This document defines common skin conditions and provides guidance on evaluating dermatology presentations in the emergency department. It reviews terminology, discusses common non-serious conditions like urticaria and eczema, and outlines serious but rare disorders involving blistering or skin loss such as erythema multiforme major, pemphigus, pemphigoid, and toxic epidermal necrolysis. Red flags are identified that warrant discussion with a senior colleague or dermatologist.

1. ED Dermatology

2. Aims
 Review terminology of skin conditions
 Identify common non-serious ED presentations
 Discuss serious but rare skin disorders

4. Definitions
 Macule
Impalpable coloured lesion
<1cm, circumscribed alteration
of skin colour
 Patch
Impalpable coloured lesion
>1cm.

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

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

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

8.  Plaque = Palpable
disc shaped lesion
 Wheal = Area of
dermal oedema

9. 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

10. 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

11. ?

12. Urticaria

13. 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
 Investigation
FBC / WCC / Eosinophils / Challenges
Complement levels with angiooedema
 Management
Remove cause / anti-histamines / steroids

14. ?

15. 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 /

16. ?

17. Psoriasis
 Itch / Pain / Decreased movement / FHx
 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 v’s 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

18. ?

19. ?

20. VZV
 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 / IFN
 Complications : Corneal ulcers / Gangrene of affected area / Phrenic Nerve palsy
/ Meningoencephalitis / Ramsay Hunt syndrome / Neuralgia / Disseminated
zoster
 NB if AIDS – major CNS effects/

21. ?

22. ?

23. HSV
 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. ?

25. 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 7-10/7
 Complications – Osteomyelitis / Septic Arthritis / Sepsis /
Pneumonia / Endocarditis
 Post strep glomerulonephritis / Scalded skin syndrome

26. ?

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

29. ?

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

31. ?

32. 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 5-7/7
may desquamate
 Clinical diagnosis of Measles wrong in 50% of cases
 Probably requires serology for confirmation /
leucopaenia / lymphopaenia
 Complications: Superimposed bacterial infection.
Encephalitis. SSPE

33. ?

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

36. 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

38. Kawasaki’s disease
 Usually < 5 yo, early phase of prolonged fever,
irritability, and involvement of mucous
membranes (conjunctivitis and mouth). Hands
and feet red and swollen early, later may have
desquamating maculopapular rash
 Association with cardiac abnormalities...
 Treatment with IV Immunoglobulin

39. ?


40. Pityriasis Rosea
 Presumed viral.
 ?HHV 7.
 Christmas tree distribution.
 Self limiting over 6-12 weeks.
 Herald patch often mistaken for
ringworm.

41. ?

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

43. ?

44. Melanoma
 Asymmetrical
 Border irregular
 Colour Variegated
 Diameter >5mm
 Evolution / Elevation

45. So far...
 Reviewed terminology
 Common, but usually not serious/life threatening
conditions

46. Serious conditions with
blistering / skin loss
 Erythema Multiforme major / SJS
 Pemphigus
 Pemphigoid
 TENS
 SSS
 ( Kawasaki’s )

47. ?

48. Erythema Multiforme Major
 Stevens Johnson Syndrome
 Symmetric erythematous macules, head and neck and lower
body
 Progresses to bullae, skin necrosis and denudation, at least
x2 mucosal surfaces involved
 Widespread rash involving up to 10% BSA skin sloughing /
blistering.
 Treatment:
 Prompt drug withdrawal.
 Admission / supportive care / general burns care.

49. ?

50. 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 / IG / Steroids etc, nil proven
 Complications: High mortality / NB Ophthalmology
involvement and regular eye irrigation

51. ?

52. Pemphigus
 Autoimmune
 Blisters in mouth followed by on skin.
 Diagnosis by biopsy – IgG in epidermis, disruption of connections
intercellular
 3 Types:
 Vulgaris – begins in mouth 50% cases
 Foliaceous – may be drug induced
• Least severe.
• Often mistaken for eczema
 Paraneoplastic.
• NHL most common
 Mx: Barrier nursing / antibx / IV fluids / systemic steroids +/-
immunosuppressants (azathioprine / cyclophosphamide / methotrexate /
gold / dapsone /ciclosporin)

53. ?

54. Pemphigoid
 More common than pemphigus
 Generally benign
 Also Autoimmune
 Affects older age group
 Affects deeper layer in skin – tense flexural areas
 Subepidermal / eosinophil rich with IgG and C3
deposited in basement membrane
 Treatment same as Pemphigus – steroids +/-
immunosupressants
 Variants
 Gestational
 Mucous membrane (Cicatricial)

55. ?

56. 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).
 Nikolsky’s sign -separation of skin with gentle pressure.
 Treatment.
 Antibiotics, supportive care.

57. ?

60. Purpuric Rash
 Petechiae <5mm.
 Purpura >5mm.
 Causes:
 Drugs: Steroids / Gold / Anticoagulants
 Senile
 Trauma
• Coughing / vomiting / direct.
 Infection
• Meningococcal, Cellulitis, Viral.
 Vasculitic
• E.g. HSP / Wegners / PAN
 Thrombocytopenia
• ITP / TTP / Leukaemia / DIC.

61. Red flags
 Unwell patient
 Other serious comorbidity, eg immunodeficiency
 Large area of skin
 Mucosal or ocular involvement
 Specific conditions with serious complications
eg Kawasaki

62. If any doubts d/w senior colleague / dermatologist
Remember you can easily send them an image of
a rash ! (in hours)
 A good reference website:
http://dermnetnz.org/doctors/