What's Rash is that!
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This document discusses how to assess and describe rashes, including key factors in the patient history and physical exam. It provides case studies on common rashes such as measles, chickenpox, meningococcal disease, and anaphylaxis. The document emphasizes that most rashes are not serious but can be anxiety-provoking. It provides tips on characterizing rashes and determining when isolation may be necessary. Treatment is often supportive with focus on identifying any infectious causes or allergic reactions.
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What's Rash is that!
- 1. What Rash is that? Is it Infectious? By Kane Guthrie
- 2. Learning Points • General assessment of rashes • Describing rashes • When to Isolate • Pearls & Pitfalls • Case studies
- 3. Rashes • Most are not evidence of serious illness • Frequently alarm patients/parents • Rashes are one of the top 20 presentations to ED • Often anxiety provoking to health care providers
- 4. Rashes! “Recognition is 99% of the problem; treatment/advice is usually simple”
- 5. Describing a Rash • It’s a little tricky • Keep it simple • Pattern recognition!
- 9. History Taking • When did it start? • How quickly did it progress? Pearl: • The more lethal – the more rapid progression!
- 10. History Taking • Has the rash changed over time? • Where did it start & progress to? • Is the lesion pruritic? – Allergic response!
- 11. History Taking • Recent travel? – In the last month! • PMHx: – Immunocompromised, asplenia, cancer, DM, ETOH • Occupation – Child care, student, military, aid workers • Medications
- 12. Physical Exam • Get them undressed! Check: • Oral cavity • Adenopathy • Hepatosplenomegaly • Genitals • Nails & fingers
- 13. Skin Exam • Characterise type of lesion • Shape of individual lesion • Arrangement of multiple lesions – Linear, annular, disseminated • Pattern of rash – Sun exposed areas, flexor/extensor surfaces
- 14. Case 1 • 10 year old girl • Coryza, conjunctivitis, cough, fever • Maculopapular rash, starts behind ears • Descends onto upper torso
- 16. Koplik’s Spots • Manifest 2-3 days before measles rash • Cluster lesions buccal mucosa http://en.wikipedia.org/wiki/Koplik%27s_spots
- 17. Measles • Acute viral disease • Incubation period 10-14 days • Highly contagious – airborne route – Airborne precautions needed! • Non-immune @ high risk!
- 18. Early Symptoms • Fever • Tiredness • Cough • Sore throat • Runny nose • Sore eyes • Photophobia http://www.nevdgp.org.au/info/murtagh/Childrens/measles.htm
- 19. The Rash • Symptoms usually worsen over 3-5 days • Blotchy rash begins on the head • Spreads to rest of body over 1-2days • Rash last 4-7 days
- 20. Measles Complications • Middle ear infection 7% of cases • Bacterial pneumonia 6% of cases • 1:1000 cases encephalitis occurs – Results in death, permanent disability
- 22. Measles Management • Vaccination is the best treatment • Supportive care • Treat complications with AB’s
- 23. Case 2 • 4 year male • C/O headache, fever, then rash develops • Explosion of lesions: 1st to face/scalp, then trunk & limbs • No rash soles or palms!
- 24. The Rash • Many papules • Become vesicles http://bit.ly/1zL2y5E
- 25. Chicken Pox • Acute generalised viral infection • Incubation period 11-17 days • Highly contagious • Transmission direct contact/airborne – Use airborne precautions
- 26. Shingles • Blistering rash – dermatome distribution • Increased age • Immunosupression • Stress http://1.usa.gov/1yBhN0c
- 27. Varicella Zoster Complications Chicken pox: • Pneumonia, congenital varicella, neonatal varicella Shingles: • Post-herpetic neuralgia, zoster keratitis, motor nerve paralysis
- 28. Varicella Management • Prevention –imunisation • Supportive care • Pneumonia – give AB’s Shingles: • Commence acyclovir ASAP – Limits post-herpetic neuralgia
- 29. Case 3 • 17 female • S/B GP c/o fever, headaches & muscle pain – Dx: viral illness – sent home to rest • 12 hours later develops peticial > purpuric rash • Arrives in ED shocked!
- 30. The Rash
- 33. Meningococcal Septicaemia • Acute Bacterial Infection • Mainly affects young children/adolescents • Transmission by direct contact Resp secretions – Droplet precautions – AB’s for staff if exposed to resp secretions • Incubation period 2-4 days
- 34. Meningitis Complications • Abscess • Cerebritis • Deafness • Cognitive impairment • Hydrocephalus • Death
- 35. Meningitis Management • AB’s within 30mins of recognition – Broad spectrum (Ceftriaxone) – Immunocompromised add (Vancomycin) • Haemodynamic support • Dexamethasone 0.15mg/kg Q6 hourly
- 38. Hand Foot & Mouth Disease • Coxsackie virus • Common in kids- can affect all age groups • Low grade fever, anorexia, sore mouth • Oral lesions develop – Vesicles/erythematous base – painful • Hand/foot lesions – red papules • Symptomatic care- mouth wash/analgesia
- 39. Case 6 • 28 male • Hx epilepsy, on phenytoin • Presents: Shocked • Severe mouth ulcers • Maculopapular rash
- 40. Stevens Johnson Syndrome Toxic Epidermal Necrosis • SJS <10% BSA, TEN >30% BSA • Dermatological emergency • Causes: – Drugs: anticonvulsants, NSAIDs, antiviral, allopurinal – Malignancy: lymphoma – Idiopathic – Infectious
- 41. Clinical Features • Prodrome: fever, URTI, malaise • Macular rash develops: – Starts centrally – spreads peripherally – May be painful – Nikolsky’s sign (skin separation via blisters) • Mucous membranes severely affected
- 42. Management • Removing inciting cause • Airway support • Fluid replacements – follow burns protocol • Wound care • AB’s if infection • Consider but controversial: – IVIG, plasmapharesis, corticosteroids
- 43. Case 7 • 4 year boy • Hx of ^ red spots to legs over past 6/7 • Now spread to legs, buttock • Not responding to cream • Systemically well
- 44. Henoch-Schonlein Purpura • HSP- autoimmune, self limiting, – IgA-mediated small vessel vasculitis • Affects children 2-8 years old Diagnosis triad: 1. Purpuric rash on lower limbs/buttock 2. Joint pain/swelling 3. Abdominal pain
- 46. Complications
- 47. Management • Check renal function • Give analgesia • Consider Prednisolone 1mg/kg - 2/52 • Abdo pain last <72 hours • Joint pain last <48 hours • Rash resolves 4-6 weeks
- 48. Case 8 • 18 male • Eating kebab after night out • Develops erythematous rash and SOB
- 49. Anaphylaxis • IgE mediated hypersensitivity reaction • Leads to profound: – Histamine & serotonin release
- 50. Urticaria Vs Anaphylaxis • Urticaria: hives, weals, nettle rash • May occur alone or R/T allergic reaction • Histamine release
- 51. Anaphylaxis Pearls • Forget about the rash! – Focus hypotension, bronchospasm • Give adrenaline – its only thing that works! – Adult 0.5mg IMI, Child 0.3mg IMI • Fluid bolus • Ranitidine • Steroid • D/C Epipen
- 53. Scabies • Skin infestation scabie mite • 4-6 wk incubation period • Not a reflection of poor hygiene! • General eruption: linear burrows, papules, pustules • Treatment: Permethrin 5% all family members http://www.wikem.org/wiki/File:ScabiesD08.JPG
- 54. The Algorithms
- 59. There’s an App!
- 61. Take Home Points • Pattern recognition is everything • Always take a good history • Isolate if unsure • Look for: – Fever, toxicity, distribution, specific signs • Management is generally simple
Editor's Notes
- Scabies