approach to the unknown rash


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approach to the unknown rash

  1. 1. (+)Heather M. Murphy-Lavoie, MD Assistant Residency Director and Assistant Professor, Louisiana State University, Section of Emergency Medicine, New Orleans, Louisiana Approach to the Unknown RashHow do you approach the unknown rash? Knowing how toidentify and classify a skin lesion is an essential componentin developing a systematic and organized approach to anylesion. The speaker will present guidelines for the properdiagnosis of various dermatologic conditions using casepresentations to illustrate these concepts.• Describe dermatologic conditions by the type of lesion and the distribution area.• Develop a systematic approach to skin lesions.• Identify dermatologic conditions requiring emergency interventions.• Discuss appropriate differential diagnoses, treatments, and dispositions for patients with dermatologic complaints.TH-267Thursday, October 8, 20099:00 AM - 9:50 AMBoston Convention & Exhibition Center(+)No significant financial relationships to disclose
  2. 2. Approach To The Unknown RashBy Heather Murphy-Lavoie, MD I. Introduction a. There are more than 3000 dermatologic diagnoses b. Approximately 5% of ED visits are for a dermatologic complaint c. Objectives i. Describe dermatologic conditions by the type of lesion and the distribution area. ii. Develop a systematic approach to skin lesions. iii. Identify dermatologic conditions requiring emergency interventions. iv. Discuss appropriate differential diagnoses, treatments, and dispositions for patients with dermatologic complaints. II. History a. Age b. Duration c. Associated symptoms i. Itching ii. Fever iii. Pain d. Travel/Location e. Sick Contacts f. Past Medical History g. Medications – new h. Menstrual history i. Sexual history j. Vaccinations III. Physical Exam a. Vital signs i. Hypotension ii. Tachycardia iii. Fever iv. Mental Status Change b. Distribution
  3. 3. i. Central ii. Peripheral iii. Flexural surfaces iv. Intertriginous v. Dermatomal vi. Neurotic Excoriation vii. Extensor surfaces viii. Mucosal surface involvement c. Appearance i. Scaly/Moist ii. Color iii. Hyper/hypopigmented iv. Honey Crusted v. Umbilicated vi. Blanching vii. Palpable d. Wood’s Lamp i. Microsporum Tinea Capitus (green) ii. Erythrasma (coral red)IV. Algorithms a. Erythematous b. Maculopapular c. Petechiae/Purpura d. Vesiculo-bullous
  4. 4. ALGORITHM ERYTHEMATOUS RASH ERYTHEMATOUS RASH NIKOLSKY’S SIGN YES NO FEBRILE AFEBRILEStaph SSS TEN (adult) (child) FEBRILE AFEBRILETEN (adult) Toxic Shock (mucous Anaphylaxis membranes) Scombroid Kawasaki Syndrome (child, Alcohol Flush hands) Scarlet Fever (sand paper)Differential Diagnosis:Staph SSS = Staphylococcal Scaled Skin Syndrome - children, IV Penicillinase-resistant penicillin, IV Fluids, local wound careToxic Shock Synd= Toxic Shock Syndrome - look for source (eg. a tampon) andremove, IV Penicillinase-resistant penicillin, IV fluids, supportive care, hospitaladmissionKawasaki= Kawasaki’s Disease - children, mucous membranes, lymph nodes, handsand feet, elevated platelet count, treat with immune globulin, aspirinScarlet Fever - children, sandpaper-like rash, strawberry tongue, tonsillitis, treatwith penicillinTEN = Toxic Epidermal Necrolysis - adults, drug reaction- often sulfa, treatmentremove offending source, wound care, IV fluids, admit to burn centerAnaphylaxis - treat with steroids, antihistamines, H2 blockers and possiblyepinephrine for the most severe casesScombroid - history of eating fish recently, treat with antihistamines, usually self-limitedAlcohol flushing - history of alcohol ingestion, prior episodes, no itching, normalvitals, no fever, self-limited
  5. 5. ALGORITHM MACULOPAPULAR RASH MACULOPAPULAR RASH CENTRAL PERIPHERAL DISTRIBUTION DISTRIBUTION FEVER / ILL? FEVER / ILL? YES NO YES NO Viral Exanthem Drug Reaction TARGET LESION Lyme Disease Pityriasis LESIONS DISTRIBUTION(erythema migrans) (herald patch) YES NO FLEXO EXTENSOR Stevens-Johnson Meningococcemia Scabies Psoriasis TEN Rocky Mountain Eczema Erythema Multiforme Spotted Fever Syphilis Lyme Disease (erythema migrans) Viral Exanthem - Measles, Rubella, Fifths, etc, self-limiting, supportive care Lyme Disease - Tick bite, erythema migrans, arthralgias, headache, doxycycline Pityriasis - scaly lesions, herald patch, Christmas tree pattern, treatment includes: UV light, moisturizing lotion, Aveeno, antihistamines Drug Reaction - remove the drug, symptomatic treatment Stevens-Johnson Syndrome - mucosal involvement, remove drug/treat illness, supportive therapy, hospital admission EM = Erythema Multiforme - treat illness/stop drug, supportive care, topical steroids and outpatient follow-up for minor cases Meningiococcemia - ill appearing, mental status change, lumbar puncture, ceftriaxone, isolation, treat close contacts, hospital admission RMSF = Rocky Mountain Spotted Fever - tick bite, endemic area, headache, arthralgias, doxycycline Scabies - excoriated burrows, itches worse at night, permethrin
  6. 6. ALGORITHM VESICULO-BULLOUS RASH VESICULO-BULLOUS RASH FEBRILE AFEBRILE DIFFUSE LOCALIZED DIFFUSE LOCALIZED DISTRIBUTION DISTRIBUTION DISTRIBUTION DISTRIBUTION Varicella / Chicken Pox Necrotizing Fasciitis Bullous Pemphigus Contact Dermatitis Small Pox Hand Foot Mouth Pemphigus Vulgaris Herpes Zoster Disseminated GC Dyshidrotic EczemaPurpurpa Fulminans / DIC BurnsDifferential Diagnosis:Varicella/Chicken Pox – excoriated lesions in multiple stages, starts centrally,isolate, rare hospitalization, symptomatic treatment, antipyretics (not Aspirin)Small Pox – all lesions in one stage, more peripheral distribution, isolate, notifyoffice of public health and CDCDisseminated GC= Gonococcemia - purple vesicles, sparce, peripheral, associatedurethritis/cervicitis/septic arthritis, ceftriaxonePurpura Fulminans/DIC = Disseminated Intervascular Coagulation - treat theunderlying cause, fresh frozen plasma, platelet transfusions, ICU admissionNecrotizing Fasciitis – surgical emergency, debridement, IV anti-streptococcalbroad spectrum antibiotic, hyperbaric oxygen therapyHand, Foot and Mouth Disease – children, vesicles on palms, soles and in mouth,self-limited, symptomatic treatmentBullous Pemphigus -chronic autoimmune blistering, elderly, usually benign,steroidsPemphigus Vulgaris – mucous membrane involvement, much higher mortality thanBullous Pemphigus, steroids, admissionZoster – acyclovir, analgesia, steroidsContact Dermatits - symptomatic treatment, long taper of steroids for severe casesDyshidrotic Eczema - topical steroids
  7. 7. ALGORITHM PETECHIAL/PURPURIC RASH PETECHIAL / PURPURIC RASH FEBRILE & TOXIC AFEBRILE & NON-TOXIC PALPABLE NOT PALPABLE PALPABLE NOT PALPABLE Meningococcemia Purpurpa Fulminans / DIC Cutaneous ITP Disseminated GC TTP Vasculitis Endocarditis RMSF HSPDifferential Diagnosis:Meningiococcemia - ill appearing, mental status change, lumbar puncture,ceftriaxone, isolation, treat close contacts, admissionDisseminated GC= Gonococcemia - purple vesicles, sparce, peripheral, associatedurethritis/cervicitis/septic arthritis, ceftriaxoneEndocarditis – new murmur, vegetations on valves, positive blood cultures, IVvancomycin and gentamicin pending culture resultsRMSF = Rocky Mountain Spotted Fever - tick bite, endemic area, headache,arthralgias, doxycyclineHSP = Henoch Schonlein Purpura – children, associated arthralgias, hematuria andGI symptoms, supportive therapyTTP= Thrombotic Thrombocytopenic Purpura - low platelet count, ICU admission,treat underlying cause, plasmapheresis, splenectomy, selective transfusion, NOplateletsVasculitis – treat the underlying process if possible, may require steroids and/orother anti-inflammatory agentsITP – Idiopathic Thrombocytopenic Purpura - transfuse platelets if bleeding or lessthan 5000/mm3 – 10000/mm3, emergent Hematology consultation
  8. 8. V. Summary With the type of lesion, distribution, and whether or not the patient is ill, one can narrow the diagnosis down to one or two diagnoses in many cases. THE VERY YOUNG THE VERY OLD Staph SSS, Kawasaki’s disease, pemphigus vulgaris, sepsis, TEN, SJS viral exanthem, meningococcemia TOXIC IMMUNOSUPPRESSED necrotizing fasciitis, meningococcemia, necrotizing fasciitis, meningococcemia, TEN, SJS, TSS, RMSF, TTP endocarditis, herpes zoster, sepsis DIFFUSE ERYTHEMA PETECHIAE / PURPURA staph SSS, staph TSS, strep TSS, meningococcemia, endocarditis, TTP, ITP TEN vasculitis, DIC, RMSF MUCOSAL LESIONS HYPOTENSION EM major, TEN, SJS, meningococcemia, TTP, pemphigus vulgaris TSS, RMSF, TEN, SJS TEN = toxic epidermal necrolysis; SJS = Stevens-Johnson Syndrome, TSS = toxic shock syndrome, RMSF = Rocky Mountain spotted fever, SSS = scalded skin syndrome, DIC = disseminated intravascular coagulopathy, EM = erythema multiforme, TTP= thrombotic thrombocytopenic purpura VI. AppendixLESION single small RASH more extensive diseased area involvementMACULE circumscribed area of change PUSTULE circumscribed area without elevation containing purulencePAPULE solid raised lesion < 0.5 cm VESICLE circumscribed fluid-filled area < 0.5 cmNODULE solid raised lesion > 0.5 cm BULLA circumscribed fluid-filled area > 0.5 cmPLAQUE circumscribed elevated PETECHIAE small red / brown macules confluence of papules > 0.5 cm < 0.5 cm that do not blanche
  9. 9. a. More Definitions i. Erosion- loss of epidermis only ii. Ulcer- extends below epidermis to involve dermis and subcutaneous tissue iii. Fissure- linear split in skin iv. Excoriation- linear superficial erosions or crusts due to scratching v. Wheal- soft smooth, raised papule, light pink (eg. Urticaria) vi. Burrow- linear “S” shaped papule 3-5mm long vii. Purpura- > 0.5cm does not blanch with pressure, red/purple maculesREFERENCES:1. Adams JG et al. Emergency Medicine. Saunders Elsevier, Philadelphia, 2008.2. Ashton, R. and B. Leppard. Differential Diagnosis in Dermatology. 3rd Ed. Radcliffe Publishing, United Kingdom 2005.3. Baroni, A., et al. Vesicular and Bullous disorders: Pemphigus. Dermatol Clin 25 (2007) 597 – 603.4. Bassam Z, et al. Pemphigus Vulgaris. on web at Braunwald, et. al. Harrison¹s Principles of Internal Medicine. 15th Ed. McGraw Hill, New York, 2001.6. Buckingham SC, et al. Clinical and Laboratory Features, Hospital Course, and Outcome of Rocky Mountain Spotted Fever in Children. J Pediatrics 2007; 150: 180-4.7. Carr, D., Houshmand, E., and M. Heffernan. Approach to the Acute, Generalized, Blistering Patient. Semin Cutan Med Surg 26: 139 – 146, 2007.8. Chan, L. Bullous Pemphigoid. Emedicine (2008). Chapman AS, et al. Rocky Mountain Spotted Fever in the United States, 1997-2002. Ann. N.Y. Acad. Sci. 2006; 1078: 154-155.10. Chia, F., and K.P. Leong. Severe Cutaneous Adverse Reactions to Drugs. Curr Opin Allergy Clin Immunol 7: 304 – 309, 2007.11. Fleischer, A., et. al. Emergency Dermatology: A Rapid Guide to Treatment. McGraw Hill, New York, 2002.12. Ghatan, H. Dermatologic Differential Diagnosis and Pearls. 2nd Ed. Parthenon Publishing, New York, 2002.13. Ghislain, P.D., and J.C. Roujeau. Treatment of Severe Drug Reactions: Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis and Hypersensitivity Syndrome. Derm Online J, vol 8 (1): 5 pp 1 – 15.14. Harwood-Nuss, A., et. al. The Clinical Practice of Emergency Medicine. 2nd Ed. Lippincott-Raven, Philadelphia, 1996.15. Hom, C. Vasculitis and Thrombophlebitis. Emedicine (2008). Mukasa, Y., and N. Craven. Management of Toxic Epidermal Necrolysis and Related Syndromes. Postgrad. Med. J. 2008: 84: 60 – 65.
  10. 10. 17. Nguyen, T and J Freedman. Dermatologic Emergencies: Diagnosing and Managing Life-Threatening Rashes. Emergency Medicine Practice, Volume 4 (9) September 2002.18. Sauer, G., and J. Hall. Manual of Skin Diseases. 7th Ed. Lippincott-Raven, Philadelphia, 1996.19. Slaven, EM, et al. Infectious Diseases: Emergency Department Diagnosis and Management. McGraw Hill, New York, 2007.20. Tintinalli JE, et al. Emergency Medicine: A Comprehensive Study Guide. 6th Edition. McGraw Hill, New York, 2004.21. Wolf, R., et al. Drug Rash with Eosinophilia and Systemic Symptoms vs. Toxic Epidermal Necrolysis: the Dilemma of Classification. Clin Derm (2005) 23, 311 – 314.22. Margileth, A. Scaled Skin Syndrome: Diagnosis, Differential Diagnosis, and Management of 42 Children. South Med J. (1975) 68: 447 - 54.23. Yamamoto, L. Kawasaki Disease. Ped Em Care. (2003) 422 – 427.24. Levi, M. Disseminated Intravascular Coagulation. Crit Care Med. (2007) 35: 2191 – 2195.25. Levi, M. Novel Approaches to the Management of Disseminated Intravascular Coagulation. Crit Care Med. (2000) 28: S20 – S24.26. Sarode, R. Atypical Presentations of Thrombotic Thrombocytopenic Purpura: A Review.  J Clin Apheresis. (2009) 00: 000 ‐ 000. 27. Bastuji‐Garin S, Fouchard N, Bertocchi M, Roujeau JC, Re‐ vuz J, Wolkenstein P.  SCORTEN: a severity of illness score for toxic epidermal necrolysis. J Invest  Dermatol 2000;115: 149 –153. 28. Mittimann, N, et al. IVIG for the Treatment of Toxic Epidermal Necrolysis.  Skin  Therapy Lett. 2007 Feb;12(1):7‐9.                      
  11. 11. UNKNOWN RASH SELF-ASSESMENT 1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________ 6. _______________________________________ 7. _______________________________________ 8. _______________________________________ 9. _______________________________________ 10. _______________________________________