This document provides an overview of cutaneous emergencies. It discusses various skin cancers including basal cell carcinoma, Kaposi's sarcoma, melanoma, and squamous cell carcinoma. It also reviews decubitus ulcers, various types of dermatitis (atopic, contact, eczema, psoriasis), fungal infections like candida and ringworm, bacterial skin infections such as abscesses and cellulitis, and parasitic infections. Treatment options are provided for many of the conditions. The document is intended to inform and educate emergency healthcare providers about evaluating and managing different skin emergencies and infections.

1. Project: Ghana Emergency Medicine Collaborative
Document Title: Cutaneous Emergencies
Author(s): Joe Lex, MD, FAAEM, FACEP (Temple University) 2013
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3. Cutaneous
Emergencies
Joe Lex, MD, FAAEM, FACEP
Department of Emergency Medicine
Temple University School of Medicine
Philadelphia, PA

4. Topics Covered
1. Cancers of the Skin
2. Decubitus Ulcer
3. Dermatitis
4. Infections / Systemic Illnesses
5. Maculopapular Lesions
6. Vesicular / Bullous Lesions
7. Imaginary Illnesses

5. 1. Cancers of the Skin
• Basal cell carcinoma
• Kaposi’s sarcoma
• Melanoma
• Squamous cell carcinoma

6. Basal Cell Carcinoma
• Nodular
• Ulcerating
• Sclerosing (cicatricial)
• Superficial, pigmented
• Danger zones: midface, behind
ears
• Refer to dermatologist

7. Basal Cell Carcinoma
Nodular UlceratingPigmented
Kuebi,
Wikimedia Commons
Kuebi, Wikimedia Commons National Institutes of
Health, Wikimedia
Commons

8. Basal Cell Carcinoma
James Heilman, MD, Wikimedia Commons
National Institutes of Health, Wikimedia
Commons

9. Kaposi’s Sarcoma
• Painless, raised brown-black or
purple papules and nodules that
do not blanch
• Face, chest, genitals, and mouth
• Not associated with increased
morbidity or mortality
• Referral if bothersome

10. Kaposi’s Sarcoma
Classic KS: elderly
male Ashkenazi and
Mediterranean Jews
HIV-associated:
homosexual men
Kuebi, Wikimedia Commons
National Institutes of Health,
Wikimedia Commons

11. Melanoma RISK
Risk factors
• Moles: atypical or common
• Red hair and freckling
• Inability to tan
• Sunburn: severe sunburn
especially before age 14
• Kindred: family history

12. Melanoma
Melanoma in situ
Superficial spreading
melanoma
Melanocytic nevus
Centers for Disease Control and
Prevention, Wikimedia Commons
National Cancer Institute, Wikimedia
Commons
National Cancer Institute,
Wikimedia Commons

13. Melanoma
• Early detection = early cure
• Have low threshold, refer if
suspected
0x6adb015, Wikimedia Commons

14. Squamous Cell Carcinoma
• Sunlight
exposure
• Age >55
• Men > women
• White > Black
National Cancer Institute, Wikimedia Commons

15. Squamous Cell Carcinoma
Treatment
• Surgery
• Radiotherapy
• Cryotherapy
• 5-fluorouracil
• 90% cure rate if
treated early
Almazi, Wikimedia Commons

16. 2. Decubitus Ulcer
• External compression of dermis
and hypodermis  ischemic
tissue damage and necrosis
• Risk factors: inadequate nursing
care, diminished sensation /
immobility, hypotension, fecal /
urinary incontinence, low serum
albumin, poor nutrition

17. Stages of Ulcers
I: Nonblanching erythema of intact
skin
II: Necrosis, superficial or partial-
thickness involving epidermis
and/or dermis. Bullae  necrosis
of dermis (black)  shallow ulcer

18. Stages of Ulcers
III: Deep necrosis, crateriform
ulceration, full-thickness skin loss;
extends to, but not through, fascia
Source Undetermined

19. Stages of Ulcers
IV: Full-thickness ulceration with
extensive damage / necrosis to
muscle, bone, support structures
Essent, Wikimedia Commons

20. Management
• Stage I and II: topical antibiotics
under moist sterile gauze
• Stage III and IV: surgical
debridement and repair
• Complications: osteomyelitis,
sepsis with resistant organisms
(VRE, MRSA, etc.)

21. 3. Dermatitis
• Atopic
• Contact
• Eczema
• Psoriasis
• Sebaceous
cysts
• Seborrhea Thomas Habif, Wikimedia Commons

22. Atopic Dermatitis = Eczema
• Itching  rubbing and scratching
 lichenification (hyperplasia)
• Diagnosis: based on clinical
findings
• Serum IgE level usually elevated
• Associated with allergic rhinitis,
asthma

23. Atopic Dermatitis: Treatment
Fraught with
problems
Dependence on
glucocorticoid
s  atrophy,
tachyphylaxis,
hypertrichosis Eisfelder, Wikimedia Commons

24. Atopic Dermatitis
Care_SMC, Flickr
Jambula, Wikimedia Commons

25. Atopic Dermatitis
Dyshidrotic eczema
Nummular eczema
Dbnll, Wikimedia Commons
Source Undetermined

26. Contact Dermatitis
Generic term applied to acute or
chronic inflammatory reactions to
substances that come in contact
with the skin
•Chemical irritant
•Allergic caused an antigen that
elicits a type IV (cell-mediated or
delayed) hypersensitivity reaction

27. Contact Dermatitis
Alborz Fallah, Wikimedia Commons
Nunyabb, Wikimedia Commons

28. Contact Dermatitis
Prevention
• Wear protective clothing
• If contact occurs, wash with water
or weak neutralizing solution
• Barrier creams

29. Contact Dermatitis
• Gauze soaked in Burow’s solution
changed every 2 to 3 hours
• Class I topical corticosteroid
preparations may be effective if
nonexudative, nonbullous
• Systemic corticosteroids if severe
(cannot function or sleep) or for
exudative lesions

30. Burow’s Solution
• Aluminum acetate in water
• Invented by ophthalmologist Karl
August Burow (1809 – 1874)

31. Topical Corticosteroids
Class 4
Mild
• Hydrocortisone 0.5-2.5%

32. Topical Corticosteroids
Class 3
Moderate (2-25 times as potent as
hydrocortisone)
• Aclometasone dipropionate
• Clobetasone butyrate
• Fluocinolone acetonide
• Triamcinolone acetonide

33. Topical Corticosteroids
Class 2
• Potent (I50-100 times as potent as
hydrocortisone)
• Betamethasone valerate/dipropionate
• Diflucortolone valerate
• Fluticasone valerate
• Hydrocortisone 17-butyrate
• Mometasone furoate
• Methylprednisolone aceponate

34. Topical Corticosteroids
Class 1
Very potent (up to 600 times as
potent as hydrocortisone)
• Clobetasol propionate
• Betamethasone dipropionate

35. Psoriasis
James Heilman, MD, Wikimedia Commons
MediaJet, Wikimedia
Commons

36. Psoriasis
Eisfelder, Wikimedia Commons
James Heilman, MD, Wikimedia Commons

37. Psoriasis – Findings
• Bilateral, often symmetrical; often
spares exposed areas; favors
elbows, knees, scalp, and
intertriginous areas; face
involvement uncommon
• Guttate psoriasis: disseminated
small lesions without predilection
of site

38. Psoriasis – Locations
Source Undetermined

39. Psoriasis – Treatment
•Remove scales – soak in water
•Topical fluorinated glucocorticoid
ointment to wet skin
(betamethasone valerate,
fluocinolone acetonide, et al.)
•Cover with plastic wrap, leave
overnight

40. Sebaceous Cyst
•Synonyms: wen, infundibular cyst,
epidermal cyst
•Most common cutaneous cyst
•Origin: epidermis or hair follicle
epithelium
•Fills with keratin, lipid-rich debris
•Rupture common

41. Sebaceous Cyst
• Treatment: drainage if infected
• Removal by surgeon
Steven Fruitsmaak, Wikimedia Commons

42. Seborrheic Dermatitis
• “Cradle cap” in infants
• Pityriasis sicca = dandruff
Amras666, Wikimedia Commons
Starfoxy, Wikimedia Commons

43. Seborrheic Dermatitis
• Yellowish-red or gray-white skin,
• Often “greasy” or scaling
macules and papules
• Varying size: 5 to 20 mm

44. Seborrheic Erythroderma
• Frightened, red, toxic patient
• Skin red, thick, scaly
• Many drugs, illnesses implicated
• Can lead to high-output failure
• Admit to warm room with blankets
• Glucocorticoids, emollients

45. Seborrheic Erythroderma
• Seborrheic erythroderma +
diarrhea + failure to thrive =
Leiner’s disease
• Associated with
immunodeficiency disorders

46. Seborrheic Erythroderma
Nbrigham, Wikimedia Commons

47. Seborrheic Erythroderma
Kilbad, Wikimedia Commons

48. 4. Infections
• Bacterial
• Fungal
• Parasitic
• Viral
• Systemic

49. Bacteria

50. Abscess
• Abscess: collection of pus with
inflammation, tissue destruction
• Furuncle: deep-seated, red, hot,
tender abscess that evolves from
staphylococcal folliculitis
• Carbuncle: deeper infection,
interconnecting abscesses

51. Abscess
Abscess
Furuncle
Carbuncle
Centers for Disease
Control and Prevention,
Wikimedia Commons Drvgaikwad, Wikimedia
Commons El Pantera,
Wikimedia
Commons

52. Abscess
• Cause: Staphylococcus aureus
• Treatment: incision and drainage
+/- antibiotic
Source Undetermined

53. Hidradenitis Suppurativa
• Chronic, suppurative disease of
apocrine gland–bearing skin in
axillae and anogenital region
• Tender, red nodules not related to
hair follicles
• Acute lesions: incise and drain
• Refer for definitive care

54. Hidradenitis Suppurativa
Source Undetermined Source Undetermined

55. Cellulitis and Erysipelas
• Acute, spreading infections of
dermal and subcutaneous tissues
• Red, hot, tender skin, often at site
of bacterial entry
• Cause: group A beta-hemolytic
streptococci or Staphylococcus
aureus

56. Cellulitis and Erysipelas
Treatment: outpatient
• Dicloxacillin
• Macrolide: EES, azithromycin,
clarithromycin
• Amoxicillin-clavulanate
• Clindamycin
• TMP-SMZ

57. Cellulitis Erysipelas
RafaelLopez, Wikimedia Commons
Centers for Disease Control and Prevention,
Wikimedia Commons

58. Cellulitis
ColmAnderson, Wikimedia Commons

59. Cellulitis
• Facial cellulitis in child 
consider Haemophilus influenzae
Source Undetermined

60. Impetigo and Ecthyma
• Superficial infection of epidermis
by Staphylococcus aureus and
Streptococcus pyogenes
• Extension into dermis 
ecthyma, crusted erosions
or ulcers

61. Impetigo and Ecthyma
The Apologue, Flickr

62. Impetigo, Nonbullous
Transient
superficial small
vesicles or
pustules rupture
 erosions 
golden-yellow
crust (often
seen, not
pathognomonic)
Source Undetermined

63. Impetigo, Bullous
U.S. Department of Health and
Human Services, Wikimedia
Commons

64. Impetigo, Ecthyma
Source Undetermined

65. Impetigo – Treatment
• Topical mupirocin (Bactroban®)
highly effective against GAS and
Staph (including MRSA)
• Systemic antimicrobials: penicillin,
dicloxacillin, erythromycin,
minocycline (for MRSA)

66. Necrotizing Infections
• Group A streptococcal gangrene
• Cellulitis  dusky blue  bullae
or vesicles (yellow  red-black
fluid)  rapid spread along fascial
planes  necrotic slough
• Treatment: early extensive
debridement, high-dose antibiotic

67. Necrotizing Infections
Source Undetermined Source Undetermined

68. Necrotizing Infections
Source Undetermined

69. Necrotizing Infections
Chaldor, Wikimedia Commons

70. Necrotizing Infections
Source Undetermined

71. Fungus
Carol Walker, geograph.org.uk

72. Candida
• Candidosis,
moniliasis
• Candida
albicans, others
–Intertrigo
–Interdigital
–Diaper
dermatitis
GrahamColm,
Wikimedia Commons

73. Candida – Intertrigo
Centers for Disease Control and Prevention,
Wikimedia Commons
Grook da Oger, Wikimedia Commons

74. Candida
Source Undetermined
Source Undetermined

75. Candida – Thrush
Source Undetermined
Source Undetermined

76. Candida – Angular Stomatitis
Source Undetermined

77. Candida – Treatment
• Nystatin (Mycostatin®) tablets or
suspension: 100,000 units QID
• Clotrimazole (Lotrimin®)
• Fluconazole (Diflucan®)
• Itraconazole (Sporanox®)
• Ketoconazole (Nizoral®)
• Voriconazole (Vfend®)

78. Tinea
• Tinea pedis
• Tinea manuum
• Tinea cruris
• Tinea corporis
• Tinea facialis
• Tinea capitis
Epidermal dermatophytes
Centers for Disease Control and
Prevention, Wikimedia Commons

79. Tinea
Robertgascoign, Wikimedia Commons
James Heilman, MD, Wikimedia Commons

80. Ringworm
Centers for Disease Control and Prevention,
Wikimedia Commons

81. Granuloma Annulare
Kreuter, et al, Wikimedia Commons

82. Tinea – Diagnosis
• Potassium hydroxide microscopic
identification of septated, tubelike
structures and spores
Source Undetermined

83. Tinea – Treatment
• Skin: topical antifungals
• Hair and nails: oral preparations
–Griseofulvin: possible elevated
transaminases
“Gray patch”
tinea capitis
Grook da Oger, Wikimedia
Commons

84. Tinea – Treatment
Kerion – do not I & D
Source Undetermined
Source Undetermined

85. Parasites

86. Pediculosis
• Head lice
• Body lice
• Pubic lice
Pediculosis, Wikimedia Commons
GerardM, Wikimedia Commons
KostaMumcuoglu, Wikimedia
Commons

87. Pediculosis – Treatment
• Permethrin cream 5% (Elimite®)
–OTC Permethrin 1% (Nix®)
• Pyrethrins (RID®)
• Lindane 1% shampoo (Kwell®)
–Seizures, aplastic anemia
• Malathion 0.5% in 78% isopropyl
alcohol (Ovide®)

88. Scabies
• Undiagnosed scabies = Seven-
Year Itch
• Mite: Sarcoptes scabiei
• Extremely itchy
• Diagnosis: burrows or scabies
prep (shave lesion, magnification)

89. Scabies
Source Undetermined

90. Scabies
Source Undetermined
Source Undetermined

91. Scabies
• Permethrin 5% cream (Elimite®)
or lindane 1% lotion (Kwell®)
• Leave on overnight, rinse off in
morning
• Lindane easier to apply, less
expensive, but some resistance
• Lindane neurotoxic to infants

92. Botfly
Source Undetermined

93. Larva Migrans
WeisSagung, Wikimedia Commons

94. Larva Migrans
Grook da Oger, Wikimedia Commons

95. Bed Bugs
• Bite pattern:
linear group
of 3 or more
bites
• Referred to as
“breakfast,
lunch, dinner”
pattern
Source Undetermined

96. Bed Bugs
Source Undetermined

97. Virus

98. Viral Infections
• Aphthous ulcer
• Erythema infectiosum
• Herpes simplex
• Herpes zoster
• Human papillomavirus (HPV)
• Molluscum contagiosum
• Warts

99. Aphthous Ulcer
• “Canker sore”
• Painful shallow
ulcer covered
with fibrin
• Adenopathy
common
Maksim, Wikimedia Commons

100. Aphthous Ulcer
• Differential
–Behçet's
–Herpes
Source Undetermined

101. Aphthous Ulcer
• Treatment
–Symptomatic
–Topical
steroids and
analgesics
Pixie, Wikimedia Commons

102. Erythema Infectiosum
• “Fifth disease”
• Parvovirus
• Fever, coryza,
headache,
malaise: 2 days
before rash
• No treatment
Source Undetermined

103. ID / Rash Trivia
• 1st disease: rubeola (measles)
• 2nd disease: scarlet fever
• 3rd disease: rubella
• 4th disease: toxin-producing
staphylococcus
• 5th disease: erythema infectiosum
(parvovirus)
• 6th disease: roseola

104. Herpes Simplex
• Herpes simplex
• Cold sore
• Fever blister
• Herpes labialis
• Herpes
gladiatorum
• Scrum pox
• Whitlow
Tzanck preparation:
multi-nucleated giant
keratinocyte
Source Undetermined

105. Herpes Simplex
Centers for Disease Control and Prevention,
Wikimedia Commons
James Heilman, MD, Wikimedia
Commons

106. Herpes Simplex
• Antivirals more effective in
primary infection than recurrence
• Acyclovir (Zovirax®) 400 mg TID
or 200 mg 5 times daily
• Valacyclovir (Valtrex®) BID
• Famciclovir (Famvir®) TID

107. Herpes Zoster
• Varicella Zoster Virus (VZV)
• “Shingles”
• Prodrome: flu-like symptoms prior
to rash
• Depression very common

108. Herpes Zoster
Fisle, Wikimedia Commons Jonathan Trobe, M.D. - University of
Michigan Kellogg Eye Center, Wikimedia
Commons

109. Herpes Zoster
• Herpes zoster ophthalmicus: CNV
–Vision-threatening condition
–Hutchinson sign: lesions on tip of
nose  nasociliary nerve
• Ramsay Hunt syndrome: CNVII
–Facial palsy resembling Bell palsy
–Vesicles in ear canal or on tympanic
membrane

110. Herpes Zoster
Gentgeen, Wikimedia Commons
James Heilman, MD, Wikimedia Commons

111. Human Papillomavirus
• Verruca vulgaris: common warts
• Verruca plantaris: plantar warts
• Verruca plana: flat warts
• Epidermodysplasia verruciformis
George Chernilevsky, Wikimedia
Commons
Enigma51, Wikimedia
Commons

112. Human Papillomavirus
Plantar warts Flat warts
Source UndeterminedLynes225, Wikimedia Commons

113. Human Papillomavirus
• Treatment: conservative, since
spontaneous remission is the rule
• Aggressive if symptomatic (e.g.
plantar, genital)
–Podofilox 0.5% (Condylox®) gel or
solution BID x 3 days  no therapy
x 4 days  repeat up to 4 cycles
–Cryotherapy

114. Molluscum Contagiosum
• Poxvirus  umbilicated papules
• Normal host: cosmetic problem,
spontaneous remission
• Immunocompromised host:
require HAART (Highly Active
AntiRetroviral Therapy) to avoid
widespread dissemination

115. Molluscum Contagiosum
Salvadorjo, Wikimedia CommonsSalvadorjo, Wikimedia Commons

116. Systemic

117. Rocky Mountain Spotted Fever
• Only in Western hemisphere
• Highest US incidence: Oklahoma,
North Carolina, Virginia, Maryland
• Rarely in Rocky Mountains
• Incubation: 3 to 14 days
• Prodrome: anorexia, irritability,
malaise, chills, fever

118. Rocky Mountain Spotted Fever
• History of tick bite ~60%
• Onset abrupt: fever (94%), severe
headache (86%), myalgias
especially back and legs (83%)
• First illness day: 14% have rash
• First 3 days: 49% have rash.
• 13%  no rash (spotless RMSF)

119. Rocky Mountain Spotted Fever
• Early lesions: 2 to 6 mm, pink,
blanchable macules
• Evolve to deep red papules
• In 2 to 4 days: hemorrhagic, no
longer blanchable
• Rarely: eschar

120. Rocky Mountain Spotted Fever
RMSF macules RMSF papules
Centers for Disease Control and Prevention,
Wikimedia Commons
Source Undetermined

121. Rocky Mountain Spotted Fever
Hemorrhagic lesions
Source Undetermined

122. Immune Thrombocytopenic Purpura
•  production
– Drugs, aplastic
•  destruction
– Drugs, TTP,
infection
• Sequestration
– Spleen
Stevenfruitsmaak, Wikimedia Commons

123. Immune Thrombocytopenic Purpura
• Common and
early site: palate
• Palatal petechiae
also seen in…
…strep throat
…mononucleosis
…rubella (measles)
Centers for Disease Control and
Prevention, Wikimedia Commons

124. German Measles (Rubella)
• Young adults
• Droplet spread
• No prodrome
• 14 – 21 day
incubation
• Lymph nodes
+/- arthralgias
Centers for Disease Control and
Prevention, Wikimedia Commons

125. Measles (Rubeola)
• Droplet spread
• 10 – 15 day
incubation
• URI, malaise,
photophobia
• Koplik spots
Source Undetermined

126. Chicken Pox (Varicella)
• 90% <10 years old
• Incubation 10 – 23
days
• Prodrome
uncommon
• Very itchy
• “Dewdrop on a
rose petal”
Camiloaranzales, Wikimedia
Commons

127. Janeway Lesions
Source Undetermined

128. Osler’s Nodes
Roberto J. Galindo, Wikimedia Commons

129. Lyme Borreleosis = ECM
Optigan13, Wikimedia Commons

130. Lyme Borreleosis = ECM
Just Some Guy, Wikimedia Commons

131. Lyme Borreleosis = ECM
Source Undetermined

132. Syphilis
Herbert L. Fred, MD, Hendrik A. van Dijk, Wikimedia Commons

133. Eczema Herpeticum
• Eczema
herpeticum
• Low-grade
fever, “tight”
skin
• Potentially
lethal
• Acyclovir
Source Undetermined

134. Eczema Herpeticum
• Eczema
herpeticum
• Low-grade
fever, “tight”
skin
• Potentially
lethal
• Acyclovir
Source Undetermined

135. 5. Maculopapular Lesions

136. 5. Maculopapular Lesions
• Erythema multiforme
• Erythema nodosum
• Henoch-Schönlein purpura (HSP)
• Pityriasis rosea
• Purpura
• Urticaria

137. Erythema Multiforme
• Idiopathic: >50%
• Drugs:
sulfonamides,
phenytoin,
barbiturates,
penicillin, allopurinol
• Infection: HSV,
mycoplasma
James Heilman, MD,
Wikimedia Commons

138. Erythema Multiforme
• Malaise, fever,
myalgias, arthralgias
• Pruritus or burning can
occur before skin
lesions develop
• “Multiforme” lesions,
“target” most familiar

139. Erythema Multiforme
Source Undetermined

140. Erythema Multiforme
Nbrigham, Wikimedia Commons

141. Erythema Multiforme
• Systemic steroids: symptomatic
relief, but don’t change duration
or outcome
• Extensive disease or mucous
membranes involvement 
hospitalize in ICU or burn unit
• Eye involvement: ophthalmology

142. Erythema Nodosum
• Inflammatory /
immunologic
reaction of
panniculus
• Painful nodules
on lower legs
• Multiple and
diverse causes
James Heilman, MD, Wikimedia
Commons

143. Erythema Nodosum
• Treat underlying cause (e.g., stop
medicine)
• Symptomatic relief: bedrest,
elevation, NSAIDs

144. Henoch-Schönlein Purpura
• Hypersensitivity
vasculitis
• Primarily children
• ~75% recent URI
with group A
streptococcus
Madhero88, Wikimedia Commons

145. Henoch-Schönlein Purpura
• Palpable purpura
• Bowel angina:
abdominal pain
worse after meal
• Bowel infarct
• Renal failure
• Arthritis
Kauczuk, Wikimedia Commons

146. Henoch-Schönlein Purpura
• Self-limiting
• Admit for pain control, blood loss,
hydration, renal monitoring
• If well-appearing, outpatient

147. Pityriasis Rosea
• Acute eruption, self-limited course
• “Herald” plaque on trunk
• Generalized secondary eruption 1
or 2 weeks later
• “Christmas tree” pattern
• Spontaneous remission in 6
weeks without therapy

148. Pityriasis Rosea
Centers for Disease Control and Prevention, Wikimedia Commons

149. Pityriasis Versicolor
Source Undetermined Source Undetermined

150. Purpura Fulminans
• Fever, shock, multiorgan failure,
rapid development hemorrhagic
skin necrosis
• Vascular collapse + disseminated
intravascular coagulation (DIC) =
dermal vascular thrombosis

151. Purpura Fulminans
Source Undetermined
Source Undetermined

152. Purpura Fulminans
Source Undetermined

153. Purpura Fulminans
Source Undetermined

154. Purpura Fulminans
Source Undetermined

155. Purpura Fulminans
Source Undetermined

156. Urticaria and Angioedema
• Urticaria: wheals  transient
edematous papules and plaques,
usually pruritic, due to edema of
papillary body
• Angioedema: larger edematous
area involving dermis and
subcutaneous tissue

157. Urticaria
Jmh649, Wikimedia Commons

158. Urticaria
Source Undetermined

159. Urticaria
• Urticaria = hives
• Cutaneous IgE-mediated
• Treatment
–Epinephrine + antihistamines +/-
steroids
–H2 receptor blocker if severe
–Cool compresses: soothing
• Refer to allergy specialist

160. Angioedema
• Angioedema of tongue, lips, face
in 0.1 to 0.2% of patients taking
ACE-inhibitor
• Management supportive, special
attention to airway
• Usual allergic-reaction drugs not
proven beneficial

161. Angioedema
James Heilman, MD, Wikimedia
Commons

162. Angioedema
Source Undetermined
BruceBlaus, Wikimedia Commons

163. Angioedema
During attack
Source Undetermined

164. 6. Papular/Nodular Lesions

165. 6. Papular/Nodular Lesions
• Hemangioma /
Lymphangioma
• Lipoma
Zeimusu, Wikimedia Commons
Source Undetermined

166. Hemangioma
• Benign vascular proliferations
• Regress without therapy
Source Undetermined Source Undetermined

167. Lymphangioma
• Multiple small fluid-
filled vesicles
(“frog-spawn”)
• Present at birth or
appears in infancy
or even in childhood
• No spontaneous
regression
Source Undetermined

168. Lipoma
• Benign subcutaneous tumor
• Soft, rounded, or lobulated
• Movable against overlying skin
• May become large
• Composed of fat cells

169. Lipoma
Source Undetermined

170. 6. Vesicular/Bullous Lesions
• Pemphigus vulgaris
• Staphylococcal scalded skin
syndrome
• Stevens Johnson syndrome
• Toxic epidermal necrolysis

171. Nikolsky’s Sign
• Epidermis
dislodged by
gentle finger
stroke near blister
• Pressure on
blister  lateral
extension of
subdermal fluid
Source Undetermined

172. Pemphigus Vulgaris
• Autoimmune, often fatal
• Age 40 to 60
• Treatment: high-dose steroids
• Other immunosuppression:
azathioprine, cyclophosphamide,
plasmapharesis, methotrexate,
etc.

173. Pemphigus Vulgaris
Source Undetermined Source Undetermined

174. Pemphigus Vulgaris
Source Undetermined

175. S.S.S.S.
• Staphylococcal scalded skin
syndrome = Ritter’s disease
• Toxin-mediated epidermolysis
• Bullous impetigo with
generalization  scarlatiniform
syndrome  generalized scalded-
skin syndrome

176. S.S.S.S.
• Erythroderma  exfoliation 
desquamation  recovery
• Tender erythema
• Positive Nikolsky’s (?)
• Spares mucous membranes
• Treatment: anti-staphylococcal
antibiotic, rehydration

177. S.S.S.S.
Source Undetermined
Source Undetermined

178. S.S.S.S.
Source Undetermined

179. Stevens-Johnson / T.E.N.
Stevens-Johnson syndrome =
Erythema Multiforme Major
Toxic epidermal necrolysis = TEN =
Lyell’s disease
• Drug-induced or idiopathic
• Skin tenderness and erythema
• Extensive cutaneous and mucosal
exfoliation

180. Stevens-Johnson / T.E.N.
~80% drug related
• Sulfa drugs:
sulfadoxine,
sulfadiazine,
sulfasalazine,
cotrimazole
• Allopurinol
• Carbamazepine
• Hydantoins
• Phenylbutazone
• Piroxicam
• Chlormezanone
• Amithiozone
• Aminopenicillins

181. Stevens-Johnson / T.E.N.
• Prodrome: fever, flu-like
symptoms 1 to 3 days prior to
mucocutaneous lesions
• Mild to moderate skin tenderness
• Positive Nikolsky’s
• Conjunctival burning or itching

182. Stevens-Johnson / T.E.N.
Dr. Thomas Habif, Wikimedia
Commons

183. Stevens-Johnson / T.E.N.
Source Undetermined
Source Undetermined

184. Stevens-Johnson / T.E.N.
Source Undetermined

185. Stevens-Johnson / T.E.N.
Source Undetermined

186. Stevens-Johnson / T.E.N.
• High mortality: dehydration and
infection
• ICU vs. burn unit

187. Think of these
conditions as
“Acute Skin
Failure” and
treat accordingly

188. …and finally
Magnus Manske, Wikimedia Commons

189. …and finally
Source Undetermined

190. Delusional Parasitosis
1. Suffered from infestation for long
time
2. Seen by numerous physicians,
exterminators, parsitologists,
hygienists and entomologists
3. Consistently and fiercely reject
negative findings or any that
deviate from their perceptions

191. Delusional Parasitosis
4. “Matchbox sign"
– Containers of dust, lint, skin
scrapings, toilet paper, dried blood
or scabs, hair or other pieces of
human tissue
5. Self mutilation ranging from
scratches to deep ulceration
– From attempting to dig out bugs

192. Delusional Parasitosis
6. One or more family members
may share delusion
– Folie à deux / Folie à trois
7. Use of home remedies, distrust
of prescription drugs
8. Self exposure to often
dangerous levels of pesticides

193. Delusional Parasitosis
• Similar to “cocaine bugs”
– Patient feels parasites crawling
under his skin
• Also associated with high fever,
extreme alcohol withdrawal
– Often associated with visual
hallucinations of insects

194. Morgellon’s Syndrome
Source Undetermined Source Undetermined
Source Undetermined
Source Undetermined

195. Morgellon’s Syndrome
1. “Filaments” in and on skin
2. Movement sensations, both
beneath and on skin
3. Skin lesions: spontaneously
appearing and self-generated
4. Musculoskeletal pain and
headaches

196. Morgellon’s Syndrome
5. Aerobic limitation: universal and
significant
6. Cognitive dysfunction: short-
term memory and attention
deficit
7. Emotional effects: loss of
boundary control