M Langran, C Laird. The ABC of community emergency care 8 MANAGEMENT OF ALLERGY, RASHES, AND ITCHING. Box 1 Article objectives

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1 728 See end of artile for authors affiliations Correspondene to: Dr M Langran, Aviemore Health Centre, Muirton, Aviemore PH22 1SY, UK; mike@ski-injury.om The ABC of ommunity emergeny are 8 MANAGEMENT OF ALLERGY, RASHES, AND ITCHING T M Langran, C Laird Emerg Med J 2004; 21: doi: /emj he vast majority of skin problems that present in the ommunity are minor in nature. Unfortunately, very oasionally, the development of seemingly innouous symptoms suh as a rash and/or ithing an be the presenting symptoms of a life threatening ondition namely anaphylaxis or meningooal septiaemia. While other linial onditions an mimi both anaphylaxis and meningitis, espeially in the early stages, there are usually lues in the presentation that help to minimise the delays in administering appropriate therapy. It is not possible in this artile to over all potential auses of a rash and/or ithing. Rather, this hapter aims to fous on important onditions that require reognition, treatment, and possible referral in the aute prehospital setting. Box 1 lists the objetives of this artile. Box 1 Artile objetives With regard to the presentation of a rash and/or ithing: To understand the basi physiology and pathology underlying allergi auses of rashes and ithing To perform a primary survey of the patient and treat any immediately life threatening problems To identify any patients who have a normal primary survey but have an obvious need for hospital admission To perform a seondary survey inorporating other body systems that may be affeted by a rash and/or ithing To onsider a list of differential diagnoses Disuss treatment based on the probable diagnosis(es) Disuss appropriate patient follow up Desribe who an be safely onsidered for home treatment BASIC PHYSIOLOGY AND PATHOLOGY UNDERLYING ALLERGIC CAUSES OF RASHES AND ITCHING Allergi reations are linked to the release of hemial mediators, whih are released from mast ells in a proess known as degranulation. 1 This ours when an allergen ross links with immunoglobulin E (IgE) bound to reeptors on mast ells. These hemials are either released immediately (immediate allergi reation), or after a few hours (late phase response). This timing helps to guide appropriate treatment. PRIMARY SURVEY Assess for an ABC problem in patients with ithing and/or a rash (see box 2): Box 2 Primary survey Arrange immediate treatment and transfer to hospital if any of the following are present: Signs of airway obstrution Respiratory rate,10 or.29 Oxygen saturation,92% on air Pulse rate,50 or.120 Systoli BP,90 Glasgow oma sore,12 The reognition of developing airway obstrution is ritial, partiularly in the presene of anaphylaxis. Patients may omplain initially of a feeling of tightening in the throat, be unable to Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

2 omplete sentenes, or have audible airway noise (stridor or wheeze). If airway obstrution beomes omplete, then prompt initiation of a surgial airway will be required. PATIENTS WITH A NORMAL PRIMARY SURVEY WITH OBVIOUS NEED FOR HOSPITAL ADMISSION The following onditions may present initially with a normal primary survey but immediate treatment (if appropriate) and hospital admission should be initiated: Table 1 Timing of release of hemial mediators and appropriate treatment Timing of release Examples Treatment Immediate Delayed Histamine, tryptase, hydrolases Prostaglandins, leukotrienes, ytokines Antihistamines (for example, hlorpheniramine, etirizine) Cortiosteroids (for example, prednisolone) Suspeted rash of meningooal septiaemia Definite exposure to a trigger that has previously lead to an anaphylati reation Self administration of adrenaline (epinephrine) by a patient for a suspeted anaphylati reation A suspeted anaphylati reation that has not fully developed Cellulitis patient linially toxi or affeting the periorbital tissues The history and findings on examination should help to establish whether you are faed with suh a senario. Although these patients may not have abnormal linial signs at the time of assessment, this should not lull you into a false sense of seurity as they may deteriorate rapidly. In the ase of suspeted meningooal septiaemia, early administration of appropriate antibioti therapy is safe and assoiated with an improved prognosis. 2 Whenever there is a suspiion of anaphylaxis, adrenaline for intramusular injetion should be readily available. 3 If the above situations present, based on the history and examination findings as desribed in this artile, then appropriate treatment should be administered and hospital admission arranged. SECONDARY SURVEY (INCLUDING HISTORY TAKING) Having ensured that your patient has no immediately life threatening problems on their primary survey or the need for immediate hospital admission, you will be left with a patient for whom a areful history and examination should eluidate whether further treatment is required and whether or not the patient an be safely left at home. A history of the presenting omplaint should be taken, any other information noted, and an examination performed as desribed earlier in this series. Remember that the skin is the largest organ in the body and adequate exposure may be required to permit a thorough examination to be ompleted. Obviously, the degree of exposure will be ditated by the prevailing irumstanes and nature of the presenting omplaint(s). HISTORY The following will be helpful in establishing the diagnosis in someone presenting with a rash or ithing. Unfortunately, Table 2 Cause Foods Venom/stings Drugs Physial ontats Other Potential triggers for anaphylaxis Examples Nuts and seeds, eggs, seafood, kiwi fruit, bananas Bees, wasps, jellyfish, ants, snakebites Antibiotis, aspirin/nsaids, vaines, radio ontrast dye Latex rubber Cold temperatures, exerise NSAIDs, non-steroidal anti-inflammatory drugs (for example, ibuprofen, dilofena, naproxen, et) there are few linial tests that an help in the diagnosti proess, whih relies heavily on the use of a logial proess to identify and eliminate serious problems. Onset of symptoms Did the symptoms ome on suddenly over the ourse of a few minutes/hours or more gradually over the ourse of several days? Has there been reent injury to the area affeted (espeially a laeration)? Can symptoms be related to a partiular event? In partiular, the patient may be able to assoiate the symptoms with a speifi trigger, for example, onsumption of a partiular meal, use of a new shampoo, et. Table 2 lists the ommon potential triggers for an anaphylati reation. Pitfall Nuts are inreasingly being used as a filler in a wide range of foods. The patient may not therefore be aware that they have onsumed nut produts Rash/swelling If a rash is present then is it loalised or generalised? What olour is the rash? Does the area of the rash itself ith or is it atually painful to touh? Does the rash hange olour when pressed against the edge of a glass? If swelling is present, whih part(s) of the body are affeted? Pay partiular heed to any swelling involving the mouth, tongue, or eyes. Assoiated symptoms Of utmost importane is whether the patient feels generally well in him/herself. Does the patient have a generalised ith all over? Is there disturbane of another bodily system for example, gastrointestinal upset? Speifi inquiry should be made about the presene of vomiting, headahe, nek pain, ough, and eye disomfort. The patient should be asked whether they have reently had an upper respiratory trat infetion, or tonsillitis, or both. Progress of symptoms It is important to asertain whether the symptoms have ontinued to worsen sine their onset. Anaphylaxis and meningooal septiaemia are progressive onditions that will steadily deteriorate with time. However, if a patient with an allergi reation but without signs of anaphylaxis has remained stable for more than an hour they are unlikely to deteriorate further. Previous episodes Ask whether a similar episode has affeted the patient before. Previous episodes of anaphylaxis are unlikely to be easily 729 Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

3 730 forgotten! Unfortunately, a history of a previous allergi reation (mild or severe) does not predit the likelihood of an anaphylati reation a reation an still our despite a long history of previous safe exposure. 4 Pitfall Someone who has had previous safe exposure to a potential trigger (for example, peanuts, seafood, speifi drugs, et) may still experiene an anaphylati reation to it in the future. Risk fators Exposure to ertain triggers is assoiated with an inreased inidene of allergi reations (table 2). Medial history/drug history Any history of similar events should be noted. Many drugs an be impliated in the development of allergi reations and anaphylaxis. Aspirin aounts for about 3% of anaphylati reations and symptoms may our hours after ingestion. 5 Those allergi to aspirin may also be sensitive to NSAIDs, whih may ause a similar reation. A similar allergi assoiation an our with peniillins and ephalosporins. Even people who have had no previous problems with peniillins may experiene an anaphylatoid reation after taking them. Diabetis are at a higher risk of ellulitis. Family history A positive family history of similar episodes suggests hereditary angio-neuroti edema (HANE), whih is inherited as an autosomal dominant trait. Soial history Has the patient been in ontat with anyone who has had similar symptoms or felt unwell? Is the patient worried about a partiular diagnosis? If so, this should be exluded if possible so that the patient may be reassured. Examination See the earlier artile in this series relating to patient examination. It is always advisable to hek and reord the vital signs of any patient who presents with a possible allergi reation or rash. This inludes the measurement of temperature, pulse, blood pressure, and respiratory rate. An inreased temperature and/or the presene of enlarged (and often painful) lymph glands in the submandibular and/or ervial regions suggest the possibility of an infetive proess. It is sensible to test for nek stiffness in any patient who presents with a rash and systemi upset. The patient s nek should be passively flexed forwards towards the hest wall, a manoeuvre that should not be painful to omplete. If nek flexion auses pain, then Kernig s and Brudzinski s signs should be tested. Kernig s sign extend the knee with the hip flexed. Positive test if hamstrings ontration ours as a result Brudzinski s sign flex the nek passively. Test is positive if the knees and hips flex as a result. Pitfall Although a positive response to Kernig s or Brudzinski s tests is diagnosti of meninigism, the absene of a positive response does not rule out meningitis General examination Note the patient s overall demeanour. Do they appear well, at ease, and able to onverse normally or are they anxious, sweaty, onfused, or making abnormal noises as they breathe? If this is the ase, go bak and reassess their primary survey and onsider whether further treatment and/ or onward referral are required. Examination of the skin As previously mentioned, it is important to ensure adequate exposure of the skin, espeially in younger hildren who may be less able or likely to bring the presene of a rash to your attention. In a signifiant proportion of patients with meningooal septiaemia, the rash starts on the palms of the hands and/or the soles of the feet so be sure to examine these arefully. Is the rash painful to the touh? Reord any swelling of the tissues, espeially around the fae and the eyes. Gently examine inside the mouth looking for swelling of the tongue. Note the presene of any srath marks on the body. Note the olour assoiated with any rash does the rash disappear or hange olour when pressure is applied? (Ideally this should be done with the base of a lear glass). Table 3 lists the ommon terms used to desribe physial hanges in the skin assoiated with the presene of a rash. Table 3 Common terms used to desribe physial hanges in the skin assoiated with the presene of a rash Terminology Desription Clinial examples Maular Non-infiltrated flat lesions whih differ Erythema, purpura in olour from adjaent areas of skin Papular Well demarated raised lesions in the skin Urtiarial wheals, planar warts of varying sizes Vesiular Small protuberanes with a entral avity Chikenpox ontaining lear liquid Exoriations Very superfiial wounds in the surfae of the skin Srathes Purpura Small pathes of non-blanhing disolouration Meningooal disease aused by bleeding from small superfiial blood vessels in the skin Petehiae small spots of purpura Idiopathi thromboytopaeni purpura (ITP) Ehymoses large onfluent pathes of purpura Henoh Shonlein purpura (HSP) Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

4 Investigations There are few investigations that will quikly onfirm the diagnosis of a rash or ithing in the aute prehospital setting. The diagnosis usually requires a linial interpretation of the symptoms and signs presented. Differential diagnosis Table 4 lists the main important onditions to be distinguished in a patient presenting with a rash and/or ithing. Further information is given later in this artile speifi to eah ondition. Management plan Depending on the suspeted diagnosis and linial ondition of the patient, the usual management plan an be summarised as one of the following four hoies Pitfall Although a non-blanhing purpuri rash should be onsidered to be indiative of meningooal septiaemia in the prehospital setting, neither the absene of a rash nor the fat that a rash blanhes should be onsidered as ruling out meningitis or septiaemia Plan 1 admit and treat immediately as an emergeny Plan 2 admit as a semi-urgent ase for further assessment and treatment Plan 3 advisable to seek further advie from hospital Plan 4 an be treated at home, assuming no features of onern Where indiated, appropriate home management options are disussed for eah ondition Table 4 The main important onditions to be distinguished in a patient presenting with a rash and/or ithing Rash+/2ith Ithing alone Immune system mediated Immune system mediated Anaphylaxis Anaphylaxis Anaphylatoid reation Anaphylatoid reation Allergi reation loal Systemi Urtiaria ( hives ) and/or Systemi upset (for example, angioedema uraemia, holestasis, blood Idiopathi thromboytopaeni disorders) purpura (ITP) Other Infetive Senile ith Baterial Solid tumours Meningooal septiaemia HIV Cellulitis Impetigo Sarlet fever Viral Variella zoster Primary infetion (hikenpox) Reativation (herpes zoster or shingles ) Measles Rubella (German measles) Non-speifi viral rash Other onditions Henoh Shonlein purpura Psoriasis Ezema IMMUNE SYSTEM MEDIATED CONDITIONS Anaphylaxis and anaphylatoid reations Management plan 1. Admit and treat immediately Anaphylaxis refers to a severe generalised allergi reation, whereby speifi triggers (for example, inset stings, peanuts) stimulate the release of IgE immunoglobulin. This IgE release auses vasodilatation, airway swelling, and apillary leakage leading to hypotension. An anaphylatoid reation results in an idential situation, but does not entail the release of IgE. An example of this is the reation that an be seen to radiography dye. 6 While no universally aepted definition exists, a good working definition is a severe allergi reation to any stimulus, (usually) having sudden onset and generally lasting less than 24 hours, involving one or more body systems and produing one or more symptoms suh as hives, flushing, ithing, angio-oedema, stridor, wheezing, shortness of breath, vomiting, diarrhoea or shok. 7 The rate of anaphylaxis in the UK has risen from 6 per million in 1990/ 91 to 41 per million in 2000/01. 8 Symptoms and signs of anaphylaxis The diagnosis of anaphylaxis is linial. Symptoms usually begin within minutes of exposure to the trigger(s), but may be delayed by several hours. Many of the symptoms and signs of anaphylaxis may mimi other linial onditions, thus leading to a delay in diagnosis (table 5). For this reason, the first attak is partiularly dangerous. Having experiened the symptoms one, a surviving patient is likely to reognise their ourrene in the future thus aiding earlier diagnosis and treatment. Over 90% of patients with anaphylaxis will develop utaneous symptoms suh as urtiaria (see later), ithing, and angio-oedema that an help to distinguish the ondition from other diagnoses. A vasovagal reation, perhaps the ommonest mimi of an anaphylati episode, does not involve utaneous hanges, tahyardia, or bronhospasm. Patients often desribe a non-speifi but frightening feeling of impending doom. Untreated, anaphylaxis will steadily worsen and a progressive deterioration in the patient s linial ondition should alert an observer to the possibility of this diagnosis. Patients with signifiant ardiovasular ollapse may be unable to give a oherent history, adding to the potential for diagnosti delay. Table 5 Symptoms and signs of anaphylaxis with differential diagnosis(es) Symptom/signs of anaphylaxis Respiratory ompromise (shortness of breath, wheeze, stridor) Loss of onsiousness (LOC) Hypotension Collapse Cutaneous skin flushing Gastrointestinal (diarrhoea, abdominal ramps, nausea, and vomiting) Differential diagnosis(es) Asthma, COPD, inhaled foreign body, pulmonary embolism Vasovagal reation, seizures, ardia event (for example, arrhythmia) Vasovagal reation, shok (ardiogeni/ septi/hypovolaemi) As for hypotension/loc plus pani attak, hyperventilation syndrome, Munhausen s syndrome Vasovagal reation, arinoid syndrome, postmenopausal flushing Hereditary angio-neuroti oedema (HANE), food poisoning 731 Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

5 732 For all severe or reurrent reations and patients with asthma give Hydroortisone mg IM/or slowly IV Consider when ompatible history of severe allergi-type reation with respiratory diffiulty and/or hypotension espeially if skin hanges present Oxygen treatment when available Stridor, wheeze, respiratory distress or linial signs of shok 1 Adrenaline (epinephrine) 2,3 1:1000 solution 0.5 ml (500 mirograms) IM Repeat in 5 minutes if no linial improvement Antihistamine (hlorphenamine) mg IM/or slow IV IN ADDITION Management of anaphylaxis The management of suspeted anaphylaxis is a medial emergeny and is summarised in figures 1 and 2. Early reognition of symptoms, removal of the triggering soure (if possible), and prompt administration of adrenaline (epinephrine) are the fundamentals of suessful management. ABCs Airway pateny must be maintained and 100% oxygen should be applied to all patients as soon as it is available. If the patient has developed signs of omplete airway obstrution then a surgial airway must be initiated. Intravenous aess should be established as large volumes of fluid may be required to treat the severe hypotension often seen in anaphylaxis, if it does not orret rapidly with drug treatment. A rapid infusion of 1 2 litres of rystalloid or olloid, given in ml boluses, may be required if the radial pulse is lost. Children should reeive an initial bolus of 20 ml/kg with boluses repeated until a response is noted. Adrenaline Adrenaline 0.5 mg (0.5 ml of 1:1000) should be injeted intramusularly, preferably into the antero-lateral aspet of the upper arm or thigh. This route of administration has been shown to be superior to subutaneous injetion. 9 Adrenaline should be re-administered every five minutes until linial improvement ours. People taking b blokers may have a suboptimal response to adrenaline, with possible persistent severe hypotension and bradyardia. 10 The latter an be If linial manifestations of shok do not respond to drug treatment give 1 2 litres IV fluid. 4 Rapid infusion or one repeat dose may be neessary Figure 1 Anaphylati reations: treatment algorithm for adults by first medial responders (reprodued with permission of the Resusitation Counil UK treated with atropine ( mg intramusularly every 10 minutes to a maximum of 2 mg). Gluagon (as a 1 mg intravenously bolus) may also be effetive for patients taking b blokers although it is not liensed for this indiation Antihistamines Histamine is one of the prime hemial mediators of the anaphylati reation. Antihistamine drugs may therefore provide rapid relief of distressing symptoms. A H 1 antagonist drug suh as hlorpheniramine (10 20 mg intramusularly or slow intravenously) may be ombined with a H 2 antagonist suh as ranitidine (150 mg orally, if able to take) to effet maximal histamine blok. 11 Cortiosteroids Cortiosteroids, in the form of hydroortisone 200 mg (intravenously or intramusularly) or prednisolone (oral) 50 mg should be administered to minimise the likelihood and severity of seond phase reations. The benefits of administering ortiosteroids an take 6 12 hours to be realised, and it is emphasised that their main therapeuti influene is upon reurrent or protrated episodes. Even so, it is reognised that patients who have reeived ortiosteroids may still develop severe biphasi or prolonged reations. Pitfall Rapid administration of intravenous hlorpheniramine or ortiosteroids an ause hypotension Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

6 Consider diagnosis of anaphylaxis when ompatible history of severe allergi-type reation with respiratory diffiulty and/or hypotension espeially if skin hanges present > 12 years: 6 12 years: > 6 months 6 years: < 6 months Call ambulane suggested diagnosis 1 Stridor, wheeze, respiratory distress or linial signs of shok 2 For hypotension, lie patient flat with legs raised (unless respiratory distress inreased) Adrenaline (epinephrine) 1:1000 solution 500 mirograms IM (0.5 ml) 250 mirograms if hild is small or prepubertal mirograms IM (0.25 ml) mirograms IM (0.12 ml) 3 50 mirograms IM (0.05 ml) 4 Repeat in 5 minutes if no linial improvement. Remember urgeny of hospital transfer. b 2 agonists Bronhospasm is often a prominent symptom of anaphylaxis and ommonly manifests itself as shortness of breath and/or wheezing. It should be treated with a b 2 agonist suh as salbutamol (Ventolin) or terbutaline (Brianyl). Depending on resoures available, these may be administered via a standard inhaler devie or through a nebuliser (oxygen driven if possible). b 2 agonist therapy an be repeated as required or given ontinuously en route to hospital aording to the degree of response ahieved. Pitfall Bronhospasm should improve with the administration of a b 2 agonist, but this does not mean that the anaphylati proess is resolving or that adrenaline is not required Admission to hospital Although most episodes of anaphylaxis will our and reover within one to eight hours, the potential for a seond phase reation remains. As a onsequene, all patients who have sustained an anaphylati reation should be observed and monitored in a hospital setting. Loal hospital poliies may vary, but seond phase reations an our up to 24 hours after the initial episode, regardless of the response to treatment. For the next 48 hours after disharge, it is reommended that the patient remains in an environment that permits easy aess to medial attention should symptoms reur. This has important impliations for those patients who live in isolated rural ommunities. Figure 2 Anaphylati reations: treatment algorithm for hildren in the ommunity (reprodued with permission of the Resusitation Counil UK Follow up arrangements After an episode of anaphylaxis, there are two important issues to address with the patient. Firstly, an attempt should be made to identify the preipitating ause and redue the likelihood of further exposure. The possible ause may be obvious from the original linial presentation or otherwise onfirmation requires referral to an allergist for a skin prik test. Those who subsequently have a onfirmed IgE mediated allergy may be amenable to speifi and potentially urative immunotherapy. Seondly, patients need to be aware of the orret ations in the event of a reurrene. They should be presribed a self injetion devie for the administration of adrenaline (for example, Epi-Pen), be instruted in its appropriate use, and advised to obtain a Medi-Alert braelet or neklae. Close relatives, friends, and/or neighbours should also be onsidered for eduation as deemed appropriate to the individual irumstane. Allergi reations loal A far more ommon ourrene than anaphylaxis is the development of a loalised reation to an allergen without the development of serious generalised symptoms. The reation seen after an inset bite (see fig 3) is a lassi example of this. There is usually (but not always) a history of exposure to a potential allergen, after whih the patient may notie the development of skin hanges suh as rash, ithing, swelling, and/or pain. If the affeted area involves the mouth or nek then the potential for airway ompromise must be onsidered. There are three simple but important differentiations to be made that help to distinguish these less serious loal reations from those that may lead to a patient s deterioration: 733 Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

7 734 Figure 3 Rash aused by an inset bite. Reprodued with permission from Dermatology Online Atlas ( The patient s symptoms are generally loalised to the affeted area The patient has no symptoms or signs of systemi upset The patient s symptoms do not progressively worsen Treatment Simple measures suh as the appliation of ie may help with swelling and pain. The use of an oral antihistamine suh as etirizine (whih an be bought over the ounter by the patient and used in patients from the age of 2 upwards) will alleviate most of the patient s symptoms within one to three days. If the reation is more severe, then a three day ourse of oral ortiosteroids, for example, prednisolone EC (1 mg/kg/d for hildren, 30 mg/d for adults) may be administered to help redue the reation. The patient should be advised to seek medial attention again if their symptoms worsen, beome generalised, or have not resolved after three days. Urtiaria ( hives ) and angio-oedema Management plan 4. Home management if no features of onern Urtiaria and angio-oedema are related onditions and our together in about 50% of ases, with urtiaria a single entity in 40% and the remaining 10% being angio-oedema alone. The British Assoiation of Dermatologists offers useful online information for both patients and dotors. 15 Simple urtiaria This ondition typially produes an ithy wheal and flare reation anywhere on the body. The lesions usually have a raised entral area and blanh on diret pressure (see figs 4 and 5). Angio-oedema and urtiaria This ondition, whih is more ommon in female patients, tends to affet the extremities (for example, lips, eyelids, and digits) and is often painful rather than ithy. Most episodes are aute and self limiting but up to 10% will beome hroni in nature. In most ases, no definite ausal agent is found although any of the substanes in table 2 may be impliated in some ases. Most symptoms will settle by six weeks and the patient an be reassured about the benign nature of the ondition. Treatment in the aute phase entails avoidane of any obvious trigger(s) and the use of an oral H 1 Figure 4 Rash aused by hives. Reprodued with permission from Dermatology Online Atlas ( antihistamine agent suh as hlorpheniramine or etirizine. In the event that one agent is ineffetive, another should be substituted. 16 In the longer term, other agents inluding oral ortiosteroids may be required if the ondition beomes hroni. Angio-oedema without urtiaria The ommonest ause of isolated angio-oedema is hereditary angio-neuroti edema (HANE) this ondition is haraterised by reurrent aute swelling affeting the utaneous tissues and muous membranes of any part of the body. Most patients inherit the ondition as an autosomal dominant gene and experiene their first episode in hildhood. The defet is a lak of C 1 esterase inhibitor protein that leads to inappropriate ativation of the omplement pathway. Triggers may inlude allergens but a reation an also our after fright or physial trauma. Patients are usually familiar with the pattern of their symptoms, whih makes the diagnosis easier as their experiene grows. Although the symptoms of swelling usually develop gradually over many Figure 5 Rash on the leg aused by utiaria. Reprodued with permission from Dermatology Online Atlas ( Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

8 hours, involvement of the upper airway tissues an ause onern. Management of an aute episode depends on its severity. While peripheral swelling does not require ative treatment, airway involvement requires ative management inluding the administration of C 1 inhibitor onentrate. 17 Some patients may arry an auto-injetor ontaining this drug, whih should be administered immediately if available. Otherwise, urgent transfer to an alerted hospital is indiated. Other auses of isolated angio-oedema may be linked to the use of ertain mediations (ACE inhibitors in partiular). Angiotension 2 reeptor antagonists (for example, losartan) an be substituted as these are not assoiated with the ondition. If no ause an be identified, the ondition is deemed to be idiopathi. Idiopathi thromboytopaeni purpura (ITP) Management plan 3. Seek further advie from hospital This is a ondition where the body s immune system attaks platelets, the blood ells that help form blood lots. This leads to a low platelet ount in the blood (deteted through a full blood ount). As a result, ITP auses small amounts of bleeding into the skin tissues. Its ause is unknown, but there are two forms one that affets hildren (usually between 2 4 years old and ommonly after a viral infetion) and one that affets adults (usually women). It results in a non-blanhing purpuri rash, sometimes with more extensive pathes of bruising, but is not autely life threatening. Usually, people with ITP show no other signs of illness other than their rash in ontrast with patients with meningooal disease. If in doubt as to the ause of purpura in the prehospital setting, further medial advie should be obtained or hospital admission arranged. INFECTIVE CONDITIONS (1) Baterial Meningooal septiaemia Management plan 1. Admit and treat immediately Meningooal septiaemia is a life threatening ondition with high morbidity and mortality. In 2003, 732 ases were reported in England and Wales. 18 Unfortunately, partiularly in its early stages, its symptoms are fairly nonspeifi and may mimi those of a ommon viral illness. Although it may not our at all, the development of a rash is an important linial sign, espeially in the presene of systemi upset (for example, headahe, vomiting and/or altered mental status). The Meningitis Researh Foundation ( is one of many resoures with pratial advie and information for health professionals and lay persons. The lassi rash of meningooal septiaemia (see fig 6) may onsist of any of the following: Tiny red or brown pin prik marks (petehiae) Purple blothes Blood blisters The rash is usually desribed as non-blanhing that is, if a glass tumbler is pressed firmly against a septiaemi rash, the marks will not fade. In its initial phase, the rash may not have any of the lassi features desribed. In the ase of any patient with a rash, the patient and/or their arers should be eduated about features of possible onern and advised to Table 6 Reommended drug doses for meningooal septiaemia Patient s age Peniillin V Ceftriaxone Infant 300 mg 100 mg/kg Child (1 9 years) 600 mg Child (10 years+) 1.2 g 1 g Adult (16 years+) 1.2 g 1 g seek advie again if the nature of the rash hanges. It often starts first on the sole of the feet or the palm of the hands. The rash may not be as distint in patients with darkly oloured skin, in whom areas suh as the onjuntiva and the roof of the mouth should be heked arefully. Patients with septiaemia will usually beome seriously ill, often within a short time frame. Symptoms may be very subtle in infants and may inlude irritability, poor feeding, weak ry, and mottled skin. If in doubt, the infant should be admitted for observation. In the ase of suspeted meningooal septiaemia, appropriate antibioti treatment should be administered as soon as possible. Prehospital antibioti administration has been shown to redue the mortality in meningooal meningitis by about 50%. The inidene of true anaphylati reations to peniillin is extremely low and treatment should not be delayed unless there is a lear personal history of suh. 19 In these irumstanes, eftriaxone is the preferred alternative. 20 Table 6 gives the reommended doses of eah drug. Cellulitis Management plan 2 (admit semi-urgently) or 4 (treat at home). Depending on severity Cellulitis is an aute baterial infetion of the skin and subutaneous tissues. Most ommonly it involves the lower leg although any part of the body may be affeted. Untreated, infetion an spread and lead to septiaemia. Cellulitis involving the peri-orbital or orbital areas is of partiular onern as infetion may spread to the sagittal sinuses. The ommonest linial sign initially is a hot, raised, and erythematosus area of skin that is tender to the touh (see fig 7). As the ellulitis develops, the patient may develop systemi signs of infetion (raised temperature, sweats, tahyardia, and a feeling of malaise). The usual organisms involved are haemolyti streptooi and staphyloous aureus. 21 The history may indiate the portal of entry for Figure 6 Rash aused by septiaemia. Reprodued with permission from The Meningitis Trust ( 735 Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

9 736 the bateria suh as a laeration, abrasion, or reent surgery. The mainstay of treatment is a ombination of antibioti therapy, analgesia, elevation of affeted limbs, and treatment of any underlying ondition. Antibioti therapy The standard antibioti ombination for ellulitis is benzyl peniillin and fluloxaillin (both 500 mg six hourly for adults see the BNF or MIMS for paediatri dosing). An alternative for those hypersensitive to peniillin is erythromyin 500 mg six hourly. Hospital admission for intravenous antibiotis is reommended for patients with involvement of the (peri)orbital tissues, systemi symptoms, and those unable to tolerate oral treatment. Analgesia Cellulitis is often painful. Adequate analgesia should be presribed and the patient advised on minimising frition pain from lothes touhing the affeted area. Elevation An important aspet of management is to keep the affeted limb elevated whenever possible. This helps to redue tissue swelling and pain. Ideally the affeted limb should be kept higher than the heart and gentle exerises promoted to enourage fluid movement and redue the inidene of ompliations suh as deep vein thrombosis and pressure uleration. Treatment of the underlying ondition Any obvious wound that may have ated as a portal of entry should be examined and treated appropriately. Embedded foreign bodies should be removed. Other predisposing fators inlude diabetes, pre-existing oedema or skin uleration, and vasular disease. Cellulitis resulting from a human or animal bite an involve multiple organisms. Wounds should be thoroughly leaned and a wide spetrum antibioti suh as o-amoxilav presribed. Impetigo Management plan 4. Treat at home Impetigo is a highly ontagious baterial infetion of the superfiial tissues of the skin. It is spread by diret ontat and is ommon among hildren. The most ommonly impliated organisms are Staphyloous aureus and group A b haemolyti streptoous. Although healthy skin an be affeted, these bateria usually enter the skin through a ut, srath, or abrasion. The nose and peri-oral regions, being suseptible to minor trauma, are the usual sites of Figure 7 Cellulitis rash. Reprodued with permission from Dermatology Online Atlas ( Figure 8 Rash resulting from impetigo. Reprodued with permission from Dermatology Online Atlas ( presentation. A red sore that oozes fluid or pus usually heralds the start of the infetion. As the infetion spreads, other lesions appear nearby that may be painful or ithy (see fig 8). The patient does not usually have a temperature but there may be swelling of the lymph glands nearby. Treatment has traditionally been with either topial or oral antibiotis. A reent meta-analysis highlighted the lak of a quality evidene base for the most effetive treatment for impetigo. 22 The authors onluded that the use of a topial antibioti (suh as mupiroin (Batroban) or fuidi aid (Fuidin)) for seven days should be reommended in a patient with limited disease and no systemi upset. 22 Oral antibiotis are reserved for more severe infetions. The agents of hoie are ephalexin, o-amoxilav or erythromyin all available in suspension form. 23 Sarlet fever Management plan 4. Treat at home This ondition is assoiated with a baterial infetion of the throat aused by group A b haemolyti streptoous. It usually ours in hildren under the age of 18. Symptoms inlude a sore throat, fever, swollen ervial glands, and a rash that usually lasts two to five days. This initially appears as tiny red bumps on the hest and abdomen before spreading all over the body. It has an appearane like sunburn with a rough feel (see figs 9 and 10). The diagnosis is onfirmed by a throat swab, but treatment in the form of antibiotis (peniillin or erythromyin) is usually started on linial grounds. Left untreated, ompliations suh as nephritis or rheumati fever an result. Figure 9 Rash on the fae aused by sarlet fever. Reprodued with permission Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

10 Figure 10 Sarlet fever rash. Reprodued with permission from Department of Health, Hong Kong. (2) Viral Management plan 4. Treat at home A rash is a linial feature of many viral infetions. Most are self limiting and require no speifi treatments other than those aimed at reduing the assoiated symptoms, espeially fever and ith. Some of the ommoner infetions to present (often with a rash) in the ommunity are desribed in more detail below. Measles and rubella are notifiable diseases in the UK under the Publi Health (Infetious Diseases) Regulations 1988; hikenpox is notifiable in Sotland only. Variella zoster hikenpox and shingles Variella zoster presents as two linial entities. Primary infetion results in the rash known as hikenpox, a highly ontagious illness, usually ourring in hildhood outbreaks. The virus then lies dormant in nerve ells but may reativate to ause herpes zoster, also known as shingles. The risk of developing shingles inreases with age and redued immunoompetene (for example, immunosuppressive drugs, HIV infetion, aner). 24 Chikenpox (notifiable in Sotland) In Sotland in 2001 there were notifiations of hikenpox (428 per population, sot.nhs.uk/sieh aessed 28 Jul 2004). The lassi symptoms of hikenpox are a rash, fever, and the general feeling of malaise seen with other viral infetions. The rash usually appears within two weeks of exposure to the virus, with superfiial spots that soon develop into blisters that burst and rust over (see fig 11). It is often intensely ithy and (a diagnosti pointer) spreads above the fae and into the hair line. The rash remains a soure of infetion until all the blisters have rusted over. Chikenpox an spread to any person who has not been previously infeted or vainated. Although in hildhood it is usually a mild illness, it an Figure 11 Rash aused by hikenpox. Reprodued with permission from Dermatology Online Atlas ( lead to ompliations inluding ellulitis, pneumonia, and enephalitis. Chikenpox an also ause problems in pregnany mothers who have no immunity should avoid ontat with people with the illness and seek urgent medial advie if ontat has taken plae. Speifi immunoglobulin an be administered to redue the likelihood of subsequent infetion. In the absene of any ompliations, treatment is symptomati and should fous on standard drugs for fever redution, and antihistamines for assoiated ith. The affeted person should be isolated from ontat with the general publi and family members with no personal history of hikenpox until the rash has ompletely rusted over. Shingles Initially, patients with shingles usually experiene a nonspeifi prodrome similar to that of other viral infetions, followed by an area of abnormal skin sensation that may last one to five days before the appearane of the rash. Clusters of vesiles then appear that ultimately may ulerate before rusting. The rash never rosses the midline and follows the line of one or more dermatomes (see figs 12 and 13). Pain of varying severity is present in virtually all patients. The rash heals in two to four weeks but may leave areas of sarring and hanged pigmentation. In the aute phase, treatment entails the administration of appropriate analgesia. Initially this may take the form of paraetamol, with or without odeine (oodamol). Resistant ases may require the use of adjuvant pain relief suh as amitriptyline, gabapentin, or arbamazepine. Antiviral therapy in the form of aylovir, valylovir, or familovir should be targeted towards those with the highest risk of ompliations the immunoompromised, the elderly population, those with a large surfae area involved, and those in severe pain at presentation. Use of these agents also redues the inidene and severity of post-herpeti neuralgia (PHN) defined as pain that persists more than 30 days after the onset of the rash. 737 Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

11 738 Figure 12 Illustration showing shingles of the hest. Reprodued with permission from Dermatology Online Atlas ( The inidene of PHN inreases with age. Patients with a shingles rash on the forehead, around the eye or the nose have a 50% risk of developing severe eye ompliations. All suh patients should be referred to an eye speialist immediately for assessment. Measles (notifiable) Measles is the most frequent ause of vaine preventable deaths in hildhood. 25 It is primarily a viral respiratory trat infetion, whih an have serious or even fatal onsequenes for infants and small hildren. In 2003, there were 2488 ases notified to the Health Protetion Ageny. 18 Protetion is urrently offered through the MMR vaination. Unfortunately, sine a link between this vaine and the development of autism was suggested in 1998, 26 redued publi onfidene has resulted in a dereased uptake in vaination, heralding the possibility of a major measles Figure 13 Shingles on the fae. Reprodued with permission from Dermatology Online Atlas ( Figure 14 Measles rash. Reprodued with permission from Dermatology Online Atlas ( outbreak. While subsequent studies have onlusively shown no assoiation and some of the authors of the original study have also oneded that MMR has no ausal role, 27 vaine uptake remains as low as 61% in the UK. Measles usually begins with a fever, a persistent ough, runny nose, and sore throat. Two or three days later, the harateristi Koplik s spots appear. These are tiny red spots on the inner muosal lining of the heek. Subsequently, the fever inreases and a more generalised red blothy rash develops on the fae, along the hairline, and behind the ears. This slightly ithy rash rapidly spreads downward to the hest and bak and, finally, to the thighs and feet (see fig 14). The rash tends to fade within seven days with the illness itself lasting days. Measles is infetious from about four days before to four days after the rash appears. Compliations inlude ear infetions, pneumonia, enephalitis, and diarrhoea/vomiting. Non-immune pregnant women should seek speialist advie. Treatment is again largely symptomati, and entails isolating the patient from the general publi and suseptible family members. Rubella German measles (notifiable) Although aused by a different virus, rubella shares some harateristis with measles (hene its synonym germanus being Latin for similar). Rubella is neither as ontagious nor as serious as measles, exept that it an have serious onsequenes for the unborn hild of an unproteted mother. Protetion is again provided by the MMR vaine, whih has dramatially redued the inidene of the ondition. General symptoms, although milder, tend to be similar to measles but rarely last longer than three days. A fine, pink rash usually begins on the fae and quikly spreads to the trunk and then the arms and legs before disappearing (see fig 15). Ahing joints may our, as may tender enlargement of the ervial lymph nodes. Rubella very rarely auses ompliations outwith pregnany, where infetion in the first trimester an lead to ongenital abnormalities developing in up to 90% of ases. Symptomati treatment and isolation are the only usual requirements for rubella. Non-speifi viral rashes Virtually any viral infetion an result in the development of a rash, usually on the fae, hest, or bak. The rash is usually very fine, red in olour, and blanhes on pressure. It usually appears several days into the illness, often around the time the fever and other symptoms are improving. It may ith slightly but should not be painful. Care should be taken to exlude more serious auses of rashes (as outlined above). Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.

12 Figure 15 Rubella rash. Reprodued with permission from Dermatology Online Atlas ( The person affeted may have symptoms suh as a sore throat, runny nose, ough, or lethargy but has no symptoms of onern. The rash itself is not infetious and symptomati treatment only is required. (3) Other onditions Henoh Shonlein purpura (HSP) Management plan 3. Seek further advie from hospital Like ITP, the importane of this ondition is that it while it presents with a purpuri rash, it is not an aute life threatening ondition. HSP lassially affets hildren aged 3 to 8 years and is more ommon in boys. It often presents with a purpuri rash over the extensor surfaes of the buttoks and legs. Other ommon features are haematuria, proteinuria, and joint pains. The ondition is largely self limiting although a small perentage of those affeted may develop renal problems. Ezema and psoriasis Management plan 4. Treat at home Ezema and psoriasis are both hroni skin onditions that usually present in hildhood and require treatment (albeit often intermittently) for life. This is usually started by the patient s GP, oasionally with input from a dermatologist. While both onditions an ommonly adversely affet a patient s quality of life, they rarely lead to serious ompliations that might present to an out of hours pratitioner with two notable exeptions: Infetion Either ondition may beome infeted, usually as a result of the patient srathing at ithy lesions. This then requires the use of either a topial or oral antibioti in addition to any ongoing treatment. Appropriate therapy should be initiated as desribed earlier (see ellulitis). Pustular psoriasis Management plan 3. Seek further advie from hospital Aute generalised pustular psoriasis is a rare but potentially life threatening ompliation of psoriasis, usually requiring inpatient hospital treatment. As its name suggests, Figure 16 Pustular psoriasis affeting sole of the foot. Reprodued with permission from Dermatology Online Atlas ( it presents in a patient with known psoriasis as widespread small pustules with areas of erythema, usually affeting the soles of the hands and/or feet (see fig 16). The pustules may oalese to form large pathes of pus. The ondition may be preipitated by infetion, pregnany, or the withdrawal of ortiosteroid therapy. If suspeted, onsultation with a dermatologist or medial registrar on all is advised. OTHER CAUSES OF ISOLATED ITCHING Management plan 4. Treat at home Ithing in isolation may be the presenting feature of a wide range of other linial onditions (table 7). All an be managed in the out hours setting by the use of basi symptomati measures and the patient should be advised to seek medial assessment thereafter. Basi symptomati measures for the relief of ithing Ithing in isolation is often assoiated with dry skin, so a moisturiser should be applied. The skin should be kept ool and the patient advised to avoid alohol and spiy foods. Shower and bath water should be kept tepid to avoid further irritation. No universally effetive drug or ream exists for the relief of ithing. Antihistamine preparations in partiular are only Table 7 Cause Senile ith Cholestasis Uraemia Solid tumours Blood disorders HIV Causes of isolated ithing Comment Ours without an obvious ause in more than 50% of those aged.70 years and is thought to be linked to drying of the skin with age 1 Common symptom in jaundied patients Assoiated with hroni renal failure and affets about 25% of those on haemodialysis. It may be limited to the site of a haemodialysis shunt. Speifi tumours are assoiated with loalised ithing Srotal ith with prostate aner Ithy nostrils with brain tumours Vulval ith with ervial aner Ith may also ompliate hemotherapy Ith is frequently assoiated with disorders suh as Hodgkin s lymphoma, leukaemia, myeloma, and polyythaemia. It may also our with iron defiieny anaemia Ith is sometimes the first symptom of HIV related disease 739 Emerg Med J: first published as /emj on 20 Otober Downloaded from on 15 August 2018 by guest. Proteted by opyright.