Dermatologic Emergencies PDF May 23, 2024

Dermatologic Emergencies Greg Jacobs, DO, DTM&H, CTropMed, FACEP, FAAEM May 23, 2024  Objectives 1. Describe the defining characteristics of various skin lesions. 2. Review important historical elements in patients with dermatologic complaints. 3. Describe symptoms,...

Dermatologic Emergencies Greg Jacobs, DO, DTM&H, CTropMed, FACEP, FAAEM May 23, 2024  Objectives 1. Describe the defining characteristics of various skin lesions. 2. Review important historical elements in patients with dermatologic complaints. 3. Describe symptoms, signs, and physical exam findings in some emergent dermatologic conditions. 4. Learn an algorithmic approach for developing a differential diagnosis in patients with key physical exam findings. 5. Describe some of the important dermatologic emergencies. Case oEva, a healthy 15-year-old on vacation with her family developed flu-like symptoms with a fever of 99.5F, so she took acetaminophen oThe next morning, she woke up with redness and blisters covering her face oRedness and blisters spread to shoulders and the rest of the body within 8 hours Case oWhen the doctor examined her, the skin around her eyes sloughed off on the doctor’s fingertips oWithin 24 hours, sloughing occurred on the neck, shoulders, stomach, and back Formulate a Differential Formulate a Differential oErythematous Rash oredness/inflammation Formulate a Differential oMaculopapular Rash oSmall bumps Formulate a Differential oPetechial/Purpuric Rash oPurplish spots or patches Formulate a Differential oVesiculobullous Rash oFluid-filled lesions https://cdn.ymaws.com/www.nmnpc.org/resource/resmgr/2017_Annual_Conference/Presentations_and_Hando uts/Cometti-Livingston_rash_skin.pdf Important Patient Historical Components oDistribution and progression oPeripheral? oCentral? oLocalized? oMost deadly rashes progress rapidly– within hours or minutes oTravel history oCaribbean/Mexico/South Florida/Louisiana à Dengue oCamping/Hiking (esp. in the NE) à tick-borne illness Important Patient Historical Components oMedical or occupational history oDM, Chemotherapy, HIV, IV drug use oCollege students, military personnel, day care workers oMedications oPotentially lethal drug reactions mandate emergency interventions oSelf-treatment may alter rash morphology oIs the rash an effect of a medication? Physical Exam Pointers oFever oMucous membrane involvement oNikolsky’s sign oSick or Not Sick Erythematous Rash Toxic Epidermal Necrolysis (TEN) A. Early eruption. Erythematous dusky red macules (flat atypical target lesions) that progressively coalesce and show epidermal detachment. B. Early presentation with vesicles and blisters, note the dusky color of blister roofs, strongly suggesting necrosis of the epidermis. C. Advanced eruption. Blisters and epidermal detachment Citation: Chapter 40. Epidermal Necrolysis (Stevens–Johnson have led to large confluent Syndrome and Toxic Epidermal Necrolysis), Goldsmith LA, Katz SI, erosions. Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Fitzpatrick's Dermatology in General Medicine, 8e; 2012. D. Complete epidermal necrolysis Available at: https://accessmedicine.mhmedical.c om/content.aspx?bookid=392&secti characterized by large erosive onid=41138737 Accessed: May 19, 2020 areas reminiscent of scalding. Copyright © 2020 McGraw-Hill Education. All rights reserved Toxic Epidermal Necrolysis (TEN) oThe most serious cutaneous drug reaction oMost commonly associated with sulfa drugs, but also associated with: o Anticonvulsants o Antivirals o NSAIDs oCan also be induced by infection (mycoplasma) or can be idiopathic (as in 1/3 of cases) https://www.aftonbladet.se/halsa/a/OnyR7w/tappade-all-hud--av-en-varktablett Toxic Epidermal Necrolysis (TEN) oPresents as a sudden onset diffuse erythema with tender skin and sloughing generally first in the face, then spreading to the shoulders, upper extremities, then entire body oMucosal involvement in 90% of cases oPathophysiology is poorly understood oWidespread keratinocyte apoptosis is cytotoxin mediated A. Extensive erosions and necroses of the lower lip and oral mucosa. B. Massive erosions covered by crusts on the lips. Note also shedding of eyelashes. Citation: Chapter 40. Epidermal Necrolysis (Stevens– Johnson Syndrome and Toxic Epidermal Necrolysis), Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Fitzpatrick's Dermatology in General Medicine, 8e; 2012. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid =392&sectionid=41138737 Accessed: May 19, 2020 Copyright © 2020 McGraw-Hill Education. All rights reserved Toxic Epidermal Necrolysis (TEN) Copyrights apply Toxic Epidermal Necrolysis (TEN) oTreatment oCessation of offending drug if known oWound care, eye care, electrolyte and fluid resuscitation oPrognosis oLong term complications include scarring, alopecia, mucosal sloughing, ocular damage or blindness oMortality is 10-70% and is dependent on how quickly treatment is initiated https://www.dailymail.co.uk/news/article-1242556/Eva-Uhlin-Miraculous- recovery-teenager-grew-face-suffering-rare-skin-disease.html Staphylococcal Scalded Skin Syndrome (SSSS, Ritter’s Disease) Staphylococcal Toxic Shock Syndrome Staphylococcal Scalded Skin Syndrome oMore common in children younger than 5 years oPresentation o scarlatiniform, erythematous rash that blisters and sloughs (positive Nikolsky sign) o Abrupt fever, erythema often of the neck, axillae, and groin, and extreme skin tenderness oPathophysiology o Exfoliative skin toxin produced by 5% of S. aureus Staphylococcal Scalded Skin Syndrome oDiagnosis oClinical diagnosis that may be confirmed by Staph positive blood cultures oDiagnostic clues include a lack of mucous membrane involvement and possibly a shallower skin cleavage plane than with TEN oTreatment oAntistaphylococcal antibiotics oFluid and electrolyte replacement oWound care Staphylococcal Scalded Skin Syndrome oPrognosis oEarly treatment can prevent serious complications oPneumonia oSeptic arthritis oHypothermia oDehydration oSecondary infections oIn adults, condition is very rare, but has a 60% mortality WITH appropriate treatment oIn children, mortality is