosteriform : Nerve distribution
History How long Had it before Is it worsening / anything improving it Distribution ie palms / plantar / face / mucosal membranes How did it start / evolve Itch Social changes eg diet / work / cleaning Meds & allergies Cutaneous manifestations of systemic disorders eg sore joints & past medical
history Family history Travel Contacts Viral symptoms or fevers
?
Urticaria
Urticaria
Physical triggers / drugs / foods / stings / viral/ atopy / blood products / temperature...
Wheals, smooth with a red flare with some clearing leaving annular pattern & scratch marks. Dermatographism
Acute / Recurrent / Chronic Investigation
FBC / WCC / Eosinophils / Challenges
Complement levels with angiooedema Management
Remove cause / anti-histamines / steroids
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Eczema Flexural Distribution Itch ++ / Scratch marks, hyper or hypopigmented lesions Age related stages Atopic vs Contact Can be vesicular Treatment
Emollients ++ Treat infected skin Moist dressings Avoid triggers Antihistamines for itch Topical / systemic steroids Increase sunlight exposure / Phototherapy Immunomodulators / Immunosupressants : Cyclosporin / Azathioprine /
Tacrolimus /
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Psoriasis Itch / Pain / Decreased movement / FHx Extensor Distribution – well demarcated salmon pink silvery scales. Red surface on
removal / capillary bleeding (Auspitz sign)/ new lesions at site of trauma (Koebner’s Phenomenon)
Plaque / Guttate / Erythrodermic / Pustular variants / Inverse Triggers – Stress, Strep, HIV, Trauma, Drugs (Lithium + BetaBlockers Especially) Psoriatic Arthritis Treatment – topical v’s systemic : Systemic if failed topical / repeated admissions /
extensive plaques in elderly / severe arthropathy / generalised pustular or erythrodermic psoriasis Emollients ++ / Keratolytic agents Topical Steroids. Coal Tar. Dithranol. Vitamin D3 Retinoids – topical or oral. Phototherapy / Photochemotherapy (& methotrexate) Immunosuppressant's – Methotrexate, Cyclosporin, Mycophenalate Infliximab / CD4 monoclonal antibodies
?
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VZV Varicella / Chicken Pox – Respiratory droplets. Infectious for 2 days prior to
lesions. Ends when crusts Rash head / trunk / Simultaneous presence of rash at different stages. Macule / Papule / Vesicle /
Pustule / Crusts A/w headache / malaise / anorexia / cough / coryza and sore throat / low grade
fever Rx symptomatic. Antivirals in certain cases / Secondary infection risk
Shingles Dermatomal distribution & enlarged draining node Presents as pain, malaise, fever, rash in same distribution several days later Dx Clinical but can do smears or titres or isolation of virus in blisters Mx – antivirals / pain relief / IV antivirals if immunocompromised / IFN Complications : Corneal ulcers / Gangrene of affected area / Phrenic Nerve palsy
/ Meningoencephalitis / Ramsay Hunt syndrome / Neuralgia / Disseminated zoster
NB if AIDS – major CNS effects/
?
?
HSV
Pain / Itch / Vesicles / Sore mouth / Gum swelling / Mouth ulcers
Small vesicles & lymph nodes Complications –
Erythema Multiforme / Encephalitis / Keratitis / Whitlow / Disseminated infection if immunocompromised / Visceral involvement / Neonatal / Meningitis
Rx topical / oral / IV antivirals
?
Impetigo Group A beta haemolytic Strep or Staph aureus Contagious Vesicles to honey coloured crusted lesions. Painless. Face
or extremities Local adenopathy / Generally afebrile Rx topical / oral antiobiotics Generally resolves 7-10/7 Complications – Osteomyelitis / Septic Arthritis / Sepsis /
Pneumonia / Endocarditis Post strep glomerulonephritis / Scalded skin syndrome
?
Erythema Multiforme Hypersensitivity reaction, polymorphous skin eruption Target Lesions
Symmetric eruption red round macules, oedematous papules, target lesions (x3 concentric areas of colour change) dorsum hands and forearms
Central dusky area due to keratinocyte necrosis. Can be vesicular and painful. Minor generally self limiting
Etiology HSV Immunologic disorders – IBD / SLE / graft v’s host Mycoplasma, TB, Histoplasmosis. Drugs: Sulphonamides. Barbiturates. Penicillin. Phenytoin. NSAIDS.
Allopurinol. Malignancy Idiopathic
Mx – Minor consider antivirals if HSV / symptomatic
?
Erythema Nodosum
Painful nodules, poorly defined. +++ tender Hx – fever / painful nodules/ arthralgias / sore throat / drugs / Cough Aetiology:
Strep / TB / Yersinia / Leprosy / Coccidioidomycosis / Histoplasmosis Sarcoid SLE Behcets IBD Drugs – Sulphonamides / OCP
Management Definitive dx – wedge biopsy CXR ASOT / Throat Swabs. Symptomatic
• Self–limiting - 3-6 weeks• NSAIDS• Elevation• Compression Stockings.
?
Koplik’s Spots / Measles
Primary infection respiratory epithelium - droplets Highly contagious Fever / Coryza / Koplik spots 2-3 days into prodrome
precedes rash (14 days). Maculopapular, lasts 5-7/7 may desquamate
Clinical diagnosis of Measles wrong in 50% of cases Probably requires serology for confirmation /
leucopaenia / lymphopaenia Complications: Superimposed bacterial infection.
Encephalitis. SSPE
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Slapped Cheek Syndrome
Fifth Disease “Erythema infectiosum” Parvovirus B19 Respiratory droplets Viral prodrome, slapped cheek, perioral pallor, later
extremities with palms and soles spared. Laced appearance
Antipyretics and antihistamines Generally benign. Rare aplastic crisis. In utero a/w
hydrops foetalis
Hand, Foot + Mouth
Usually Coxsackie A or Enterovirus Usually children, very infectious, incubation 3
days then fever malaise and rash / painful oral lesions
Treatment supportive
Kawasaki’s disease
Usually < 5 yo, early phase of prolonged fever, irritability, and involvement of mucous membranes (conjunctivitis and mouth). Hands and feet red and swollen early, later may have desquamating maculopapular rash
Association with cardiac abnormalities...
Treatment with IV Immunoglobulin
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Pityriasis Rosea
Presumed viral. ?HHV 7. Christmas tree distribution. Self limiting over 6-12 weeks. Herald patch often mistaken for
ringworm.
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Scabies Sarcoptes scabiei Intense itch Permethrin or Malathion
Applied at bedtime to whole body from chin to soles.
Treat all close contacts even if asymptomatic.
Wash all towels, clothes worn in last week and bedlinen
Vacuum house and furniture! Itch can persist for 6 weeks even after
successful treatment due to dead mites in skin.
?
Melanoma
Asymmetrical Border irregular Colour Variegated Diameter >5mm Evolution / Elevation
So far...
Reviewed terminology
Common, but usually not serious/life threatening conditions
Serious conditions with blistering / skin loss
Erythema Multiforme major / SJS Pemphigus Pemphigoid TENS SSS ( Kawasaki’s )
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Erythema Multiforme Major
Stevens Johnson Syndrome Symmetric erythematous macules, head and neck and lower
body Progresses to bullae, skin necrosis and denudation, at least
x2 mucosal surfaces involved Widespread rash involving up to 10% BSA skin sloughing /
blistering. Treatment: Prompt drug withdrawal. Admission / supportive care / general burns care.
?
Toxic Epidermal Necrolysis Widespread rash like sunburn initially >30% TBSA with later
necrosis and sloughing. +ve Nikolsky sign Large mucous membrane involvement. Remove causative agent & manage as severe burns (ICU /
Burns unit) Mostly thought to be drug related Debates re plasmapheresis / IG / Steroids etc, nil proven Complications: High mortality / NB Ophthalmology
involvement and regular eye irrigation
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Pemphigus Autoimmune Blisters in mouth followed by on skin. Diagnosis by biopsy – IgG in epidermis, disruption of connections
intercellular 3 Types:
Vulgaris – begins in mouth 50% cases Foliaceous – may be drug induced
• Least severe.• Often mistaken for eczema
Paraneoplastic.• NHL most common
Mx: Barrier nursing / antibx / IV fluids / systemic steroids +/- immunosuppressants (azathioprine / cyclophosphamide / methotrexate / gold / dapsone /ciclosporin)
?
Pemphigoid
More common than pemphigus Generally benign Also Autoimmune Affects older age group Affects deeper layer in skin – tense flexural areas
Subepidermal / eosinophil rich with IgG and C3 deposited in basement membrane
Treatment same as Pemphigus – steroids +/- immunosupressants
Variants Gestational Mucous membrane (Cicatricial)
?
Scalded Skin Syndrome Syndrome of acute exfoliation of the skin typically following an
erythematous cellulitis. Severity varies from a few blisters to a severe exfoliation affecting almost the entire body, but doesn’t involve mucous membranes as in TENS.
Staph aureus with epidermolytic exotoxins (A+B).
Nikolsky’s sign -separation of skin with gentle pressure.
Treatment. Antibiotics, supportive care.
?
Purpuric Rash
Petechiae <5mm. Purpura >5mm. Causes:
Drugs: Steroids / Gold / Anticoagulants Senile Trauma
• Coughing / vomiting / direct. Infection
• Meningococcal, Cellulitis, Viral. Vasculitic
• E.g. HSP / Wegners / PAN Thrombocytopenia
• ITP / TTP / Leukaemia / DIC.
Red flags
Unwell patient Other serious comorbidity, eg immunodeficiency Large area of skin Mucosal or ocular involvement Specific conditions with serious complications
eg Kawasaki
If any doubts d/w senior colleague / dermatologist
Remember you can easily send them an image of
a rash ! (in hours)
A good reference website:
http://dermnetnz.org/doctors/