Dermatology lecture

1. DERMATOLOGIC DISORDERS
COMMONLY MISSED IN THE
ED.
Donny Perez, DO and Michael Tomlinson RN

3. DEFINITIONS
 Macule
Impalpable colored lesion
<1cm, circumscribed alteration
of skin color
 Patch
Impalpable colored lesion
>1cm.

4.  Papule
Palpable lump <1cm
diameter.
 Nodule
Palpable lump >1cm.

5.  Vesicle
Palpable fluid filled
lesion <1cm.
 Bulla
Palpable fluid-filled
lesion >1cm

6.  Petechiae
red, non blanching
spots <5mm
 Purpura
red, non blanching
spots >5mm

7.  Plaque = Palpable
disc shaped lesion
 Wheal = Area of
dermal edema

8. DESCRIPTIVE
TERMS
 Annular : Ring shaped, hollow centre
 Arcuate : Curved
 Circinate : Circular
 Confluent : Lesions that run together
 Discoid : Circular without hollow centre
 Eczematous : Inflammed and crusted
 Keratotic: Thickened
 Lichenified: Thickened and roughed with accentuated
skin markings
 Zosteriform : Nerve distribution

9. HISTORY
 How long
 Had it before
 Is it worsening / anything improving it
 Distribution ie palms / plantar / face / mucosal membranes
 How did it start / evolve
 Itch
 Social changes eg diet / work / cleaning
 Meds & allergies
 Cutaneous manifestations of systemic disorders eg sore joints & past medical
history
 Family history
 Travel
 Contacts
 Viral symptoms or fevers

10. ?

11. URTICARIA

12. URTICARIA
 Physical triggers / drugs / foods / stings / viral/ atopy / blood
products / temperature...
 Wheals, smooth with a red flare with some clearing leaving
annular pattern & scratch marks. Dermatographism
 Acute / Recurrent / Chronic
 Management
Remove cause / anti-histamines / steroids

13. ?

14. ECZEMA
 Flexural Distribution
 Itch ++ / Scratch marks, hyper or hypopigmented lesions
 Age related stages
 Atopic vs Contact
 Can be vesicular
 Treatment
 Emollients ++
 Treat infected skin
 Moist dressings
 Avoid triggers
 Antihistamines for itch
 Topical / systemic steroids
 Increase sunlight exposure / Phototherapy
 Immunomodulators / Immunosupressants : Cyclosporin / Azathioprine /
Tacrolimus /

15. ?

16. PSORIASIS
 Itch / Pain / Decreased movement / Family Hx
 Extensor Distribution – well demarcated salmon pink silvery scales. Red surface on
removal / capillary bleeding (Auspitz sign)/ new lesions at site of trauma (Koebner’s
Phenomenon)
 Plaque / Guttate / Erythrodermic / Pustular variants / Inverse
 Triggers – Stress, Strep, HIV, Trauma, Drugs (Lithium + BetaBlockers Especially)
 Psoriatic Arthritis
 Treatment – topical vs systemic : Systemic if failed topical / repeated admissions /
extensive plaques in elderly / severe arthropathy / generalised pustular or
erythrodermic psoriasis
 Emollients ++ / Keratolytic agents
 Topical Steroids.
 Coal Tar.
 Dithranol.
 Vitamin D3
 Retinoids – topical or oral.
 Phototherapy / Photochemotherapy (& methotrexate)
 Immunosuppressant's – Methotrexate, Cyclosporin, Mycophenalate
 Infliximab / CD4 monoclonal antibodies

17. ?

18. ?

19. VARICELLA ZOSTER VIRUS
 Varicella / Chicken Pox – Respiratory droplets. Infectious for 2 days prior to
lesions. Ends when crusts
 Rash head / trunk /
 Simultaneous presence of rash at different stages. Macule / Papule / Vesicle /
Pustule / Crusts
 A/w headache / malaise / anorexia / cough / coryza and sore throat / low grade
fever
 Rx symptomatic. Antivirals in certain cases / Secondary infection risk
 Shingles
 Dermatomal distribution & enlarged draining node
 Presents as pain, malaise, fever, rash in same distribution several days later
 Dx Clinical but can do smears or titres or isolation of virus in blisters
 Mx – antivirals / pain relief / IV antivirals if immunocompromised
 Complications : Corneal ulcers / Gangrene of affected area / Phrenic Nerve palsy
/ Meningoencephalitis / Ramsay Hunt syndrome / Neuralgia / Disseminated
zoster

20. NURSING
CONSIDERATIONS
• Place patient on airborne and contact precautions
• Anticipate antivirals
• Non adherent dressings
• Pain management
• Educate patients on self care
- Calamine lotion and cold compresses
- Keep rash dry and avoid lotion/creams

21. ?

22. ?

23. HERPES SIMPLEX VIRUS
 Pain / Itch / Vesicles / Sore mouth / Gum swelling /
Mouth ulcers
 Small vesicles & lymph nodes
 Complications –
 Erythema Multiforme / Encephalitis / Keratitis /
Whitlow / Disseminated infection if
immunocompromised / Visceral involvement /
Neonatal / Meningitis
 Rx topical / oral / IV antivirals

24. NURSING
CONSIDERATIONS
• Distinguish HSV type 1 and HSV type 2
• Administer antiviral therapy
• Pain management
• Educate patient to avoid sexual contact during outbreak
• Emphasize importance of protected sex
• Encourage patients that condition is manageable
Trigger factors for outbreak
-Stress
-illness

25. ?

26. IMPETIGO
 Group A beta haemolytic Strep or Staph aureus
 Contagious
 Vesicles to honey coloured crusted lesions. Painless. Face
or extremities
 Local adenopathy / Generally afebrile
 Rx topical / oral antiobiotics
 Generally resolves 7-10 days
 Complications – Osteomyelitis / Septic Arthritis / Sepsis /
Pneumonia / Endocarditis
 Post strep glomerulonephritis / Scalded skin syndrome

27. NURSING
CONSIDERATIONS
• Contagious with present lesions (Contact Precautions)
• Assess for fevers and possible systemic infection
• Determine exposure
• Encourage hand washing
• Administer antibiotics

28. ?

30. ERYTHEMA MULTIFORME
 Hypersensitivity reaction, polymorphous skin eruption
 Target Lesions
 Symmetric eruption red round macules, edematous papules, target
lesions (x3 concentric areas of colour change) dorsum hands and
forearms
 Central dusky area
 Can be vesicular and painful.
 Minor generally self limiting
 Etiology
 HSV
 Immunologic disorders – IBD / SLE / graft vs host
 Mycoplasma, TB, Histoplasmosis.
 Drugs: Sulphonamides. Barbiturates. Penicillin. Phenytoin. NSAIDS.
Allopurinol.
 Malignancy
 Idiopathic
 Mx – Minor consider antivirals if HSV / symptomatic

31. NURSING MANAGEMENT
• Determine risk factors
• Educate patient to keep diary of outbreaks
• Avoid triggers
• Treat underlying conditions

32. ?

33. ERYTHEMA NODOSUM
 Painful nodules, poorly defined. +++ tender
 Hx – fever / painful nodules/ arthralgias / sore throat / drugs / Cough
 Etiology:
 Strep / TB / Yersinia / Leprosy / Coccidioidomycosis / Histoplasmosis
 Sarcoid
 SLE
 Behcets
 IBD
 Drugs – Sulphonamides / OCP
 Management
 Definitive dx – wedge biopsy
 CXR
 Rapid strep / Throat Swabs.
 Symptomatic
• Self–limiting - 3-6 weeks
• NSAIDS
• Elevation
• Compression Stockings.

34. ?

35. KOPLIK’S SPOTS / MEASLES
 Primary infection respiratory epithelium - droplets
 Highly contagious
 Fever / Coryza / Koplik spots 2-3 days into prodrome
precedes rash (14 days). Maculopapular, lasts 5-7
days, may desquamate
 Clinical diagnosis of Measles wrong in 50% of cases
 Probably requires serology for confirmation /
leukopenia / lymphopenia
 Complications: Superimposed bacterial infection.
Encephalitis

36. NURSING
CONSIDERATIONS
Communicable period- 4 days before rash appears and
ending 4 days after rash has been present
• Determine risk factors such as outbreaks, travel and
immunization
• Airborne precautions
• Advise patients to avoid contact during communicable
period

37. ?

38. SLAPPED CHEEK SYNDROME
 Fifth Disease “Erythema infectiosum”
 Parvovirus B19
 Respiratory droplets
 Viral prodrome, slapped cheek, perioral pallor, later
extremities with palms and soles spared.
 Antipyretics and antihistamines
 Generally benign. Rare aplastic crisis. In utero a/w
hydrops foetalis

39. ?

40. HAND, FOOT + MOUTH
 Usually Coxsackie A or Enterovirus
 Usually children, very infectious, incubation 3
days then fever malaise and rash / painful oral
lesions
 Treatment supportive

41. ?


42. PITYRIASIS ROSEA
 Presumed viral.
 ?HHV 7.
 Christmas tree distribution.
 Self limiting over 6-12 weeks.
 Herald patch often mistaken for
ringworm.

43. ?

44. SCABIES
 Sarcoptes scabiei
 Intense itch
 Permethrin or Malathion
 Applied at bedtime to whole body from
scalp to soles.
 Treat all close contacts even if
asymptomatic.
 Wash all towels, clothes worn in last week
and bed linen
 Vacuum house and furniture!
 Itch can persist for 6 weeks even after
successful treatment due to dead mites in skin.

45. ?

46. MELANOMA
 Asymmetrical
 Border irregular
 Varicolored
 Diameter >5mm
 Elevation

47. DECUBITUS ULCERS
Results from prolong pressure to bony area of the skin
including (sacrum, heels, shoulder, hip, ankles)

48. NURSING MANAGEMENT
• Determine patients at risk
• Assess for signs of infection
• Wound culture if indicated
• Document wounds and take pictures
• Cover open wounds with non adhesive dressings
• Keep patients dry
• Reposition patients frequently and pad bony prominences
• Wound care consult

49. SO FAR...
 Reviewed terminology
 Common, but usually not serious/life threatening
conditions

50. SERIOUS CONDITIONS WITH
BLISTERING / SKIN LOSS
 Erythema Multiforme major / SJS
 Pemphigus
 Pemphigoid
 TENS
 SSS
 ( Kawasaki’s )

51. ?

52. ERYTHEMA MULTIFORME
MAJOR
 Stevens Johnson Syndrome
 Symmetric erythematous macules, head and neck and lower
body
 Progresses to bullae, skin necrosis and denudation, at least
2 mucosal surfaces involved
 Widespread rash involving up to 10% BSA skin sloughing /
blistering.
 Treatment:
 Prompt drug withdrawal.
 Admission / supportive care / general burns care.

53. ?

54. TOXIC EPIDERMAL
NECROLYSIS
 Widespread rash like sunburn initially >30% TBSA with
later necrosis and sloughing. +ve Nikolsky sign
 Large mucous membrane involvement.
 Remove causative agent & manage as severe burns (ICU /
Burns unit)
 Mostly thought to be drug related
 Debates re: plasmapheresis / IVIG / Steroids etc, nil proven
 Complications: High mortality
 Ophthalmology involvement and regular eye
irrigation

55. NURSING MANAGEMENT
OF SJS/TEN
• Obtain thorough background information
• Cover open wounds to prevent infection
• Pain management and fluid replacement
• Educate patient on risk factors
• Anticipate transfer to burn unit

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57. PEMPHIGUS
 Autoimmune
 Blisters in mouth followed by on skin.
 Positive Nikolsky Sign
 3 Types:
 Vulgaris – begins in mouth 50% cases
 Foliaceous – may be drug induced
• Least severe.
• Often mistaken for eczema
 Paraneoplastic.
• Non Hodgkins Lymphoma most common
 Tx: Antibiotics / IV fluids / systemic steroids +/- immunosuppressants
(azathioprine / cyclophosphamide / methotrexate / gold / dapsone/
cyclosporine)

58. ?

59. PEMPHIGOID
 More common than pemphigus
 Generally benign
 Also Autoimmune
 Affects older age group
 No Mucous Membrane involvement
 Negative Nikolsky Sign
 Treatment same as Pemphigus – steroids +/-
immunosupressants
 Variants
 Gestational
 Mucous membrane (Cicatricial)

60. ?

61. SCALDED SKIN
SYNDROME
 Syndrome of acute exfoliation of the skin typically following
an erythematous cellulitis. Severity varies from a few
blisters to a severe exfoliation affecting almost the entire
body, but doesn’t involve mucous membranes as in TENS.
 Staph aureus with epidermolytic exotoxins (A+B).
 Positive Nikolsky’s sign - separation of skin with gentle
pressure.
 Treatment.
 Antibiotics, supportive care.

62. ?

65. PURPURIC
RASH
 Petechiae <5mm.
 Purpura >5mm.
 Causes:
 Drugs: Steroids / Gold / Anticoagulants
 Senile
 Trauma
• Coughing / vomiting
 Infection
• Meningococcal, Cellulitis, Viral.
 Vasculitic
• E.g. HSP / Wegners
 Thrombocytopenia
• ITP / TTP / Leukemia / DIC.

66. OTHER SERIOUS SKIN
CONDITIONS
o Necrotizing fasciitis
o Rocky mountain spotted fever
o Hereditary Angioedema

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70. RED
FLAGS
 Unwell patient
 Other serious comorbidity, eg immunodeficiency
 Large area of skin
 Mucosal or ocular involvement
 Specific conditions with serious complications