This document discusses emergency dermatology situations that require prompt management. It focuses on three main areas: severe drug reactions like toxic epidermal necrolysis which requires immediate drug cessation; serious infections like meningococcal disease signaled by palpable purpura that needs rapid antibiotics; and erythroderma involving over 90% of body surface that can cause systemic issues like fluid/electrolyte imbalance. Early recognition and treatment of these conditions is important to minimize patient harm.

1. Emergency Dermatology
Dr Daniel Hewitt
Dermatologist
Skin and Cancer Foundation Westmead

2. Emergency Dermatology
Emergencies are rare in general dermatology but there are
certain situations that require prompt management.
These include severe drug reactions, severe
infections, allergic reactions and severe flares of
inflammatory dermatoses.

3. The following three areas will be briefly discussed.
Severe drug reactions
Serious infections
Erythroderma

4. Serious drug reactions
Drug reactions in the skin are usually innocuous and self-
limiting.
The most common presentation is of a blotchy erythema
predominantly involving the trunk. This may be referred
to as a “morbilliform” (measles-like) rash or as a
“macuo-papular” rash. This presentation can also be
referred to as a toxic erythema, this is discussed in
another module.
However, medications can produce many other types of
skin changes including
urticaria, erythema mutliforme, lichenoid changes,
pustules, pigmentation, blisters and mucosal changes

5. Drug eruptions

6. The list of medications that can cause drug reactions is
extremely long, but the most common medications
causing drug reactions are
Antibiotics – beta lactams, sulphonamides
Anticonvulsants – phenytoin, carbamazepine,
lamotrigine
Cardiac medications – frusemide, thiazide diuretics,
ACE inhibitors
Nonsteroidal anti-inflammatories
Allopurinol
Antiretrovirals

7. The most serious drug reaction is toxic epidermal
necrolysis. A severe type IV hypersensitvity reaction
causes widespread skin necrosis and can lead to
multiorgan failure and overwhelming sepsis.
It needs early recognition, immediate cessation of the
offending drug and early intensive supportive
management. It is an emergency.
Important signs of a potentially more serious drug reaction
are
fever and systemic upset
mucous membrane involvement
targetoid lesions with central duskiness or blistering
skin pain and tenderness
blistering and shedding of sheets of epidermis

8. Toxic epidermal necrolysis
Toxic epidermal necrolysis

9. Toxic epidermal necrolysis
Toxic epidermal necrolysis

10. Toxic epidermal necrolysis

11. Serious infections
Ocassionally cutaneous findings are an early feature of
serious infections. Usually other systemic findings will
aid in early diagnosis.
A classic example is meningococcal disease, caused by
the bacteria Neisseria meningitidis.
This needs early antibiotic treatment. A delay of just hours
can be fatal.
The hallmark is palpable purpura – due to vasulitis and
vascular occlusion and damage.

12. Early changes of
Meningococcal disease

13. Later changes of meningococcal disease

14. Other examples of severe cutaneous reactions in infections
occur in Kawasaki disease and Staphylococcal Scalded
Skin Syndrome.
Kawasaki disease is defined by fevers, a widespread
exanthem, conjunctivitis, mucositis and
lymphadenopathy.
Staphylococcal Scalded Skin Syndrome comprises
irritability, fevers and widespread erythema developing
into blisters and then skin changes like a burn

15. Kawasaki disease Staphylococcal Scalded Skin Syndrome

16. Erythroderma
This is erythema involving 90% or more of the body surface
area.
It often necessitates admission as patients are systemically
unwell. Older patients are especially prone to fluid
loss, electrolyte imbalance, cardiac failure and
hypothermia.
The most common causes are
psoriasis
dermatitis
drug reactions
pityriasis rubra pilaris
lymphoma
In approximately 10%, no cause can be identified.

17. Erythoderma due to dermatitis

18. Erythoderma due to psoriasis

19. Erythoderma due to Sezary syndrome (lymphoma)

20. Conclusion
Like all of these modules, this is a very brief introduction to
some skin conditions that must be recognized early to
minimize patient harm.
There are certain dermatological conditions that must be
treated early to prevent significnat morbidity or even
mortality.