Acute Dermatologic Conditions

• Acute dermatologic conditions are frequently encountered in primary care settings
• Prompt recognition and appropriate management are essential to alleviate patient discomfort and prevent complications
• Diagnostic accuracy relies on a thorough history, physical examination, and, when necessary, targeted investigations

Common Acute Dermatologic Conditions

• Urticaria (Hives): Characterized by pruritic, raised wheals that appear and resolve within hours
  • Often triggered by allergic reactions to foods, medications, insect stings, or infections
  • Treatment involves identifying and eliminating the trigger, if possible
  • Antihistamines, both H1 and H2 blockers, are the mainstay of symptomatic relief
  • In severe cases, systemic corticosteroids or epinephrine may be required
• Contact Dermatitis: An inflammatory reaction caused by direct contact with an irritant or allergen
  • Irritant contact dermatitis results from exposure to substances that directly damage the skin, such as harsh soaps or chemicals
  • Allergic contact dermatitis is a delayed hypersensitivity reaction to specific allergens like poison ivy or nickel
  • Management includes avoidance of the offending agent, topical corticosteroids, and emollients
  • Severe cases may necessitate systemic corticosteroids
• Eczema (Atopic Dermatitis): A chronic, relapsing inflammatory skin condition often associated with pruritus
  • Acute flares are characterized by intensely itchy, red, and weeping lesions
  • Triggers can include allergens, irritants, stress, and infections
  • Treatment focuses on restoring the skin barrier with emollients, topical corticosteroids for inflammation, and antihistamines for pruritus
  • Topical calcineurin inhibitors may be used as steroid-sparing agents
• Infections: Bacterial, viral, and fungal infections can manifest with acute dermatologic symptoms
  • Bacterial Infections:
    • Impetigo: A superficial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, presenting as honey-colored crusted lesions
      • Treatment involves topical or oral antibiotics
    • Cellulitis: A deeper skin infection characterized by erythema, warmth, swelling, and pain
      • Requires systemic antibiotics
  • Viral Infections:
    • Herpes Simplex Virus (HSV): Causes painful vesicles that often occur in clusters, typically on the oral or genital mucosa
      • Antiviral medications can reduce the duration and severity of outbreaks
    • Varicella-Zoster Virus (VZV): Causes chickenpox (varicella) in primary infection and shingles (herpes zoster) upon reactivation
      • Chickenpox presents with widespread itchy vesicular lesions
      • Shingles manifests as a painful, unilateral vesicular rash along a dermatome
      • Antiviral medications are effective for both conditions, especially when started early
  • Fungal Infections:
    • Tinea (Ringworm): A fungal infection that can affect the skin, hair, and nails, causing scaly, itchy lesions
      • Topical or oral antifungal medications, depending on the location and severity
    • Candidiasis: A yeast infection often occurring in moist areas, such as the mouth (thrush) or skin folds, causing red, itchy patches
      • Topical or oral antifungal medications
• Drug Eruptions: Adverse cutaneous reactions to medications, ranging from mild rashes to severe blistering conditions
  • Can present in various forms, including maculopapular eruptions, urticaria, fixed drug eruptions, and Stevens-Johnson syndrome (SJS)
  • Management involves discontinuing the suspected drug and providing symptomatic treatment with antihistamines or corticosteroids
  • Severe reactions like SJS require immediate hospitalization and specialist care
• Acne Vulgaris: A common inflammatory skin condition characterized by comedones, papules, pustules, and cysts
  • Although it can be chronic, acute flares often require prompt intervention
  • Topical treatments include retinoids, benzoyl peroxide, and antibiotics
  • Oral antibiotics or isotretinoin may be necessary for severe cases

Diagnostic Approach

• History:
  • Onset, duration, and progression of the skin condition
  • Associated symptoms, such as pruritus, pain, or fever
  • History of allergies, medications, and underlying medical conditions
  • Exposure to potential irritants, allergens, or infectious agents
• Physical Examination:
  • Careful inspection of the skin lesions, noting their morphology, distribution, and arrangement
  • Palpation of the lesions to assess texture, tenderness, and depth
  • Examination of mucous membranes and other body areas for involvement
• Investigations:
  • Skin scrapings for microscopic examination to diagnose fungal infections
  • Tzanck smear to detect herpes simplex or varicella-zoster virus
  • Patch testing to identify allergens in contact dermatitis
  • Skin biopsy for histopathological examination in uncertain cases
  • Bacterial culture and sensitivity testing for suspected bacterial infections

Management Principles

• Topical Corticosteroids: Effective for reducing inflammation in various dermatologic conditions
  • Available in different potencies
  • Low-potency corticosteroids are suitable for mild conditions and sensitive areas, such as the face and groin
  • High-potency corticosteroids are reserved for more severe conditions and less sensitive areas
  • Prolonged use can cause side effects, such as skin atrophy, telangiectasia, and striae
• Emollients: Help restore the skin barrier and reduce dryness and irritation
  • Should be applied liberally and frequently, especially after bathing
• Antihistamines: Relieve pruritus associated with urticaria, eczema, and other conditions
  • Both H1 and H2 blockers can be used
  • Sedating antihistamines may be helpful at night to improve sleep
• Antimicrobials: Used to treat bacterial, viral, and fungal infections
  • Topical or oral antibiotics for bacterial infections
  • Antiviral medications for herpes simplex and varicella-zoster virus infections
  • Topical or oral antifungal medications for fungal infections
• Wound Care: Proper wound care is essential for preventing secondary infections and promoting healing
  • Cleanse the affected area with mild soap and water
  • Apply a sterile dressing to protect the wound
  • Consider topical antibiotics for infected wounds
• Patient Education:
  • Provide clear and concise instructions regarding medication use, wound care, and preventive measures
  • Educate patients about potential triggers and how to avoid them
  • Encourage patients to follow up if symptoms worsen or do not improve

When to Refer

• Diagnostic uncertainty
• Severe or widespread skin involvement
• Lack of response to initial treatment
• Suspected drug eruption or other serious adverse reaction
• Involvement of mucous membranes or other critical areas
• Underlying medical conditions that may complicate management