Petechiae red, non blanching spots <5mm Purpura red, non blanching spots >5mm
Plaque = Palpable disc shaped lesion Wheal = Area of dermal oedema
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
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
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/
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
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
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
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.
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.
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
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)
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)
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.