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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, …

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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  • 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. 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. Cutaneous Emergencies Joe Lex, MD, FAAEM, FACEP Department of Emergency Medicine Temple University School of Medicine Philadelphia, PA
  • 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. 1. Cancers of the Skin • Basal cell carcinoma • Kaposi’s sarcoma • Melanoma • Squamous cell carcinoma
  • 6. Basal Cell Carcinoma • Nodular • Ulcerating • Sclerosing (cicatricial) • Superficial, pigmented • Danger zones: midface, behind ears • Refer to dermatologist
  • 7. Basal Cell Carcinoma Nodular UlceratingPigmented Kuebi, Wikimedia Commons Kuebi, Wikimedia Commons National Institutes of Health, Wikimedia Commons
  • 8. Basal Cell Carcinoma James Heilman, MD, Wikimedia Commons National Institutes of Health, Wikimedia Commons
  • 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. 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. 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. 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. Melanoma • Early detection = early cure • Have low threshold, refer if suspected 0x6adb015, Wikimedia Commons
  • 14. Squamous Cell Carcinoma • Sunlight exposure • Age >55 • Men > women • White > Black National Cancer Institute, Wikimedia Commons
  • 15. Squamous Cell Carcinoma Treatment • Surgery • Radiotherapy • Cryotherapy • 5-fluorouracil • 90% cure rate if treated early Almazi, Wikimedia Commons
  • 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. 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. Stages of Ulcers III: Deep necrosis, crateriform ulceration, full-thickness skin loss; extends to, but not through, fascia Source Undetermined
  • 19. Stages of Ulcers IV: Full-thickness ulceration with extensive damage / necrosis to muscle, bone, support structures Essent, Wikimedia Commons
  • 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. 3. Dermatitis • Atopic • Contact • Eczema • Psoriasis • Sebaceous cysts • Seborrhea Thomas Habif, Wikimedia Commons
  • 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. Atopic Dermatitis: Treatment Fraught with problems Dependence on glucocorticoid s  atrophy, tachyphylaxis, hypertrichosis Eisfelder, Wikimedia Commons
  • 24. Atopic Dermatitis Care_SMC, Flickr Jambula, Wikimedia Commons
  • 25. Atopic Dermatitis Dyshidrotic eczema Nummular eczema Dbnll, Wikimedia Commons Source Undetermined
  • 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. Contact Dermatitis Alborz Fallah, Wikimedia Commons Nunyabb, Wikimedia Commons
  • 28. Contact Dermatitis Prevention • Wear protective clothing • If contact occurs, wash with water or weak neutralizing solution • Barrier creams
  • 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. Burow’s Solution • Aluminum acetate in water • Invented by ophthalmologist Karl August Burow (1809 – 1874)
  • 31. Topical Corticosteroids Class 4 Mild • Hydrocortisone 0.5-2.5%
  • 32. Topical Corticosteroids Class 3 Moderate (2-25 times as potent as hydrocortisone) • Aclometasone dipropionate • Clobetasone butyrate • Fluocinolone acetonide • Triamcinolone acetonide
  • 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. Topical Corticosteroids Class 1 Very potent (up to 600 times as potent as hydrocortisone) • Clobetasol propionate • Betamethasone dipropionate
  • 35. Psoriasis James Heilman, MD, Wikimedia Commons MediaJet, Wikimedia Commons
  • 36. Psoriasis Eisfelder, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  • 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. Psoriasis – Locations Source Undetermined
  • 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. 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. Sebaceous Cyst • Treatment: drainage if infected • Removal by surgeon Steven Fruitsmaak, Wikimedia Commons
  • 42. Seborrheic Dermatitis • “Cradle cap” in infants • Pityriasis sicca = dandruff Amras666, Wikimedia Commons Starfoxy, Wikimedia Commons
  • 43. Seborrheic Dermatitis • Yellowish-red or gray-white skin, • Often “greasy” or scaling macules and papules • Varying size: 5 to 20 mm
  • 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. Seborrheic Erythroderma • Seborrheic erythroderma + diarrhea + failure to thrive = Leiner’s disease • Associated with immunodeficiency disorders
  • 46. Seborrheic Erythroderma Nbrigham, Wikimedia Commons
  • 47. Seborrheic Erythroderma Kilbad, Wikimedia Commons
  • 48. 4. Infections • Bacterial • Fungal • Parasitic • Viral • Systemic
  • 49. Bacteria
  • 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. Abscess Abscess Furuncle Carbuncle Centers for Disease Control and Prevention, Wikimedia Commons Drvgaikwad, Wikimedia Commons El Pantera, Wikimedia Commons
  • 52. Abscess • Cause: Staphylococcus aureus • Treatment: incision and drainage +/- antibiotic Source Undetermined
  • 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. Hidradenitis Suppurativa Source Undetermined Source Undetermined
  • 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. Cellulitis and Erysipelas Treatment: outpatient • Dicloxacillin • Macrolide: EES, azithromycin, clarithromycin • Amoxicillin-clavulanate • Clindamycin • TMP-SMZ
  • 57. Cellulitis Erysipelas RafaelLopez, Wikimedia Commons Centers for Disease Control and Prevention, Wikimedia Commons
  • 58. Cellulitis ColmAnderson, Wikimedia Commons
  • 59. Cellulitis • Facial cellulitis in child  consider Haemophilus influenzae Source Undetermined
  • 60. Impetigo and Ecthyma • Superficial infection of epidermis by Staphylococcus aureus and Streptococcus pyogenes • Extension into dermis  ecthyma, crusted erosions or ulcers
  • 61. Impetigo and Ecthyma The Apologue, Flickr
  • 62. Impetigo, Nonbullous Transient superficial small vesicles or pustules rupture  erosions  golden-yellow crust (often seen, not pathognomonic) Source Undetermined
  • 63. Impetigo, Bullous U.S. Department of Health and Human Services, Wikimedia Commons
  • 64. Impetigo, Ecthyma Source Undetermined
  • 65. Impetigo – Treatment • Topical mupirocin (Bactroban®) highly effective against GAS and Staph (including MRSA) • Systemic antimicrobials: penicillin, dicloxacillin, erythromycin, minocycline (for MRSA)
  • 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. Necrotizing Infections Source Undetermined Source Undetermined
  • 68. Necrotizing Infections Source Undetermined
  • 69. Necrotizing Infections Chaldor, Wikimedia Commons
  • 70. Necrotizing Infections Source Undetermined
  • 71. Fungus Carol Walker, geograph.org.uk
  • 72. Candida • Candidosis, moniliasis • Candida albicans, others –Intertrigo –Interdigital –Diaper dermatitis GrahamColm, Wikimedia Commons
  • 73. Candida – Intertrigo Centers for Disease Control and Prevention, Wikimedia Commons Grook da Oger, Wikimedia Commons
  • 74. Candida Source Undetermined Source Undetermined
  • 75. Candida – Thrush Source Undetermined Source Undetermined
  • 76. Candida – Angular Stomatitis Source Undetermined
  • 77. Candida – Treatment • Nystatin (Mycostatin®) tablets or suspension: 100,000 units QID • Clotrimazole (Lotrimin®) • Fluconazole (Diflucan®) • Itraconazole (Sporanox®) • Ketoconazole (Nizoral®) • Voriconazole (Vfend®)
  • 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. Tinea Robertgascoign, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  • 80. Ringworm Centers for Disease Control and Prevention, Wikimedia Commons
  • 81. Granuloma Annulare Kreuter, et al, Wikimedia Commons
  • 82. Tinea – Diagnosis • Potassium hydroxide microscopic identification of septated, tubelike structures and spores Source Undetermined
  • 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. Tinea – Treatment Kerion – do not I & D Source Undetermined Source Undetermined
  • 85. Parasites
  • 86. Pediculosis • Head lice • Body lice • Pubic lice Pediculosis, Wikimedia Commons GerardM, Wikimedia Commons KostaMumcuoglu, Wikimedia Commons
  • 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. Scabies • Undiagnosed scabies = Seven- Year Itch • Mite: Sarcoptes scabiei • Extremely itchy • Diagnosis: burrows or scabies prep (shave lesion, magnification)
  • 89. Scabies Source Undetermined
  • 90. Scabies Source Undetermined Source Undetermined
  • 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. Botfly Source Undetermined
  • 93. Larva Migrans WeisSagung, Wikimedia Commons
  • 94. Larva Migrans Grook da Oger, Wikimedia Commons
  • 95. Bed Bugs • Bite pattern: linear group of 3 or more bites • Referred to as “breakfast, lunch, dinner” pattern Source Undetermined
  • 96. Bed Bugs Source Undetermined
  • 97. Virus
  • 98. Viral Infections • Aphthous ulcer • Erythema infectiosum • Herpes simplex • Herpes zoster • Human papillomavirus (HPV) • Molluscum contagiosum • Warts
  • 99. Aphthous Ulcer • “Canker sore” • Painful shallow ulcer covered with fibrin • Adenopathy common Maksim, Wikimedia Commons
  • 100. Aphthous Ulcer • Differential –Behçet's –Herpes Source Undetermined
  • 101. Aphthous Ulcer • Treatment –Symptomatic –Topical steroids and analgesics Pixie, Wikimedia Commons
  • 102. Erythema Infectiosum • “Fifth disease” • Parvovirus • Fever, coryza, headache, malaise: 2 days before rash • No treatment Source Undetermined
  • 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. Herpes Simplex • Herpes simplex • Cold sore • Fever blister • Herpes labialis • Herpes gladiatorum • Scrum pox • Whitlow Tzanck preparation: multi-nucleated giant keratinocyte Source Undetermined
  • 105. Herpes Simplex Centers for Disease Control and Prevention, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  • 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. Herpes Zoster • Varicella Zoster Virus (VZV) • “Shingles” • Prodrome: flu-like symptoms prior to rash • Depression very common
  • 108. Herpes Zoster Fisle, Wikimedia Commons Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center, Wikimedia Commons
  • 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. Herpes Zoster Gentgeen, Wikimedia Commons James Heilman, MD, Wikimedia Commons
  • 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. Human Papillomavirus Plantar warts Flat warts Source UndeterminedLynes225, Wikimedia Commons
  • 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. Molluscum Contagiosum • Poxvirus  umbilicated papules • Normal host: cosmetic problem, spontaneous remission • Immunocompromised host: require HAART (Highly Active AntiRetroviral Therapy) to avoid widespread dissemination
  • 115. Molluscum Contagiosum Salvadorjo, Wikimedia CommonsSalvadorjo, Wikimedia Commons
  • 116. Systemic
  • 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. 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. 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. Rocky Mountain Spotted Fever RMSF macules RMSF papules Centers for Disease Control and Prevention, Wikimedia Commons Source Undetermined
  • 121. Rocky Mountain Spotted Fever Hemorrhagic lesions Source Undetermined
  • 122. Immune Thrombocytopenic Purpura •  production – Drugs, aplastic •  destruction – Drugs, TTP, infection • Sequestration – Spleen Stevenfruitsmaak, Wikimedia Commons
  • 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. 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. Measles (Rubeola) • Droplet spread • 10 – 15 day incubation • URI, malaise, photophobia • Koplik spots Source Undetermined
  • 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. Janeway Lesions Source Undetermined
  • 128. Osler’s Nodes Roberto J. Galindo, Wikimedia Commons
  • 129. Lyme Borreleosis = ECM Optigan13, Wikimedia Commons
  • 130. Lyme Borreleosis = ECM Just Some Guy, Wikimedia Commons
  • 131. Lyme Borreleosis = ECM Source Undetermined
  • 132. Syphilis Herbert L. Fred, MD, Hendrik A. van Dijk, Wikimedia Commons
  • 133. Eczema Herpeticum • Eczema herpeticum • Low-grade fever, “tight” skin • Potentially lethal • Acyclovir Source Undetermined
  • 134. Eczema Herpeticum • Eczema herpeticum • Low-grade fever, “tight” skin • Potentially lethal • Acyclovir Source Undetermined
  • 135. 5. Maculopapular Lesions
  • 136. 5. Maculopapular Lesions • Erythema multiforme • Erythema nodosum • Henoch-Schönlein purpura (HSP) • Pityriasis rosea • Purpura • Urticaria
  • 137. Erythema Multiforme • Idiopathic: >50% • Drugs: sulfonamides, phenytoin, barbiturates, penicillin, allopurinol • Infection: HSV, mycoplasma James Heilman, MD, Wikimedia Commons
  • 138. Erythema Multiforme • Malaise, fever, myalgias, arthralgias • Pruritus or burning can occur before skin lesions develop • “Multiforme” lesions, “target” most familiar
  • 139. Erythema Multiforme Source Undetermined
  • 140. Erythema Multiforme Nbrigham, Wikimedia Commons
  • 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. Erythema Nodosum • Inflammatory / immunologic reaction of panniculus • Painful nodules on lower legs • Multiple and diverse causes James Heilman, MD, Wikimedia Commons
  • 143. Erythema Nodosum • Treat underlying cause (e.g., stop medicine) • Symptomatic relief: bedrest, elevation, NSAIDs
  • 144. Henoch-Schönlein Purpura • Hypersensitivity vasculitis • Primarily children • ~75% recent URI with group A streptococcus Madhero88, Wikimedia Commons
  • 145. Henoch-Schönlein Purpura • Palpable purpura • Bowel angina: abdominal pain worse after meal • Bowel infarct • Renal failure • Arthritis Kauczuk, Wikimedia Commons
  • 146. Henoch-Schönlein Purpura • Self-limiting • Admit for pain control, blood loss, hydration, renal monitoring • If well-appearing, outpatient
  • 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. Pityriasis Rosea Centers for Disease Control and Prevention, Wikimedia Commons
  • 149. Pityriasis Versicolor Source Undetermined Source Undetermined
  • 150. Purpura Fulminans • Fever, shock, multiorgan failure, rapid development hemorrhagic skin necrosis • Vascular collapse + disseminated intravascular coagulation (DIC) = dermal vascular thrombosis
  • 151. Purpura Fulminans Source Undetermined Source Undetermined
  • 152. Purpura Fulminans Source Undetermined
  • 153. Purpura Fulminans Source Undetermined
  • 154. Purpura Fulminans Source Undetermined
  • 155. Purpura Fulminans Source Undetermined
  • 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. Urticaria Jmh649, Wikimedia Commons
  • 158. Urticaria Source Undetermined
  • 159. Urticaria • Urticaria = hives • Cutaneous IgE-mediated • Treatment –Epinephrine + antihistamines +/- steroids –H2 receptor blocker if severe –Cool compresses: soothing • Refer to allergy specialist
  • 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. Angioedema James Heilman, MD, Wikimedia Commons
  • 162. Angioedema Source Undetermined BruceBlaus, Wikimedia Commons
  • 163. Angioedema During attack Source Undetermined
  • 164. 6. Papular/Nodular Lesions
  • 165. 6. Papular/Nodular Lesions • Hemangioma / Lymphangioma • Lipoma Zeimusu, Wikimedia Commons Source Undetermined
  • 166. Hemangioma • Benign vascular proliferations • Regress without therapy Source Undetermined Source Undetermined
  • 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. Lipoma • Benign subcutaneous tumor • Soft, rounded, or lobulated • Movable against overlying skin • May become large • Composed of fat cells
  • 169. Lipoma Source Undetermined
  • 170. 6. Vesicular/Bullous Lesions • Pemphigus vulgaris • Staphylococcal scalded skin syndrome • Stevens Johnson syndrome • Toxic epidermal necrolysis
  • 171. Nikolsky’s Sign • Epidermis dislodged by gentle finger stroke near blister • Pressure on blister  lateral extension of subdermal fluid Source Undetermined
  • 172. Pemphigus Vulgaris • Autoimmune, often fatal • Age 40 to 60 • Treatment: high-dose steroids • Other immunosuppression: azathioprine, cyclophosphamide, plasmapharesis, methotrexate, etc.
  • 173. Pemphigus Vulgaris Source Undetermined Source Undetermined
  • 174. Pemphigus Vulgaris Source Undetermined
  • 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. S.S.S.S. • Erythroderma  exfoliation  desquamation  recovery • Tender erythema • Positive Nikolsky’s (?) • Spares mucous membranes • Treatment: anti-staphylococcal antibiotic, rehydration
  • 177. S.S.S.S. Source Undetermined Source Undetermined
  • 178. S.S.S.S. Source Undetermined
  • 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. Stevens-Johnson / T.E.N. ~80% drug related • Sulfa drugs: sulfadoxine, sulfadiazine, sulfasalazine, cotrimazole • Allopurinol • Carbamazepine • Hydantoins • Phenylbutazone • Piroxicam • Chlormezanone • Amithiozone • Aminopenicillins
  • 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. Stevens-Johnson / T.E.N. Dr. Thomas Habif, Wikimedia Commons
  • 183. Stevens-Johnson / T.E.N. Source Undetermined Source Undetermined
  • 184. Stevens-Johnson / T.E.N. Source Undetermined
  • 185. Stevens-Johnson / T.E.N. Source Undetermined
  • 186. Stevens-Johnson / T.E.N. • High mortality: dehydration and infection • ICU vs. burn unit
  • 187. Think of these conditions as “Acute Skin Failure” and treat accordingly
  • 188. …and finally Magnus Manske, Wikimedia Commons
  • 189. …and finally Source Undetermined
  • 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. 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. 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. 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. Morgellon’s Syndrome Source Undetermined Source Undetermined Source Undetermined Source Undetermined
  • 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. 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