Project: Ghana Emergency Medicine Collaborative
Document Title: Cutaneous Emergencies
Author(s): Joe Lex, MD, FAAEM, FACEP...
Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy
Use + Share + Adapt
Make Your Own A...
Cutaneous
Emergencies
Joe Lex, MD, FAAEM, FACEP
Department of Emergency Medicine
Temple University School of Medicine
Phil...
Topics Covered
1. Cancers of the Skin
2. Decubitus Ulcer
3. Dermatitis
4. Infections / Systemic Illnesses
5. Maculopapular...
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, b...
Basal Cell Carcinoma
Nodular UlceratingPigmented
Kuebi,
Wikimedia Commons
Kuebi, Wikimedia Commons National Institutes of
...
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, ...
Kaposi’s Sarcoma
Classic KS: elderly
male Ashkenazi and
Mediterranean Jews
HIV-associated:
homosexual men
Kuebi, Wikimedia...
Melanoma RISK
Risk factors
• Moles: atypical or common
• Red hair and freckling
• Inability to tan
• Sunburn: severe sunbu...
Melanoma
Melanoma in situ
Superficial spreading
melanoma
Melanocytic nevus
Centers for Disease Control and
Prevention, Wik...
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 C...
Squamous Cell Carcinoma
Treatment
• Surgery
• Radiotherapy
• Cryotherapy
• 5-fluorouracil
• 90% cure rate if
treated early...
2. Decubitus Ulcer
• External compression of dermis
and hypodermis  ischemic
tissue damage and necrosis
• Risk factors: i...
Stages of Ulcers
I: Nonblanching erythema of intact
skin
II: Necrosis, superficial or partial-
thickness involving epiderm...
Stages of Ulcers
III: Deep necrosis, crateriform
ulceration, full-thickness skin loss;
extends to, but not through, fascia...
Stages of Ulcers
IV: Full-thickness ulceration with
extensive damage / necrosis to
muscle, bone, support structures
Essent...
Management
• Stage I and II: topical antibiotics
under moist sterile gauze
• Stage III and IV: surgical
debridement and re...
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 clinic...
Atopic Dermatitis: Treatment
Fraught with
problems
Dependence on
glucocorticoid
s  atrophy,
tachyphylaxis,
hypertrichosis...
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...
Contact Dermatitis
Alborz Fallah, Wikimedia Commons
Nunyabb, Wikimedia Commons
Contact Dermatitis
Prevention
• Wear protective clothing
• If contact occurs, wash with water
or weak neutralizing solutio...
Contact Dermatitis
• Gauze soaked in Burow’s solution
changed every 2 to 3 hours
• Class I topical corticosteroid
preparat...
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
• Clobetason...
Topical Corticosteroids
Class 2
• Potent (I50-100 times as potent as
hydrocortisone)
• Betamethasone valerate/dipropionate...
Topical Corticosteroids
Class 1
Very potent (up to 600 times as
potent as hydrocortisone)
• Clobetasol propionate
• Betame...
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
intertri...
Psoriasis – Locations
Source Undetermined
Psoriasis – Treatment
•Remove scales – soak in water
•Topical fluorinated glucocorticoid
ointment to wet skin
(betamethaso...
Sebaceous Cyst
•Synonyms: wen, infundibular cyst,
epidermal cyst
•Most common cutaneous cyst
•Origin: epidermis or hair fo...
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, Wikime...
Seborrheic Dermatitis
• Yellowish-red or gray-white skin,
• Often “greasy” or scaling
macules and papules
• Varying size: ...
Seborrheic Erythroderma
• Frightened, red, toxic patient
• Skin red, thick, scaly
• Many drugs, illnesses implicated
• Can...
Seborrheic Erythroderma
• Seborrheic erythroderma +
diarrhea + failure to thrive =
Leiner’s disease
• Associated with
immu...
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 absce...
Abscess
Abscess
Furuncle
Carbuncle
Centers for Disease
Control and Prevention,
Wikimedia Commons Drvgaikwad, Wikimedia
Com...
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
• ...
Hidradenitis Suppurativa
Source Undetermined Source Undetermined
Cellulitis and Erysipelas
• Acute, spreading infections of
dermal and subcutaneous tissues
• Red, hot, tender skin, often ...
Cellulitis and Erysipelas
Treatment: outpatient
• Dicloxacillin
• Macrolide: EES, azithromycin,
clarithromycin
• Amoxicill...
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 ...
Impetigo and Ecthyma
The Apologue, Flickr
Impetigo, Nonbullous
Transient
superficial small
vesicles or
pustules rupture
 erosions 
golden-yellow
crust (often
seen...
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 a...
Necrotizing Infections
• Group A streptococcal gangrene
• Cellulitis  dusky blue  bullae
or vesicles (yellow  red-black...
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,
Wikim...
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®)
• Flucona...
Tinea
• Tinea pedis
• Tinea manuum
• Tinea cruris
• Tinea corporis
• Tinea facialis
• Tinea capitis
Epidermal dermatophyte...
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 Unde...
Tinea – Treatment
• Skin: topical antifungals
• Hair and nails: oral preparations
–Griseofulvin: possible elevated
transam...
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,...
Pediculosis – Treatment
• Permethrin cream 5% (Elimite®)
–OTC Permethrin 1% (Nix®)
• Pyrethrins (RID®)
• Lindane 1% shampo...
Scabies
• Undiagnosed scabies = Seven-
Year Itch
• Mite: Sarcoptes scabiei
• Extremely itchy
• Diagnosis: burrows or scabi...
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
• Lindan...
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 Undete...
Bed Bugs
Source Undetermined
Virus
Viral Infections
• Aphthous ulcer
• Erythema infectiosum
• Herpes simplex
• Herpes zoster
• Human papillomavirus (HPV)
• M...
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
...
ID / Rash Trivia
• 1st disease: rubeola (measles)
• 2nd disease: scarlet fever
• 3rd disease: rubella
• 4th disease: toxin...
Herpes Simplex
• Herpes simplex
• Cold sore
• Fever blister
• Herpes labialis
• Herpes
gladiatorum
• Scrum pox
• Whitlow
T...
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 m...
Herpes Zoster
• Varicella Zoster Virus (VZV)
• “Shingles”
• Prodrome: flu-like symptoms prior
to rash
• Depression very co...
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  n...
Herpes Zoster
Gentgeen, Wikimedia Commons
James Heilman, MD, Wikimedia Commons
Human Papillomavirus
• Verruca vulgaris: common warts
• Verruca plantaris: plantar warts
• Verruca plana: flat warts
• Epi...
Human Papillomavirus
Plantar warts Flat warts
Source UndeterminedLynes225, Wikimedia Commons
Human Papillomavirus
• Treatment: conservative, since
spontaneous remission is the rule
• Aggressive if symptomatic (e.g.
...
Molluscum Contagiosum
• Poxvirus  umbilicated papules
• Normal host: cosmetic problem,
spontaneous remission
• Immunocomp...
Molluscum Contagiosum
Salvadorjo, Wikimedia CommonsSalvadorjo, Wikimedia Commons
Systemic
Rocky Mountain Spotted Fever
• Only in Western hemisphere
• Highest US incidence: Oklahoma,
North Carolina, Virginia, Mary...
Rocky Mountain Spotted Fever
• History of tick bite ~60%
• Onset abrupt: fever (94%), severe
headache (86%), myalgias
espe...
Rocky Mountain Spotted Fever
• Early lesions: 2 to 6 mm, pink,
blanchable macules
• Evolve to deep red papules
• In 2 to 4...
Rocky Mountain Spotted Fever
RMSF macules RMSF papules
Centers for Disease Control and Prevention,
Wikimedia Commons
Sourc...
Rocky Mountain Spotted Fever
Hemorrhagic lesions
Source Undetermined
Immune Thrombocytopenic Purpura
•  production
– Drugs, aplastic
•  destruction
– Drugs, TTP,
infection
• Sequestration
–...
Immune Thrombocytopenic Purpura
• Common and
early site: palate
• Palatal petechiae
also seen in…
…strep throat
…mononucle...
German Measles (Rubella)
• Young adults
• Droplet spread
• No prodrome
• 14 – 21 day
incubation
• Lymph nodes
+/- arthralg...
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
ros...
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
• Pu...
Erythema Multiforme
• Idiopathic: >50%
• Drugs:
sulfonamides,
phenytoin,
barbiturates,
penicillin, allopurinol
• Infection...
Erythema Multiforme
• Malaise, fever,
myalgias, arthralgias
• Pruritus or burning can
occur before skin
lesions develop
• ...
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 m...
Erythema Nodosum
• Inflammatory /
immunologic
reaction of
panniculus
• Painful nodules
on lower legs
• Multiple and
divers...
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
M...
Henoch-Schönlein Purpura
• Palpable purpura
• Bowel angina:
abdominal pain
worse after meal
• Bowel infarct
• Renal failur...
Henoch-Schönlein Purpura
• Self-limiting
• Admit for pain control, blood loss,
hydration, renal monitoring
• If well-appea...
Pityriasis Rosea
• Acute eruption, self-limited course
• “Herald” plaque on trunk
• Generalized secondary eruption 1
or 2 ...
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 + di...
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
...
Urticaria
Jmh649, Wikimedia Commons
Urticaria
Source Undetermined
Urticaria
• Urticaria = hives
• Cutaneous IgE-mediated
• Treatment
–Epinephrine + antihistamines +/-
steroids
–H2 receptor...
Angioedema
• Angioedema of tongue, lips, face
in 0.1 to 0.2% of patients taking
ACE-inhibitor
• Management supportive, spe...
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 ch...
Lipoma
• Benign subcutaneous tumor
• Soft, rounded, or lobulated
• Movable against overlying skin
• May become large
• Com...
Lipoma
Source Undetermined
6. Vesicular/Bullous Lesions
• Pemphigus vulgaris
• Staphylococcal scalded skin
syndrome
• Stevens Johnson syndrome
• Toxi...
Nikolsky’s Sign
• Epidermis
dislodged by
gentle finger
stroke near blister
• Pressure on
blister  lateral
extension of
su...
Pemphigus Vulgaris
• Autoimmune, often fatal
• Age 40 to 60
• Treatment: high-dose steroids
• Other immunosuppression:
aza...
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
...
S.S.S.S.
• Erythroderma  exfoliation 
desquamation  recovery
• Tender erythema
• Positive Nikolsky’s (?)
• Spares mucou...
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 d...
Stevens-Johnson / T.E.N.
~80% drug related
• Sulfa drugs:
sulfadoxine,
sulfadiazine,
sulfasalazine,
cotrimazole
• Allopuri...
Stevens-Johnson / T.E.N.
• Prodrome: fever, flu-like
symptoms 1 to 3 days prior to
mucocutaneous lesions
• Mild to moderat...
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, parsitolo...
Delusional Parasitosis
4. “Matchbox sign"
– Containers of dust, lint, skin
scrapings, toilet paper, dried blood
or scabs, ...
Delusional Parasitosis
6. One or more family members
may share delusion
– Folie à deux / Folie à trois
7. Use of home reme...
Delusional Parasitosis
• Similar to “cocaine bugs”
– Patient feels parasites crawling
under his skin
• Also associated wit...
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: spont...
Morgellon’s Syndrome
5. Aerobic limitation: universal and
significant
6. Cognitive dysfunction: short-
term memory and att...
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GEMC- Cutaneous Emergency- Resident Training

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This is a lecture by Joe Lex, MD from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC- Cutaneous Emergency- Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Cutaneous Emergencies Author(s): Joe Lex, MD, FAAEM, FACEP (Temple University) 2013 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  3. 3. Cutaneous Emergencies Joe Lex, MD, FAAEM, FACEP Department of Emergency Medicine Temple University School of Medicine Philadelphia, PA
  4. 4. 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
  5. 5. 1. Cancers of the Skin • Basal cell carcinoma • Kaposi’s sarcoma • Melanoma • Squamous cell carcinoma
  6. 6. Basal Cell Carcinoma • Nodular • Ulcerating • Sclerosing (cicatricial) • Superficial, pigmented • Danger zones: midface, behind ears • Refer to dermatologist
  7. 7. Basal Cell Carcinoma Nodular UlceratingPigmented Kuebi, Wikimedia Commons Kuebi, Wikimedia Commons National Institutes of Health, Wikimedia Commons
  8. 8. Basal Cell Carcinoma James Heilman, MD, Wikimedia Commons National Institutes of Health, Wikimedia Commons
  9. 9. 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
  10. 10. Kaposi’s Sarcoma Classic KS: elderly male Ashkenazi and Mediterranean Jews HIV-associated: homosexual men Kuebi, Wikimedia Commons National Institutes of Health, Wikimedia Commons
  11. 11. 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
  12. 12. 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
  13. 13. Melanoma • Early detection = early cure • Have low threshold, refer if suspected 0x6adb015, Wikimedia Commons
  14. 14. Squamous Cell Carcinoma • Sunlight exposure • Age >55 • Men > women • White > Black National Cancer Institute, Wikimedia Commons
  15. 15. Squamous Cell Carcinoma Treatment • Surgery • Radiotherapy • Cryotherapy • 5-fluorouracil • 90% cure rate if treated early Almazi, Wikimedia Commons
  16. 16. 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
  17. 17. 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
  18. 18. Stages of Ulcers III: Deep necrosis, crateriform ulceration, full-thickness skin loss; extends to, but not through, fascia Source Undetermined
  19. 19. Stages of Ulcers IV: Full-thickness ulceration with extensive damage / necrosis to muscle, bone, support structures Essent, Wikimedia Commons
  20. 20. 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.)
  21. 21. 3. Dermatitis • Atopic • Contact • Eczema • Psoriasis • Sebaceous cysts • Seborrhea Thomas Habif, Wikimedia Commons
  22. 22. Atopic Dermatitis = Eczema • Itching  rubbing and scratching  lichenification (hyperplasia) • Diagnosis: based on clinical findings • Serum IgE level usually elevated • Associated with allergic rhinitis, asthma
  23. 23. Atopic Dermatitis: Treatment Fraught with problems Dependence on glucocorticoid s  atrophy, tachyphylaxis, hypertrichosis Eisfelder, Wikimedia Commons
  24. 24. Atopic Dermatitis Care_SMC, Flickr Jambula, Wikimedia Commons
  25. 25. Atopic Dermatitis Dyshidrotic eczema Nummular eczema Dbnll, Wikimedia Commons Source Undetermined
  26. 26. 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
  27. 27. Contact Dermatitis Alborz Fallah, Wikimedia Commons Nunyabb, Wikimedia Commons
  28. 28. Contact Dermatitis Prevention • Wear protective clothing • If contact occurs, wash with water or weak neutralizing solution • Barrier creams
  29. 29. 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
  30. 30. Burow’s Solution • Aluminum acetate in water • Invented by ophthalmologist Karl August Burow (1809 – 1874)
  31. 31. Topical Corticosteroids Class 4 Mild • Hydrocortisone 0.5-2.5%
  32. 32. Topical Corticosteroids Class 3 Moderate (2-25 times as potent as hydrocortisone) • Aclometasone dipropionate • Clobetasone butyrate • Fluocinolone acetonide • Triamcinolone acetonide
  33. 33. 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
  34. 34. Topical Corticosteroids Class 1 Very potent (up to 600 times as potent as hydrocortisone) • Clobetasol propionate • Betamethasone dipropionate
  35. 35. Psoriasis James Heilman, MD, Wikimedia Commons MediaJet, Wikimedia Commons
  36. 36. Psoriasis Eisfelder, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  37. 37. 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
  38. 38. Psoriasis – Locations Source Undetermined
  39. 39. 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
  40. 40. 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
  41. 41. Sebaceous Cyst • Treatment: drainage if infected • Removal by surgeon Steven Fruitsmaak, Wikimedia Commons
  42. 42. Seborrheic Dermatitis • “Cradle cap” in infants • Pityriasis sicca = dandruff Amras666, Wikimedia Commons Starfoxy, Wikimedia Commons
  43. 43. Seborrheic Dermatitis • Yellowish-red or gray-white skin, • Often “greasy” or scaling macules and papules • Varying size: 5 to 20 mm
  44. 44. 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
  45. 45. Seborrheic Erythroderma • Seborrheic erythroderma + diarrhea + failure to thrive = Leiner’s disease • Associated with immunodeficiency disorders
  46. 46. Seborrheic Erythroderma Nbrigham, Wikimedia Commons
  47. 47. Seborrheic Erythroderma Kilbad, Wikimedia Commons
  48. 48. 4. Infections • Bacterial • Fungal • Parasitic • Viral • Systemic
  49. 49. Bacteria
  50. 50. 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
  51. 51. Abscess Abscess Furuncle Carbuncle Centers for Disease Control and Prevention, Wikimedia Commons Drvgaikwad, Wikimedia Commons El Pantera, Wikimedia Commons
  52. 52. Abscess • Cause: Staphylococcus aureus • Treatment: incision and drainage +/- antibiotic Source Undetermined
  53. 53. 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
  54. 54. Hidradenitis Suppurativa Source Undetermined Source Undetermined
  55. 55. 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
  56. 56. Cellulitis and Erysipelas Treatment: outpatient • Dicloxacillin • Macrolide: EES, azithromycin, clarithromycin • Amoxicillin-clavulanate • Clindamycin • TMP-SMZ
  57. 57. Cellulitis Erysipelas RafaelLopez, Wikimedia Commons Centers for Disease Control and Prevention, Wikimedia Commons
  58. 58. Cellulitis ColmAnderson, Wikimedia Commons
  59. 59. Cellulitis • Facial cellulitis in child  consider Haemophilus influenzae Source Undetermined
  60. 60. Impetigo and Ecthyma • Superficial infection of epidermis by Staphylococcus aureus and Streptococcus pyogenes • Extension into dermis  ecthyma, crusted erosions or ulcers
  61. 61. Impetigo and Ecthyma The Apologue, Flickr
  62. 62. Impetigo, Nonbullous Transient superficial small vesicles or pustules rupture  erosions  golden-yellow crust (often seen, not pathognomonic) Source Undetermined
  63. 63. Impetigo, Bullous U.S. Department of Health and Human Services, Wikimedia Commons
  64. 64. Impetigo, Ecthyma Source Undetermined
  65. 65. Impetigo – Treatment • Topical mupirocin (Bactroban®) highly effective against GAS and Staph (including MRSA) • Systemic antimicrobials: penicillin, dicloxacillin, erythromycin, minocycline (for MRSA)
  66. 66. 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
  67. 67. Necrotizing Infections Source Undetermined Source Undetermined
  68. 68. Necrotizing Infections Source Undetermined
  69. 69. Necrotizing Infections Chaldor, Wikimedia Commons
  70. 70. Necrotizing Infections Source Undetermined
  71. 71. Fungus Carol Walker, geograph.org.uk
  72. 72. Candida • Candidosis, moniliasis • Candida albicans, others –Intertrigo –Interdigital –Diaper dermatitis GrahamColm, Wikimedia Commons
  73. 73. Candida – Intertrigo Centers for Disease Control and Prevention, Wikimedia Commons Grook da Oger, Wikimedia Commons
  74. 74. Candida Source Undetermined Source Undetermined
  75. 75. Candida – Thrush Source Undetermined Source Undetermined
  76. 76. Candida – Angular Stomatitis Source Undetermined
  77. 77. Candida – Treatment • Nystatin (Mycostatin®) tablets or suspension: 100,000 units QID • Clotrimazole (Lotrimin®) • Fluconazole (Diflucan®) • Itraconazole (Sporanox®) • Ketoconazole (Nizoral®) • Voriconazole (Vfend®)
  78. 78. Tinea • Tinea pedis • Tinea manuum • Tinea cruris • Tinea corporis • Tinea facialis • Tinea capitis Epidermal dermatophytes Centers for Disease Control and Prevention, Wikimedia Commons
  79. 79. Tinea Robertgascoign, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  80. 80. Ringworm Centers for Disease Control and Prevention, Wikimedia Commons
  81. 81. Granuloma Annulare Kreuter, et al, Wikimedia Commons
  82. 82. Tinea – Diagnosis • Potassium hydroxide microscopic identification of septated, tubelike structures and spores Source Undetermined
  83. 83. Tinea – Treatment • Skin: topical antifungals • Hair and nails: oral preparations –Griseofulvin: possible elevated transaminases “Gray patch” tinea capitis Grook da Oger, Wikimedia Commons
  84. 84. Tinea – Treatment Kerion – do not I & D Source Undetermined Source Undetermined
  85. 85. Parasites
  86. 86. Pediculosis • Head lice • Body lice • Pubic lice Pediculosis, Wikimedia Commons GerardM, Wikimedia Commons KostaMumcuoglu, Wikimedia Commons
  87. 87. 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®)
  88. 88. Scabies • Undiagnosed scabies = Seven- Year Itch • Mite: Sarcoptes scabiei • Extremely itchy • Diagnosis: burrows or scabies prep (shave lesion, magnification)
  89. 89. Scabies Source Undetermined
  90. 90. Scabies Source Undetermined Source Undetermined
  91. 91. 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
  92. 92. Botfly Source Undetermined
  93. 93. Larva Migrans WeisSagung, Wikimedia Commons
  94. 94. Larva Migrans Grook da Oger, Wikimedia Commons
  95. 95. Bed Bugs • Bite pattern: linear group of 3 or more bites • Referred to as “breakfast, lunch, dinner” pattern Source Undetermined
  96. 96. Bed Bugs Source Undetermined
  97. 97. Virus
  98. 98. Viral Infections • Aphthous ulcer • Erythema infectiosum • Herpes simplex • Herpes zoster • Human papillomavirus (HPV) • Molluscum contagiosum • Warts
  99. 99. Aphthous Ulcer • “Canker sore” • Painful shallow ulcer covered with fibrin • Adenopathy common Maksim, Wikimedia Commons
  100. 100. Aphthous Ulcer • Differential –Behçet's –Herpes Source Undetermined
  101. 101. Aphthous Ulcer • Treatment –Symptomatic –Topical steroids and analgesics Pixie, Wikimedia Commons
  102. 102. Erythema Infectiosum • “Fifth disease” • Parvovirus • Fever, coryza, headache, malaise: 2 days before rash • No treatment Source Undetermined
  103. 103. 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
  104. 104. Herpes Simplex • Herpes simplex • Cold sore • Fever blister • Herpes labialis • Herpes gladiatorum • Scrum pox • Whitlow Tzanck preparation: multi-nucleated giant keratinocyte Source Undetermined
  105. 105. Herpes Simplex Centers for Disease Control and Prevention, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  106. 106. 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
  107. 107. Herpes Zoster • Varicella Zoster Virus (VZV) • “Shingles” • Prodrome: flu-like symptoms prior to rash • Depression very common
  108. 108. Herpes Zoster Fisle, Wikimedia Commons Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center, Wikimedia Commons
  109. 109. 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
  110. 110. Herpes Zoster Gentgeen, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  111. 111. Human Papillomavirus • Verruca vulgaris: common warts • Verruca plantaris: plantar warts • Verruca plana: flat warts • Epidermodysplasia verruciformis George Chernilevsky, Wikimedia Commons Enigma51, Wikimedia Commons
  112. 112. Human Papillomavirus Plantar warts Flat warts Source UndeterminedLynes225, Wikimedia Commons
  113. 113. 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
  114. 114. Molluscum Contagiosum • Poxvirus  umbilicated papules • Normal host: cosmetic problem, spontaneous remission • Immunocompromised host: require HAART (Highly Active AntiRetroviral Therapy) to avoid widespread dissemination
  115. 115. Molluscum Contagiosum Salvadorjo, Wikimedia CommonsSalvadorjo, Wikimedia Commons
  116. 116. Systemic
  117. 117. 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
  118. 118. 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)
  119. 119. 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
  120. 120. Rocky Mountain Spotted Fever RMSF macules RMSF papules Centers for Disease Control and Prevention, Wikimedia Commons Source Undetermined
  121. 121. Rocky Mountain Spotted Fever Hemorrhagic lesions Source Undetermined
  122. 122. Immune Thrombocytopenic Purpura •  production – Drugs, aplastic •  destruction – Drugs, TTP, infection • Sequestration – Spleen Stevenfruitsmaak, Wikimedia Commons
  123. 123. 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
  124. 124. German Measles (Rubella) • Young adults • Droplet spread • No prodrome • 14 – 21 day incubation • Lymph nodes +/- arthralgias Centers for Disease Control and Prevention, Wikimedia Commons
  125. 125. Measles (Rubeola) • Droplet spread • 10 – 15 day incubation • URI, malaise, photophobia • Koplik spots Source Undetermined
  126. 126. Chicken Pox (Varicella) • 90% <10 years old • Incubation 10 – 23 days • Prodrome uncommon • Very itchy • “Dewdrop on a rose petal” Camiloaranzales, Wikimedia Commons
  127. 127. Janeway Lesions Source Undetermined
  128. 128. Osler’s Nodes Roberto J. Galindo, Wikimedia Commons
  129. 129. Lyme Borreleosis = ECM Optigan13, Wikimedia Commons
  130. 130. Lyme Borreleosis = ECM Just Some Guy, Wikimedia Commons
  131. 131. Lyme Borreleosis = ECM Source Undetermined
  132. 132. Syphilis Herbert L. Fred, MD, Hendrik A. van Dijk, Wikimedia Commons
  133. 133. Eczema Herpeticum • Eczema herpeticum • Low-grade fever, “tight” skin • Potentially lethal • Acyclovir Source Undetermined
  134. 134. Eczema Herpeticum • Eczema herpeticum • Low-grade fever, “tight” skin • Potentially lethal • Acyclovir Source Undetermined
  135. 135. 5. Maculopapular Lesions
  136. 136. 5. Maculopapular Lesions • Erythema multiforme • Erythema nodosum • Henoch-Schönlein purpura (HSP) • Pityriasis rosea • Purpura • Urticaria
  137. 137. Erythema Multiforme • Idiopathic: >50% • Drugs: sulfonamides, phenytoin, barbiturates, penicillin, allopurinol • Infection: HSV, mycoplasma James Heilman, MD, Wikimedia Commons
  138. 138. Erythema Multiforme • Malaise, fever, myalgias, arthralgias • Pruritus or burning can occur before skin lesions develop • “Multiforme” lesions, “target” most familiar
  139. 139. Erythema Multiforme Source Undetermined
  140. 140. Erythema Multiforme Nbrigham, Wikimedia Commons
  141. 141. 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
  142. 142. Erythema Nodosum • Inflammatory / immunologic reaction of panniculus • Painful nodules on lower legs • Multiple and diverse causes James Heilman, MD, Wikimedia Commons
  143. 143. Erythema Nodosum • Treat underlying cause (e.g., stop medicine) • Symptomatic relief: bedrest, elevation, NSAIDs
  144. 144. Henoch-Schönlein Purpura • Hypersensitivity vasculitis • Primarily children • ~75% recent URI with group A streptococcus Madhero88, Wikimedia Commons
  145. 145. Henoch-Schönlein Purpura • Palpable purpura • Bowel angina: abdominal pain worse after meal • Bowel infarct • Renal failure • Arthritis Kauczuk, Wikimedia Commons
  146. 146. Henoch-Schönlein Purpura • Self-limiting • Admit for pain control, blood loss, hydration, renal monitoring • If well-appearing, outpatient
  147. 147. 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
  148. 148. Pityriasis Rosea Centers for Disease Control and Prevention, Wikimedia Commons
  149. 149. Pityriasis Versicolor Source Undetermined Source Undetermined
  150. 150. Purpura Fulminans • Fever, shock, multiorgan failure, rapid development hemorrhagic skin necrosis • Vascular collapse + disseminated intravascular coagulation (DIC) = dermal vascular thrombosis
  151. 151. Purpura Fulminans Source Undetermined Source Undetermined
  152. 152. Purpura Fulminans Source Undetermined
  153. 153. Purpura Fulminans Source Undetermined
  154. 154. Purpura Fulminans Source Undetermined
  155. 155. Purpura Fulminans Source Undetermined
  156. 156. 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
  157. 157. Urticaria Jmh649, Wikimedia Commons
  158. 158. Urticaria Source Undetermined
  159. 159. Urticaria • Urticaria = hives • Cutaneous IgE-mediated • Treatment –Epinephrine + antihistamines +/- steroids –H2 receptor blocker if severe –Cool compresses: soothing • Refer to allergy specialist
  160. 160. 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
  161. 161. Angioedema James Heilman, MD, Wikimedia Commons
  162. 162. Angioedema Source Undetermined BruceBlaus, Wikimedia Commons
  163. 163. Angioedema During attack Source Undetermined
  164. 164. 6. Papular/Nodular Lesions
  165. 165. 6. Papular/Nodular Lesions • Hemangioma / Lymphangioma • Lipoma Zeimusu, Wikimedia Commons Source Undetermined
  166. 166. Hemangioma • Benign vascular proliferations • Regress without therapy Source Undetermined Source Undetermined
  167. 167. Lymphangioma • Multiple small fluid- filled vesicles (“frog-spawn”) • Present at birth or appears in infancy or even in childhood • No spontaneous regression Source Undetermined
  168. 168. Lipoma • Benign subcutaneous tumor • Soft, rounded, or lobulated • Movable against overlying skin • May become large • Composed of fat cells
  169. 169. Lipoma Source Undetermined
  170. 170. 6. Vesicular/Bullous Lesions • Pemphigus vulgaris • Staphylococcal scalded skin syndrome • Stevens Johnson syndrome • Toxic epidermal necrolysis
  171. 171. Nikolsky’s Sign • Epidermis dislodged by gentle finger stroke near blister • Pressure on blister  lateral extension of subdermal fluid Source Undetermined
  172. 172. Pemphigus Vulgaris • Autoimmune, often fatal • Age 40 to 60 • Treatment: high-dose steroids • Other immunosuppression: azathioprine, cyclophosphamide, plasmapharesis, methotrexate, etc.
  173. 173. Pemphigus Vulgaris Source Undetermined Source Undetermined
  174. 174. Pemphigus Vulgaris Source Undetermined
  175. 175. S.S.S.S. • Staphylococcal scalded skin syndrome = Ritter’s disease • Toxin-mediated epidermolysis • Bullous impetigo with generalization  scarlatiniform syndrome  generalized scalded- skin syndrome
  176. 176. S.S.S.S. • Erythroderma  exfoliation  desquamation  recovery • Tender erythema • Positive Nikolsky’s (?) • Spares mucous membranes • Treatment: anti-staphylococcal antibiotic, rehydration
  177. 177. S.S.S.S. Source Undetermined Source Undetermined
  178. 178. S.S.S.S. Source Undetermined
  179. 179. 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
  180. 180. Stevens-Johnson / T.E.N. ~80% drug related • Sulfa drugs: sulfadoxine, sulfadiazine, sulfasalazine, cotrimazole • Allopurinol • Carbamazepine • Hydantoins • Phenylbutazone • Piroxicam • Chlormezanone • Amithiozone • Aminopenicillins
  181. 181. 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
  182. 182. Stevens-Johnson / T.E.N. Dr. Thomas Habif, Wikimedia Commons
  183. 183. Stevens-Johnson / T.E.N. Source Undetermined Source Undetermined
  184. 184. Stevens-Johnson / T.E.N. Source Undetermined
  185. 185. Stevens-Johnson / T.E.N. Source Undetermined
  186. 186. Stevens-Johnson / T.E.N. • High mortality: dehydration and infection • ICU vs. burn unit
  187. 187. Think of these conditions as “Acute Skin Failure” and treat accordingly
  188. 188. …and finally Magnus Manske, Wikimedia Commons
  189. 189. …and finally Source Undetermined
  190. 190. 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
  191. 191. 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
  192. 192. 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
  193. 193. 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
  194. 194. Morgellon’s Syndrome Source Undetermined Source Undetermined Source Undetermined Source Undetermined
  195. 195. 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
  196. 196. 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
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