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Morning Report Derm Day
Ecthyma gangrenosum
• Cutaneous infection most commonly associated with
Pseudomonas bacteremia
• Pts who are critically il...
Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Pseudomonas aeruginosa infection. E...
Workup
• Gram stain of fluid from the central
haemorrhagic pustule or blister can rapidly
indicate the diagnosis
• Blood c...
Treatment
• Treat underlying bacteremia
Pyoderma gangrenosum
• Rare, inflammatory disease of unknown
etiology
• Sterile neutrophilic infiltration of the skin
• Fe...
Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Established lesion of ulcerative py...
Workup
• No specific serologic testing available
• Histopathologic findings not specific, but may
be suggestive of the dia...
Treatment
• Systemic immunosuppressive medication is
mainstay
• Topical and local therapy as indicated
• Treatment of caus...
Acute Febrile Neutrophilic
Dermatosis
• Commonly known as Sweet Syndrome
• Characterized by acute onset of fever, neutroph...
Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Multiple confluent papules and plaq...
Workup
• Skin biopsy
– Mature neutrophilic infiltration of dermis
– Lesion should also be sent for infectious cultures
Treatment
• Systemic corticosteroids, potassium iodide
and colchicine are all first line therapies
Erysipelas
• Superficial cutaneous cellulitis with marked dermal
lymphatic vessel involvement
• Classically caused by Grou...
Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Erysipelas is a group A streptococc...
Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Erysipelas. Painful, edematous eryt...
Treatment
• Depends on severity and presumed causative organism
• Choice of antibiotic should reflect local resistance
pat...
Skin disease for internist
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Skin disease for internist

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Skin disease for internist

  1. 1. Morning Report Derm Day
  2. 2. Ecthyma gangrenosum • Cutaneous infection most commonly associated with Pseudomonas bacteremia • Pts who are critically ill and immunocompromised • Characteristic lesions of ecthyma gangrenosum are hemorrhagic pustules that evolve into necrotic ulcers • Painless, round, red patches in the skin which rapidly become pustular with surrounding redness • Gangrenous ulcer with a black/gray scab surrounded by a red halo • Mainly affects the anogenital area and armpits
  3. 3. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved. Pseudomonas aeruginosa infection. Ecthyma gangrenosum. This 32-year-old man with human immunodeficiency virus infection noted the onset of a very tender plaque on the right buttock associated with fever and malaise. A. Five-day-old lesion with a central infarcted, necrotic area surrounded by erythema. B. At 5 weeks, the lesions had improved after ciprofloxacin treatment, which was discontinued because of an adverse drug reaction. Without antibiotic treatment, the necrotic area enlarged and was associated with bacteremia. Eventually, the lesion reepithelialized, but the patient died of pseudomonal pneumonia. Legend: From: Part 9. Disease Due to Microbial Agents, Infestations, Bites, and Stings Fitzpatrick's Dermatology in General Medicine, 8e, 2012 From: Part 9. Disease Due to Microbial Agents, Infestations, Bites, and Stings Fitzpatrick's Dermatology in General Medicine, 8e, 2012
  4. 4. Workup • Gram stain of fluid from the central haemorrhagic pustule or blister can rapidly indicate the diagnosis • Blood cultures prior to antibiotics • Skin biopsy: – Histopathology shows vascular necrosis with few inflammatory cells but many surrounding bacteria – Gram negative rods seen surrounding necrotic vessels
  5. 5. Treatment • Treat underlying bacteremia
  6. 6. Pyoderma gangrenosum • Rare, inflammatory disease of unknown etiology • Sterile neutrophilic infiltration of the skin • Female predominance • Typically associated with other systemic diseases – IBD, arthritis, malignancy • Multiple subtypes – Ulcerative, bullous, pustular, vegetative
  7. 7. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved. Established lesion of ulcerative pyoderma gangrenosum showing well-defined ulceration with surrounding zone of erythema. Legend: From: Chapter 33. Pyoderma Gangrenosum Fitzpatrick's Dermatology in General Medicine, 8e, 2012 From: Chapter 33. Pyoderma Gangrenosum Fitzpatrick's Dermatology in General Medicine, 8e, 2012
  8. 8. Workup • No specific serologic testing available • Histopathologic findings not specific, but may be suggestive of the diagnosis in right clinical context – Tissue neutrophilia without significant leukocytoclastic vasculitis • Must exclude other mimicking conditions – Infection, vascular insult, malignancy
  9. 9. Treatment • Systemic immunosuppressive medication is mainstay • Topical and local therapy as indicated • Treatment of causative systemic illness as indicated – IBD, arthritis, malignancy
  10. 10. Acute Febrile Neutrophilic Dermatosis • Commonly known as Sweet Syndrome • Characterized by acute onset of fever, neutrophilia, with erythematous, tender skin lesions • All manifestations resolve rapidly with initiation of systemic corticosteroids • Multiple types – Classical: associated with upper respiratory/gastrointestinal infections, IBD, pregnancy – Malignancy-associated: undiagnosed hematologic malignancy or suggestive of recurrence of known hematologic malignancy – Drug-induced: typically due to G-CSF
  11. 11. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved. Multiple confluent papules and plaques of Sweet syndrome that at first sight give the illusion of vesiculation but are solid on palpation. (From Honigsmann et al: Akute febrile neutrophile Dermatose. Wien Klin Wochenschr 91:842, 1979, with permission.)  Legend: From: Part 2. Disorders Presenting in Skin and Mucous Membranes Fitzpatrick's Dermatology in General Medicine, 8e, 2012 From: Part 2. Disorders Presenting in Skin and Mucous Membranes Fitzpatrick's Dermatology in General Medicine, 8e, 2012
  12. 12. Workup • Skin biopsy – Mature neutrophilic infiltration of dermis – Lesion should also be sent for infectious cultures
  13. 13. Treatment • Systemic corticosteroids, potassium iodide and colchicine are all first line therapies
  14. 14. Erysipelas • Superficial cutaneous cellulitis with marked dermal lymphatic vessel involvement • Classically caused by Group A streptococci – Can be caused by Staphylococci, Group C/G strep • Differences between erysipelas and classic cellulitis – Sharply defined borders – Erythema classically bright red – Skin can be described as peau d’orange • Distribution – 70-80% of cases involve lower extremities – Up to 10% involve face • Classically start unilaterally but tend to cross nasal bridge and involve face symmetrically
  15. 15. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved. Erysipelas is a group A streptococcal infection of the superficial dermis and consists of well-demarcated, erythematous, edematous, warm plaques. Legend: From: Chapter e7. Atlas of Rashes Associated With Fever Harrison's Principles of Internal Medicine, 18e, 2012 From: Chapter e7. Atlas of Rashes Associated With Fever Harrison's Principles of Internal Medicine, 18e, 2012
  16. 16. Date of download: 5/15/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved. Erysipelas. Painful, edematous erythema with sharp margination on both cheeks and the nose. There is tenderness, and the patient has fever and chills. Legend: From: Chapter 178. Non-Necrotizing Infections of the Dermis and Subcutaneous Fat: Cellulitis and Erysipelas Fitzpatrick's Dermatology in General Medicine, 8e, 2012 From: Chapter 178. Non-Necrotizing Infections of the Dermis and Subcutaneous Fat: Cellulitis and Erysipelas Fitzpatrick's Dermatology in General Medicine, 8e, 2012
  17. 17. Treatment • Depends on severity and presumed causative organism • Choice of antibiotic should reflect local resistance patterns • Outpatient – Penicillinase-resistant PCN/oral cephalosporin for suspected non-MRSA – TMP/SMX, clindamycin, doxycycline, fluoroquinolone for suspected MRSA • Inpatient – IV forms of outpatient abx for suspected non-MRSA – IV vancomycin for suspected MRSA

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