Emergency Dermatology

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Emergency Dermatology

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Emergency Dermatology

  1. 1. ED Dermatology
  2. 2. Aims Review terminology of skin conditions Identify common non-serious ED presentations Discuss serious but rare skin disorders
  3. 3. Definitions Macule Impalpable coloured lesion <1cm, circumscribed alteration of skin colour Patch Impalpable coloured lesion >1cm.
  4. 4.  Papule Palpable lump <1cm diameter. Nodule Palpable lump >1cm.
  5. 5.  Vesicle Palpable fluid filled lesion <1cm. Bulla Palpable fluid-filled lesion >1cm
  6. 6.  Petechiae red, non blanching spots <5mm Purpura red, non blanching spots >5mm
  7. 7.  Plaque = Palpable disc shaped lesion Wheal = Area of dermal oedema
  8. 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. 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. 10. ?
  11. 11. Urticaria
  12. 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 Investigation FBC / WCC / Eosinophils / Challenges Complement levels with angiooedema Management Remove cause / anti-histamines / steroids
  13. 13. ?
  14. 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. 15. ?
  16. 16. 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)  Immunosuppressants – Methotrexate, Cyclosporin, Mycophenalate  Infliximab / CD4 monoclonal antibodies
  17. 17. ?
  18. 18. ?
  19. 19. 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/
  20. 20. ?
  21. 21. ?
  22. 22. 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
  23. 23. ?
  24. 24. 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
  25. 25. ?
  26. 26. 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
  27. 27. ?
  28. 28. 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.
  29. 29. ?
  30. 30. 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
  31. 31. ?
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. ? 
  36. 36. Pityriasis Rosea Presumed viral. ?HHV 7. Christmas tree distribution. Self limiting over 6-12 weeks. Herald patch often mistaken for ringworm.
  37. 37. ?
  38. 38. 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.
  39. 39. ?
  40. 40. Melanoma Asymmetrical Border irregular Colour Variegated Diameter >5mm Evolution / Elevation
  41. 41. So far... Reviewed terminology Common, but usually not serious/life threatening conditions
  42. 42. Serious conditions with blistering / skin loss Erythema Multiforme major / SJS Pemphigus Pemphigoid TENS SSS ( Kawasaki’s )
  43. 43. ?
  44. 44. 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.
  45. 45. ?
  46. 46. 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
  47. 47. ?
  48. 48. 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)
  49. 49. ?
  50. 50. 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)
  51. 51. ?
  52. 52. 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.
  53. 53. ?
  54. 54. 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.
  55. 55. Red flags Unwell patient Other serious comorbidity, eg immunodeficiency Large area of skin Mucosal or ocular involvement Specific conditions with serious complications eg Kawasaki
  56. 56. If any doubts d/w senior colleague / dermatologistRemember you can easily send them an image ofa rash ! (in hours) A good reference website:http://dermnetnz.org/doctors/

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