Primary genetic defect in skin barrier function (filaggrin).
Care of a patient with SJS/TEN requires: Cessation of suspected causative drug(s) – the patient is less likely to die and complications are less if the culprit drug is stopped no later than the day that blisters/erosions appear Hospital admission – preferably immediately to an intensive care and/or burns unit as this improves survival, reduces infection and shortens hospital stay Nutritional and fluid replacement (crystalloid) by intravenous and nasogastric routes – reviewed and adjusted daily Temperature maintenance – as body temperature regulation is impaired Pain relief – as pain can be extreme Sterile handling and reverse isolation procedures Skin care: topical antiseptics e.g. silver nitrate or chlorhexidine, (but not silver sulfadiazine as it is a sulfa drug) dressings such as gauze with petrolatum or non-adherent nanocrystalline-containing gauze biosynthetic skin substitutes can reduce pain avoid using adhesive tapes preferable not to remove the dead skin; leave the blister roof as a ‘biological dressing’ daily examination and skin culture to detect bacterial infection Eye care: daily assessment by ophthalmologist, frequent eye drops/ointments (antiseptic, antibiotic, cortisone) Mouth care: mouthwashes topical oral anaesthetic Lung care: may include aerosols, bronchial aspiration, physiotherapy may require intubation and mechanical ventilation if trachea and bronchi are involved Urinary catheter because of genital involvement and immobility Psychiatric support for extreme anxiety and emotional lability Physiotherapy to maintain joint movement and reduce risk of pneumonia Regular assessment for infection including of skin, mucous membranes, catheter sites: Staphylococcal infection is common; gram negative infection may also arise appropriate antibiotic should be given if infection develops prophylactic antibiotics are not recommended and may even increase the risk of sepsis
Dermatology without pics
Dr Alistair Brown
Descriptive terms in dermatology
Common skin conditions
What are you describing?
Lesion – altered area of skin
Rash – eruption
Naevus – localised malformation of tissue
Comedone – plug in a sebaceous follicle
containing sebum – may be open (blackhead) or
“The patient has a rash…”
Where is it?
Generalised – all over body
Widespread – extensive
Localised – one area of skin
Flexural – body fold eg groin, axilla
Extensor – eg knees, shins
Pressure areas – sacrum, buttocks, ankles, heels.
Dermatome – skin supplied by single nerve
Photosensitive areas – sun exposed.
“The patient has a widespread rash affecting their torso”
What colour is it?
Erythema – redness (due to inflammation and
vasodilation) blanches on pressure.
Purpura – red or purple colour (due to bleeding into
the skin or mucous membranes) does not blanch to
pressure. Petechiae (small pinpoint macules) and
ecchymoses (larger bruise like patches)
Hypopigmentation (pityriasis vesicolor)
Confluent – lesions merge together
What shape is it?
Macule – flat area of altered colour
Patch – larger area of altered colour
Papule – solid raised lesion <0.5cm in diameter
Nodule – Solid raised lesion >0.5cm diameter
Plaque – palpable raised lesion >0.5cm
Vesicle – raised clear fluid filled lesion <0.5cm
Bulla – raised clear fluid filled lesion >0.5cm diameter.
Itchy papules and vesicles on an erythematous base.
Affects face and extensor in infants, flexor aspect
children and adults.
Occurs in early childhood, usually resolves.
Risk factors: fhx of atopy, assoc asthma, allergic rhinitis
Exacerbating factors: infections, allergens (chemical,
food, dust, pets), sweating, heat, stress.
Complications: secondary bacterial/viral infection
Avoid exacerbating agents
Topical steroids for flares
Antihistamine for symptomatic relief
Urticaria, Angioedema, Anaphylaxis
Causes – food, drugs, insect bites, contact eg
latex, autoimmune, hereditary (angiodema), etc
Urticaria – swelling superficial dermis – raises
epidermis causing itch wheals.
Angiodema – deeper swelling involving dermis
and subcutaneous tissue – tongue and lips.
Anaphylaxis – bronchospasm, facial and
laryngeal oedema, hypotension, can start with
angiodema and urticaria.
ABC approach – call for help if concerned.
Urticaria only – antihistamines
Angioedema and severe urticaria –
corticosteroids and antihistamines.
Anaphylaxis – get help!
Adrenaline 0.5 mg IM = 0.5 mL of 1:1000
Antihistamine – chlorphenamine
Rapidly spreading infection of the deep fascia with secondary
Group A haemolytic strep or mixed anaerobic and aerobic
Risk factors – abdominal surgery, diabetes, immunosuppression,
BUT 50% occur in previously healthy individuals
Pain disproportionate to signs, erythematous blistering necrotic
skin, systemically unwell with fever and tachycardia, subcutanceos
Urgent surgical debridement and antibiotics
Streptococcus pyogenes and/or Staphylococcus aureus
Enlarging pustules and round, oozing patches +/- golden
Exposed areas such as the hands and face, or in skin folds
particularly the armpits.
Antiseptic or antibiotic ointment eg. Fusidic acid
Avoid close contact with others.
Affected children must stay away from school until crusts have dried
Use separate towels and flannels.
Change and launder clothes and linen daily.
Itchy rash on trunk and limbs, finger webspaces,
wrist, spares the scalp
Burrow tracts can be seen
Diagnosis on microscopic examination of tracts.
Treatment (all contacts simultaneously!)
25% Benzyl benzoate lotion, applied daily for 3 days
5% Permethrin cream, left on for 8-10 hours
0.5% Aqueous malathion lotion, left on for 24 hours
Atopic Eczema True or False
A. a family history of atopy
B. If occurs early and defined has bad
C. In children it is common on cheeks
D. In adults more common on flexor area
E. Pruritis is absent
What skin condition
is this likely to be?
What else should
True or False which of the following are known
risk factors for melanoma?
Sun bed use
Living in the South West
How would you manage this
Watch and wait
Punch biopsy of the lesion for
Take a picture and review in
3months to see if it has grown
Surgically remove with a 2mm
margin for histology
WLE with a 2-3cm margin
A 60 year old woman presents with raised, erythematous
lesions on the limbs and blistering in the mouth and
eyes. She had been taking a number of drugs prescribed
by her GP. Which may be responsible for her
What is the most important first management?
A 22 year old male presents with generalised pruritus
of six weeks duration. Examination reveals little
except for erythematous papules between the fingers.
Which of the following therapies would be most
appropriate for this patient?
Which of the following is a recognised
feature of psoriasis?
loss of hair
response to chloroquine