Project: Ghana Emergency Medicine Collaborative

Document Title: Cutaneous Emergencies

Author(s): Joe Lex, MD, FAAEM, FACEP (Temple University) 2013

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2

Cutaneous

Emergencies

Joe Lex, MD, FAAEM, FACEP

Department of Emergency Medicine

Temple University School of Medicine

Philadelphia, PA

Topics Covered

1. Cancers of the Skin

2. Decubitus Ulcer

3. Dermatitis

4. Infections / Systemic Illnesses

5. Maculopapular Lesions

6. Vesicular / Bullous Lesions

7. Imaginary Illnesses

1. Cancers of the Skin

• Basal cell carcinoma

• Kaposi’s sarcoma

• Melanoma

• Squamous cell carcinoma

Basal Cell Carcinoma

• Nodular

• Ulcerating

• Sclerosing (cicatricial)

• Superficial, pigmented

• Danger zones: midface, behind

ears

• Refer to dermatologist

Basal Cell Carcinoma

Nodular Ulcerating Pigmented

Kuebi,

Wikimedia Commons

Kuebi, Wikimedia Commons National Institutes of

Health, Wikimedia

Commons

Basal Cell Carcinoma

James Heilman, MD, Wikimedia Commons

National Institutes of Health, Wikimedia

Commons

Kaposi’s Sarcoma

• Painless, raised brown-black or

purple papules and nodules that

do not blanch

• Face, chest, genitals, and mouth

• Not associated with increased

morbidity or mortality

• Referral if bothersome

Kaposi’s Sarcoma

Classic KS: elderly

male Ashkenazi and

Mediterranean Jews

HIV-associated:

homosexual men

Kuebi, Wikimedia Commons

National Institutes of Health,

Wikimedia Commons

Melanoma RISK

Risk factors

• Moles: atypical or common

• Red hair and freckling

• Inability to tan

• Sunburn: severe sunburn especially before age 14

• Kindred: family history

Melanoma

Melanoma in situ

Superficial spreading

melanoma

Melanocytic nevus

Centers for Disease Control and

Prevention, Wikimedia Commons

National Cancer Institute, Wikimedia

Commons

National Cancer Institute,

Wikimedia Commons

Melanoma

• Early detection = early cure

• Have low threshold, refer if

suspected

0x6adb015, Wikimedia Commons

Squamous Cell Carcinoma

• Sunlight

exposure

• Age >55

• Men > women

• White > Black

National Cancer Institute, Wikimedia Commons

Squamous Cell Carcinoma

Treatment

• Surgery

• Radiotherapy

• Cryotherapy

• 5-fluorouracil

• 90% cure rate if

treated early Almazi, Wikimedia Commons

2. Decubitus Ulcer

• External compression of dermis

and hypodermis ischemic

tissue damage and necrosis

• Risk factors: inadequate nursing

care, diminished sensation /

immobility, hypotension, fecal /

urinary incontinence, low serum

albumin, poor nutrition

Stages of Ulcers

I: Nonblanching erythema of intact

skin

II: Necrosis, superficial or partial-

thickness involving epidermis

and/or dermis. Bullae necrosis

of dermis (black) shallow ulcer

Stages of Ulcers

III: Deep necrosis, crateriform

ulceration, full-thickness skin loss;

extends to, but not through, fascia

Source Undetermined

Stages of Ulcers

IV: Full-thickness ulceration with

extensive damage / necrosis to

muscle, bone, support structures

Essent, Wikimedia Commons

Management

• Stage I and II: topical antibiotics

under moist sterile gauze

• Stage III and IV: surgical

debridement and repair

• Complications: osteomyelitis,

sepsis with resistant organisms

(VRE, MRSA, etc.)

3. Dermatitis

• Atopic

• Contact

• Eczema

• Psoriasis

• Sebaceous

cysts

• Seborrhea Thomas Habif, Wikimedia Commons

Atopic Dermatitis = Eczema

• Itching rubbing and scratching

lichenification (hyperplasia)

• Diagnosis: based on clinical

findings

• Serum IgE level usually elevated

• Associated with allergic rhinitis,

asthma

Atopic Dermatitis: Treatment

Fraught with

problems

Dependence on

glucocorticoid

s atrophy,

tachyphylaxis,

hypertrichosis Eisfelder, Wikimedia Commons

Atopic Dermatitis

Care_SMC, Flickr

Jambula, Wikimedia Commons

Atopic Dermatitis

Dyshidrotic eczema Nummular eczema

Dbnll, Wikimedia Commons Source Undetermined

Contact Dermatitis

Generic term applied to acute or

chronic inflammatory reactions to

substances that come in contact

with the skin

• Chemical irritant

• Allergic caused an antigen that

elicits a type IV (cell-mediated or

delayed) hypersensitivity reaction

Contact Dermatitis

Alborz Fallah, Wikimedia Commons

Nunyabb, Wikimedia Commons

Contact Dermatitis

Prevention

• Wear protective clothing

• If contact occurs, wash with water

or weak neutralizing solution

• Barrier creams

Contact Dermatitis

• Gauze soaked in Burow’s solution

changed every 2 to 3 hours

• Class I topical corticosteroid

preparations may be effective if

nonexudative, nonbullous

• Systemic corticosteroids if severe

(cannot function or sleep) or for

exudative lesions

Burow’s Solution

• Aluminum acetate in water

• Invented by ophthalmologist Karl

August Burow (1809 – 1874)

Topical Corticosteroids

Class 4

Mild

• Hydrocortisone 0.5-2.5%

Topical Corticosteroids

Class 3

Moderate (2-25 times as potent as

hydrocortisone)

• Aclometasone dipropionate

• Clobetasone butyrate

• Fluocinolone acetonide

• Triamcinolone acetonide

Topical Corticosteroids

Class 2

• Potent (I50-100 times as potent as hydrocortisone)

• Betamethasone valerate/dipropionate

• Diflucortolone valerate

• Fluticasone valerate

• Hydrocortisone 17-butyrate

• Mometasone furoate

• Methylprednisolone aceponate

Topical Corticosteroids

Class 1

Very potent (up to 600 times as

potent as hydrocortisone)

• Clobetasol propionate

• Betamethasone dipropionate

Psoriasis

James Heilman, MD, Wikimedia Commons

MediaJet, Wikimedia

Commons

Psoriasis

Eisfelder, Wikimedia Commons

James Heilman, MD, Wikimedia Commons

Psoriasis – Findings

• Bilateral, often symmetrical; often

spares exposed areas; favors

elbows, knees, scalp, and

intertriginous areas; face

involvement uncommon

• Guttate psoriasis: disseminated

small lesions without predilection

of site

Psoriasis – Locations

Source Undetermined

Psoriasis – Treatment

• Remove scales – soak in water

• Topical fluorinated glucocorticoid

ointment to wet skin

(betamethasone valerate,

fluocinolone acetonide, et al.)

• Cover with plastic wrap, leave

overnight

Sebaceous Cyst

• Synonyms: wen, infundibular cyst,

epidermal cyst

• Most common cutaneous cyst

• Origin: epidermis or hair follicle

epithelium

• Fills with keratin, lipid-rich debris

• Rupture common

Sebaceous Cyst

• Treatment: drainage if infected

• Removal by surgeon

Steven Fruitsmaak, Wikimedia Commons

Seborrheic Dermatitis

• “Cradle cap” in infants

• Pityriasis sicca = dandruff

Amras666, Wikimedia Commons Starfoxy, Wikimedia Commons

Seborrheic Dermatitis

• Yellowish-red or gray-white skin,

• Often “greasy” or scaling

macules and papules

• Varying size: 5 to 20 mm

Seborrheic Erythroderma

• Frightened, red, toxic patient

• Skin red, thick, scaly

• Many drugs, illnesses implicated

• Can lead to high-output failure

• Admit to warm room with blankets

• Glucocorticoids, emollients

Seborrheic Erythroderma

• Seborrheic erythroderma +

diarrhea + failure to thrive =

Leiner’s disease

• Associated with

immunodeficiency disorders

Seborrheic Erythroderma

Nbrigham, Wikimedia Commons

Seborrheic Erythroderma

Kilbad, Wikimedia Commons

4. Infections

• Bacterial

• Fungal

• Parasitic

• Viral

• Systemic

Bacteria

Abscess

• Abscess: collection of pus with

inflammation, tissue destruction

• Furuncle: deep-seated, red, hot,

tender abscess that evolves from

staphylococcal folliculitis

• Carbuncle: deeper infection,

interconnecting abscesses

Abscess

Abscess

Furuncle Carbuncle

Centers for Disease

Control and Prevention,

Wikimedia Commons Drvgaikwad, Wikimedia

Commons El Pantera,

Wikimedia

Commons

Abscess

• Cause: Staphylococcus aureus

• Treatment: incision and drainage

+/- antibiotic

Source Undetermined

Hidradenitis Suppurativa

• Chronic, suppurative disease of

apocrine gland–bearing skin in

axillae and anogenital region

• Tender, red nodules not related to

hair follicles

• Acute lesions: incise and drain

• Refer for definitive care

Hidradenitis Suppurativa

Source Undetermined Source Undetermined

Cellulitis and Erysipelas

• Acute, spreading infections of

dermal and subcutaneous tissues

• Red, hot, tender skin, often at site

of bacterial entry

• Cause: group A beta-hemolytic

streptococci or Staphylococcus

aureus

Cellulitis and Erysipelas

Treatment: outpatient

• Dicloxacillin

• Macrolide: EES, azithromycin,

clarithromycin

• Amoxicillin-clavulanate

• Clindamycin

• TMP-SMZ

Cellulitis Erysipelas

RafaelLopez, Wikimedia Commons

Centers for Disease Control and Prevention,

Wikimedia Commons

Cellulitis

ColmAnderson, Wikimedia Commons

Cellulitis

• Facial cellulitis in child

consider Haemophilus influenzae

Source Undetermined

Impetigo and Ecthyma

• Superficial infection of epidermis

by Staphylococcus aureus and

Streptococcus pyogenes

• Extension into dermis

ecthyma, crusted erosions

or ulcers

Impetigo and Ecthyma

The Apologue, Flickr

Impetigo, Nonbullous

Transient superficial small vesicles or pustules rupture erosions golden-yellow crust (often seen, not pathognomonic)

Source Undetermined

Impetigo, Bullous

U.S. Department of Health and

Human Services, Wikimedia

Commons

Impetigo, Ecthyma

Source Undetermined

Impetigo – Treatment

• Topical mupirocin (Bactroban®)

highly effective against GAS and

Staph (including MRSA)

• Systemic antimicrobials: penicillin,

dicloxacillin, erythromycin,

minocycline (for MRSA)

Necrotizing Infections

• Group A streptococcal gangrene

• Cellulitis dusky blue bullae

or vesicles (yellow red-black

fluid) rapid spread along fascial

planes necrotic slough

• Treatment: early extensive

debridement, high-dose antibiotic

Necrotizing Infections

Source Undetermined Source Undetermined

Necrotizing Infections

Source Undetermined

Necrotizing Infections

Chaldor, Wikimedia Commons

Necrotizing Infections

Source Undetermined

Fungus

Carol Walker, geograph.org.uk

Candida

• Candidosis,

moniliasis

• Candida

albicans, others

– Intertrigo

– Interdigital

– Diaper

dermatitis

GrahamColm,

Wikimedia Commons

Candida – Intertrigo

Centers for Disease Control and Prevention,

Wikimedia Commons

Grook da Oger, Wikimedia Commons

Candida

Source Undetermined

Source Undetermined

Candida – Thrush

Source Undetermined Source Undetermined

Candida – Angular Stomatitis

Source Undetermined

Candida – Treatment

• Nystatin (Mycostatin®) tablets or

suspension: 100,000 units QID

• Clotrimazole (Lotrimin®)

• Fluconazole (Diflucan®)

• Itraconazole (Sporanox®)

• Ketoconazole (Nizoral®)

• Voriconazole (Vfend®)

Tinea

• Tinea pedis

• Tinea manuum

• Tinea cruris

• Tinea corporis

• Tinea facialis

• Tinea capitis

Epidermal dermatophytes

Centers for Disease Control and

Prevention, Wikimedia Commons

Tinea

Robertgascoign, Wikimedia Commons

James Heilman, MD, Wikimedia Commons

Ringworm

Centers for Disease Control and Prevention,

Wikimedia Commons

Granuloma Annulare

Kreuter, et al, Wikimedia Commons

Tinea – Diagnosis

• Potassium hydroxide microscopic

identification of septated, tubelike

structures and spores

Source Undetermined

Tinea – Treatment

• Skin: topical antifungals

• Hair and nails: oral preparations

– Griseofulvin: possible elevated

transaminases

“Gray patch” tinea capitis

Grook da Oger, Wikimedia

Commons

Tinea – Treatment

Kerion – do not I & D

Source Undetermined

Source Undetermined

Parasites

Pediculosis

• Head lice

• Body lice

• Pubic lice

Pediculosis, Wikimedia Commons

GerardM, Wikimedia Commons

KostaMumcuoglu, Wikimedia

Commons

Pediculosis – Treatment

• Permethrin cream 5% (Elimite®)

– OTC Permethrin 1% (Nix®)

• Pyrethrins (RID®)

• Lindane 1% shampoo (Kwell®)

– Seizures, aplastic anemia

• Malathion 0.5% in 78% isopropyl

alcohol (Ovide®)

Scabies

• Undiagnosed scabies = Seven-

Year Itch

• Mite: Sarcoptes scabiei

• Extremely itchy

• Diagnosis: burrows or scabies

prep (shave lesion, magnification)

Scabies

Source Undetermined

Scabies

Source Undetermined Source Undetermined

Scabies

• Permethrin 5% cream (Elimite®)

or lindane 1% lotion (Kwell®)

• Leave on overnight, rinse off in

morning

• Lindane easier to apply, less

expensive, but some resistance

• Lindane neurotoxic to infants

Botfly

Source Undetermined

Larva Migrans

WeisSagung, Wikimedia Commons

Larva Migrans

Grook da Oger, Wikimedia Commons

Bed Bugs

• Bite pattern:

linear group

of 3 or more

bites

• Referred to as

“breakfast,

lunch, dinner” pattern

Source Undetermined

Bed Bugs

Source Undetermined

Virus

Viral Infections

• Aphthous ulcer

• Erythema infectiosum

• Herpes simplex

• Herpes zoster

• Human papillomavirus (HPV)

• Molluscum contagiosum

• Warts

Aphthous Ulcer

• “Canker sore”

• Painful shallow

ulcer covered

with fibrin

• Adenopathy

common Maksim, Wikimedia Commons

Aphthous Ulcer

• Differential

– Behçet's

– Herpes

Source Undetermined

Aphthous Ulcer

• Treatment

– Symptomatic

– Topical

steroids and

analgesics

Pixie, Wikimedia Commons

Erythema Infectiosum

• “Fifth disease”

• Parvovirus

• Fever, coryza,

headache,

malaise: 2 days

before rash

• No treatment

Source Undetermined

ID / Rash Trivia

• 1st disease: rubeola (measles)

• 2nd disease: scarlet fever

• 3rd disease: rubella

• 4th disease: toxin-producing staphylococcus

• 5th disease: erythema infectiosum (parvovirus)

• 6th disease: roseola

Herpes Simplex

• Herpes simplex

• Cold sore

• Fever blister

• Herpes labialis

• Herpes

gladiatorum

• Scrum pox

• Whitlow

Tzanck preparation:

multi-nucleated giant

keratinocyte

Source Undetermined

Herpes Simplex

Centers for Disease Control and Prevention,

Wikimedia Commons

James Heilman, MD, Wikimedia

Commons

Herpes Simplex

• Antivirals more effective in

primary infection than recurrence

• Acyclovir (Zovirax®) 400 mg TID

or 200 mg 5 times daily

• Valacyclovir (Valtrex®) BID

• Famciclovir (Famvir®) TID

Herpes Zoster

• Varicella Zoster Virus (VZV)

• “Shingles”

• Prodrome: flu-like symptoms prior

to rash

• Depression very common

Herpes Zoster

Fisle, Wikimedia Commons Jonathan Trobe, M.D. - University of

Michigan Kellogg Eye Center, Wikimedia

Commons

Herpes Zoster

• Herpes zoster ophthalmicus: CNV

– Vision-threatening condition

– Hutchinson sign: lesions on tip of

nose nasociliary nerve

• Ramsay Hunt syndrome: CNVII

– Facial palsy resembling Bell palsy

– Vesicles in ear canal or on tympanic

membrane

Herpes Zoster

Gentgeen, Wikimedia Commons

James Heilman, MD, Wikimedia Commons

Human Papillomavirus

• Verruca vulgaris: common warts

• Verruca plantaris: plantar warts

• Verruca plana: flat warts

• Epidermodysplasia verruciformis

George Chernilevsky, Wikimedia

Commons

Enigma51, Wikimedia

Commons

Human Papillomavirus

Plantar warts Flat warts

Source Undetermined Lynes225, Wikimedia Commons

Human Papillomavirus

• Treatment: conservative, since

spontaneous remission is the rule

• Aggressive if symptomatic (e.g.

plantar, genital)

– Podofilox 0.5% (Condylox®) gel or

solution BID x 3 days no therapy

x 4 days repeat up to 4 cycles

– Cryotherapy

Molluscum Contagiosum

• Poxvirus umbilicated papules

• Normal host: cosmetic problem,

spontaneous remission

• Immunocompromised host:

require HAART (Highly Active

AntiRetroviral Therapy) to avoid

widespread dissemination

Molluscum Contagiosum

Salvadorjo, Wikimedia Commons Salvadorjo, Wikimedia Commons

Systemic

Rocky Mountain Spotted Fever

• Only in Western hemisphere

• Highest US incidence: Oklahoma,

North Carolina, Virginia, Maryland

• Rarely in Rocky Mountains

• Incubation: 3 to 14 days

• Prodrome: anorexia, irritability,

malaise, chills, fever

Rocky Mountain Spotted Fever

• History of tick bite ~60%

• Onset abrupt: fever (94%), severe

headache (86%), myalgias

especially back and legs (83%)

• First illness day: 14% have rash

• First 3 days: 49% have rash.

• 13% no rash (spotless RMSF)

Rocky Mountain Spotted Fever

• Early lesions: 2 to 6 mm, pink,

blanchable macules

• Evolve to deep red papules

• In 2 to 4 days: hemorrhagic, no

longer blanchable

• Rarely: eschar

Rocky Mountain Spotted Fever

RMSF macules RMSF papules

Centers for Disease Control and Prevention,

Wikimedia Commons Source Undetermined

Rocky Mountain Spotted Fever

Hemorrhagic lesions

Source Undetermined

Immune Thrombocytopenic Purpura

• production

– Drugs, aplastic

• destruction

– Drugs, TTP,

infection

• Sequestration

– Spleen

Stevenfruitsmaak, Wikimedia Commons

Immune Thrombocytopenic Purpura

• Common and

early site: palate

• Palatal petechiae

also seen in…

…strep throat

…mononucleosis

…rubella (measles) Centers for Disease Control and

Prevention, Wikimedia Commons

German Measles (Rubella)

• Young adults

• Droplet spread

• No prodrome

• 14 – 21 day

incubation

• Lymph nodes

+/- arthralgias Centers for Disease Control and

Prevention, Wikimedia Commons

Measles (Rubeola)

• Droplet spread

• 10 – 15 day

incubation

• URI, malaise,

photophobia

• Koplik spots

Source Undetermined

Chicken Pox (Varicella)

• 90% <10 years old

• Incubation 10 – 23

days

• Prodrome

uncommon

• Very itchy

• “Dewdrop on a

rose petal” Camiloaranzales, Wikimedia

Commons

Janeway Lesions

Source Undetermined

Osler’s Nodes

Roberto J. Galindo, Wikimedia Commons

Lyme Borreleosis = ECM

Optigan13, Wikimedia Commons

Lyme Borreleosis = ECM

Just Some Guy, Wikimedia Commons

Lyme Borreleosis = ECM

Source Undetermined

Syphilis

Herbert L. Fred, MD, Hendrik A. van Dijk, Wikimedia Commons

Eczema Herpeticum

• Eczema

herpeticum

• Low-grade

fever, “tight” skin

• Potentially

lethal

• Acyclovir Source Undetermined

Eczema Herpeticum

• Eczema

herpeticum

• Low-grade

fever, “tight” skin

• Potentially

lethal

• Acyclovir Source Undetermined

5. Maculopapular Lesions

5. Maculopapular Lesions

• Erythema multiforme

• Erythema nodosum

• Henoch-Schönlein purpura (HSP)

• Pityriasis rosea

• Purpura

• Urticaria

Erythema Multiforme

• Idiopathic: >50%

• Drugs:

sulfonamides,

phenytoin,

barbiturates,

penicillin, allopurinol

• Infection: HSV,

mycoplasma

James Heilman, MD,

Wikimedia Commons

Erythema Multiforme

• Malaise, fever,

myalgias, arthralgias

• Pruritus or burning can

occur before skin

lesions develop

• “Multiforme” lesions,

“target” most familiar

Erythema Multiforme

Source Undetermined

Erythema Multiforme

Nbrigham, Wikimedia Commons

Erythema Multiforme

• Systemic steroids: symptomatic

relief, but don’t change duration

or outcome

• Extensive disease or mucous

membranes involvement

hospitalize in ICU or burn unit

• Eye involvement: ophthalmology

Erythema Nodosum

• Inflammatory /

immunologic

reaction of

panniculus

• Painful nodules

on lower legs

• Multiple and

diverse causes James Heilman, MD, Wikimedia

Commons

Erythema Nodosum

• Treat underlying cause (e.g., stop

medicine)

• Symptomatic relief: bedrest,

elevation, NSAIDs

Henoch-Schönlein Purpura

• Hypersensitivity

vasculitis

• Primarily children

• ~75% recent URI

with group A

streptococcus

Madhero88, Wikimedia Commons

Henoch-Schönlein Purpura

• Palpable purpura

• Bowel angina:

abdominal pain

worse after meal

• Bowel infarct

• Renal failure

• Arthritis

Kauczuk, Wikimedia Commons

Henoch-Schönlein Purpura

• Self-limiting

• Admit for pain control, blood loss,

hydration, renal monitoring

• If well-appearing, outpatient

Pityriasis Rosea

• Acute eruption, self-limited course

• “Herald” plaque on trunk

• Generalized secondary eruption 1

or 2 weeks later

• “Christmas tree” pattern

• Spontaneous remission in 6

weeks without therapy

Pityriasis Rosea

Centers for Disease Control and Prevention, Wikimedia Commons

Pityriasis Versicolor

Source Undetermined Source Undetermined

Purpura Fulminans

• Fever, shock, multiorgan failure,

rapid development hemorrhagic

skin necrosis

• Vascular collapse + disseminated

intravascular coagulation (DIC) =

dermal vascular thrombosis

Purpura Fulminans

Source Undetermined

Source Undetermined

Purpura Fulminans

Source Undetermined

Purpura Fulminans

Source Undetermined

Purpura Fulminans

Source Undetermined

Purpura Fulminans

Source Undetermined

Urticaria and Angioedema

• Urticaria: wheals transient

edematous papules and plaques,

usually pruritic, due to edema of

papillary body

• Angioedema: larger edematous

area involving dermis and

subcutaneous tissue

Urticaria

Jmh649, Wikimedia Commons

Urticaria

Source Undetermined

Urticaria

• Urticaria = hives

• Cutaneous IgE-mediated

• Treatment

– Epinephrine + antihistamines +/- steroids

– H2 receptor blocker if severe

– Cool compresses: soothing

• Refer to allergy specialist

Angioedema

• Angioedema of tongue, lips, face

in 0.1 to 0.2% of patients taking

ACE-inhibitor

• Management supportive, special

attention to airway

• Usual allergic-reaction drugs not

proven beneficial

Angioedema

James Heilman, MD, Wikimedia

Commons

Angioedema

Source Undetermined

BruceBlaus, Wikimedia Commons

Angioedema

During attack

Source Undetermined

6. Papular/Nodular Lesions

6. Papular/Nodular Lesions

• Hemangioma /

Lymphangioma

• Lipoma

Zeimusu, Wikimedia Commons

Source Undetermined

Hemangioma

• Benign vascular proliferations

• Regress without therapy

Source Undetermined Source Undetermined

Lymphangioma

• Multiple small fluid-

filled vesicles

(“frog-spawn”)

• Present at birth or

appears in infancy

or even in childhood

• No spontaneous

regression

Source Undetermined

Lipoma

• Benign subcutaneous tumor

• Soft, rounded, or lobulated

• Movable against overlying skin

• May become large

• Composed of fat cells

Lipoma

Source Undetermined

6. Vesicular/Bullous Lesions

• Pemphigus vulgaris

• Staphylococcal scalded skin

syndrome

• Stevens Johnson syndrome

• Toxic epidermal necrolysis

Nikolsky’s Sign

• Epidermis

dislodged by

gentle finger

stroke near blister

• Pressure on

blister lateral

extension of

subdermal fluid

Source Undetermined

Pemphigus Vulgaris

• Autoimmune, often fatal

• Age 40 to 60

• Treatment: high-dose steroids

• Other immunosuppression:

azathioprine, cyclophosphamide,

plasmapharesis, methotrexate,

etc.

Pemphigus Vulgaris

Source Undetermined Source Undetermined

Pemphigus Vulgaris

Source Undetermined

S.S.S.S.

• Staphylococcal scalded skin

syndrome = Ritter’s disease

• Toxin-mediated epidermolysis

• Bullous impetigo with

generalization scarlatiniform

syndrome generalized scalded-

skin syndrome

S.S.S.S.

• Erythroderma exfoliation

desquamation recovery

• Tender erythema

• Positive Nikolsky’s (?)

• Spares mucous membranes

• Treatment: anti-staphylococcal

antibiotic, rehydration

S.S.S.S.

Source Undetermined

Source Undetermined

S.S.S.S.

Source Undetermined

Stevens-Johnson / T.E.N.

Stevens-Johnson syndrome = Erythema Multiforme Major

Toxic epidermal necrolysis = TEN = Lyell’s disease

• Drug-induced or idiopathic

• Skin tenderness and erythema

• Extensive cutaneous and mucosal exfoliation

Stevens-Johnson / T.E.N.

~80% drug related

• Sulfa drugs:

sulfadoxine,

sulfadiazine,

sulfasalazine,

cotrimazole

• Allopurinol

• Carbamazepine

• Hydantoins

• Phenylbutazone

• Piroxicam

• Chlormezanone

• Amithiozone

• Aminopenicillins

Stevens-Johnson / T.E.N.

• Prodrome: fever, flu-like

symptoms 1 to 3 days prior to

mucocutaneous lesions

• Mild to moderate skin tenderness

• Positive Nikolsky’s

• Conjunctival burning or itching

Stevens-Johnson / T.E.N.

Dr. Thomas Habif, Wikimedia

Commons

Stevens-Johnson / T.E.N.

Source Undetermined

Source Undetermined

Stevens-Johnson / T.E.N.

Source Undetermined

Stevens-Johnson / T.E.N.

Source Undetermined

Stevens-Johnson / T.E.N.

• High mortality: dehydration and

infection

• ICU vs. burn unit

Think of these

conditions as

“Acute Skin

Failure” and

treat accordingly

…and finally

Magnus Manske, Wikimedia Commons

…and finally

Source Undetermined

Delusional Parasitosis

1. Suffered from infestation for long

time

2. Seen by numerous physicians,

exterminators, parsitologists,

hygienists and entomologists

3. Consistently and fiercely reject

negative findings or any that

deviate from their perceptions

Delusional Parasitosis

4. “Matchbox sign"

– Containers of dust, lint, skin

scrapings, toilet paper, dried blood

or scabs, hair or other pieces of

human tissue

5. Self mutilation ranging from

scratches to deep ulceration

– From attempting to dig out bugs

Delusional Parasitosis

6. One or more family members

may share delusion

– Folie à deux / Folie à trois

7. Use of home remedies, distrust

of prescription drugs

8. Self exposure to often

dangerous levels of pesticides

Delusional Parasitosis

• Similar to “cocaine bugs”

– Patient feels parasites crawling

under his skin

• Also associated with high fever,

extreme alcohol withdrawal

– Often associated with visual

hallucinations of insects

Morgellon’s Syndrome

Source Undetermined Source Undetermined

Source Undetermined Source Undetermined

Morgellon’s Syndrome

1. “Filaments” in and on skin

2. Movement sensations, both

beneath and on skin

3. Skin lesions: spontaneously

appearing and self-generated

4. Musculoskeletal pain and

headaches

Morgellon’s Syndrome

5. Aerobic limitation: universal and

significant

6. Cognitive dysfunction: short-

term memory and attention

deficit

7. Emotional effects: loss of

boundary control