The document discusses skin emergencies and defines terminology used to describe various skin conditions. It outlines clinical clues that may indicate a potential dermatologic emergency, such as fever and rash, or blistering in immunocompromised individuals. Several serious but rare conditions are then reviewed in more detail, including toxic epidermal necrolysis (TENS), Stevens-Johnson syndrome, pemphigus, pemphigoid, and necrotizing fasciitis. The document emphasizes identifying these conditions promptly and initiating appropriate treatment to prevent adverse outcomes.

1. Skin emergency
By
Dr. Hamdy Abdalla Badawy

2. 22
Aims
 Review terminology of skin conditions
 Discuss serious but rare skin disorders
 Identify clinical clues to the diagnosis of
potentially life-threatening dermatologic
conditions
 Discuss infectious and pharmacologic causes of
life-threatening dermatoses

3. Clues to the Presence of a Potential
Dermatologic Emergency
 Fever and rash
 Fever and blisters
 Rash in immunocompromised
 Palpable purpura
 “Full body redness”

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

5. 55
 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. 99
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. 1010
?

11. 1111
Urticaria

12. 1212
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
 Acute / Recurrent / Chronic
 Investigation
FBC / WCC / Eosinophils
 Management
Remove cause / anti-histamines / steroids

13. 1313
?

14. 1414
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

15. 1515
?

16. 1616
?

17. 1717
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
 Complications : Corneal ulcers / Gangrene of affected area / Phrenic Nerve palsy
/ Meningoencephalitis / Ramsay Hunt syndrome / Neuralgia / Disseminated
zoster
 NB if AIDS – major CNS effects/

18. 1818
?

19. 1919
?

20. 2020
HSV
 Pain / Itch / Vesicles / Sore mouth / Gum swelling /
Mouth ulcers
 Small vesicles & lymph nodes
 Complications –
 Erythema Multiforme / Encephalitis / Keratitis /
Disseminated infection if immunocompromised /
Visceral involvement / Neonatal / Meningitis
 Rx topical / oral / IV antivirals

21. 2121
?

22. 2222
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

23. ?

24. Staphylococcal Scalded Skin Syndrome
 Dermatologic findings
 Erythema periorificially on the face, neck, axilla,
groin. Then generalized within 48 hrs as the color
deepens
 Skin tenderness
 bullae w positive Nikolsky sign
 Within 1-2 days, flexural areas begin to slough off
 Complete re-epithelialization in 2 weeks
 Nikolsky Sign
Positive when a blister occurs on normal appearing
skin after application of lateral pressure w/ a finger
 Occurs in any superficial blistering process

25.  Clinical presentation
 Prodrome of fever, malaise, sore throat
 Complication
Mortality rate is 3% in kids, > 50% in adults
and 100% in adults with underlying diseases
If in newborn nursery, needs isolation

26. ?

27. Cellulitis and ErysipelasCellulitis and Erysipelas
 Spreading erythema and swelling
Erysipelas when intradermal and due to GpAStrep
 90% Haemolytic Strep (Group A)
 10% Staphylococcus aureus
 ? Anaerobe involvement
Rx:
Clindamycin + Ciprofloxacin

28. ?

29. Necrotizing fasciitis
 Etiology
 Necrosis of subcutaneous tissue due to infection
Type I : mixed anaerobes, gram negative
aerobic bacilli and enterococci
Type II: group A streptococci
 Risk factors: diabetes, peripheral vascular
disease, immunosuppression
 Dermatologic findings
 Diffuse edema and erythema of the affected skin-
> bullae-> burgundy color-> gangrene
 Severe pain, anesthesia. crepitus, exudates

30.  Clinical presentation
 Shock and organ failure
 Management
 Need surgical debridement of the necrotic tissue

31. ?

32. Meningococcemia
 Etiology
 Neisseria meningitides (gram neg diplococcus) spread
by respiratory route
 Often seen in young adults and children
 Risk factor: immunoglobulin or terminal complement
deficiencies
 Dermatologic findings
 Abrupt onset of maculopapular or petechial eruption on
trunk or lower extremities -> progression to purpura in
hours
 Angular edge with “gun metal gray” center
 +/- mucosal involvement

33.  Clinical presentation
 Flu like symptoms: fever, chills, malaise
 DIC, shock, death

34. 3434
?

35. 3535

36. 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
 Mycoplasma, TB, Histoplasmosis.
 Drugs: Sulphonamides. Barbiturates. Penicillin. Phenytoin. NSAIDS.
Allopurinol.
 Malignancy
 Idiopathic
 Rx – Minor consider antivirals if HSV / symptomatic

37. 3737
?

38. 3838
Erythema Nodosum
 Painful nodules, poorly defined. +++ tender
 Hx – fever / painful nodules/ arthralgias / sore throat / drugs / Cough
 Aetiology:
 Strep / TB / Yersinia / Leprosy / Histoplasmosis
 Sarcoid
 SLE
 Behcets
 IBD
 Drugs – Sulphonamides / OCP
 Management
 Definitive dx – wedge biopsy
 CXR
 Throat Swabs.
 Symptomatic
 Self–limiting - 3-6 weeks
 NSAIDS
 Elevation
 Compression Stockings.

39. 3939
So far...
 Reviewed terminology
 Common, but usually not serious/life threatening
conditions

40. Serious conditions with
blistering / skin loss
 Erythema Multiforme major / SJS
 Pemphigus
 Pemphigoid
 TENS
 Angioedema

41. 4141
?

42. 4242
Erythema Multiforme Major
 Stevens Johnson Syndrome
 Drug induced mucocutaneous reaction
 Culprit medications: Sulfonamides, anticonvulsants,
allopurinol, NSAIDs. Usually given 1-3 weeks before onset
 Genetic susceptibility
 +/- Clinical presentation
 Prodrome: fever, chills, malaise
 Stinging eyes, difficulty swallowing and urinating

43.  Dermatologic findings
 Skin tenderness
 Dusky erythema
 Epidermal detachment and desquamation
 Mucosal involvement
 Widespread rash involving up to 10% BSA skin
sloughing / blistering.

44. 4444
?

45. 4545
Toxic Epidermal Necrolysis
 Mostly thought to be drug related
 Culprit medications: Sulfonamides, anticonvulsants,
allopurinol, NSAIDs.
 Widespread rash like sunburn initially >30% TBSA with later
necrosis and sloughing. +ve Nikolsky sign
( Nikolsky’s sign -separation of skin with gentle pressure.)
 Large mucous membrane involvement.
 Complications:
 High mortality
 Ophthalmology involvement and regular eye irrigation

46. Treatment SJS/TEN:
 Prompt drug withdrawal.
 Admission / Burn unit, ICU
 Ophthalmology, urology
 IVIG
 Systemic steroid is controversial

47. ?

48. Angioedema
 Pathophysiology
 Increased intravascular permeability
 Dermatologic findings
 Well circumscribed acute cutaneous edema due to
increased intravascular permeability
 Face, lips, extremities, genitalia
 Painful, usually not pruritic
 Clinical presentation
 Abdominal pain
 Respiratory distress

49.  Etiology:
 Often idiopathic
 Medications
angiotensin-converting- enzyme inhibitor in 10-25%
of cases
Penicillin
NSAID
 Allergens (foods, radiographic contrast media)
 Physical agents (cold, vibration, etc)
 C1 esterase inhibitor deficiency: hereditary vs
associated with autoimmune disorder or malignancy

50.  Management
 Airway management
In cases with laryngeal involvement, a definitive airway If the airway
cannot be effectively secured with an endotracheal tube, a surgical
airway is indicated, usually in the form of an emergency
cricothyrotomy
 epinephrine : Used in pts who demonstrate upper airway obstruction,
respiratory failure or shock
 Antihistamines
 Cool compresses
 Avoid triggers
 For pts with C1 esterase inhibitor deficiency:
C1 esterase inhibitor concentrate,

51. 5151
?

52. 5252
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.
 Rx: Barrier nursing / antibx / IV fluids / systemic steroids +/-
immunosuppressants (azathioprine / cyclophosphamide / methotrexate /
gold / dapsone /ciclosporin)

53. 5353
?

54. 5454
Pemphigoid
 More common than pemphigus
 Generally benign
 Also Autoimmune
 Affects older age group
 Affects deeper layer in skin – tense flexural areas
 Treatment same as Pemphigus – steroids +/-
immunosupressants
 Variants
 Gestational
 Mucous membrane (Cicatricial)

55. 5555
?

56. 5656

58. Purpuric Rash
 Petechiae <5mm.
 Purpura >5mm.
 Causes:
 Drugs: Steroids / Gold / Anticoagulants
 Senile
 Trauma
 Coughing / vomiting / direct.
 Infection
 Meningococcal, Cellulitis, Viral.
 Vasculitic
 Thrombocytopenia
 ITP / TTP / Leukaemia / DIC.

59. 5959
Red flags
 Unwell patient
 Other serious comorbidity, eg immunodeficiency
 Large area of skin
 Mucosal or ocular involvement

60. If any doubts d/w senior colleague / dermatologist
Remember you can easily send them an image of
a rash !

61. THANK YOU FOR YOUR
ATTENTION !