Dermatology Pearls for Inpatient Medicine. Dr Peter J Green MD FRCPC Professor, Division of Dermatology Dalhousie University

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1 Dermatology Pearls for Inpatient Medicine Dr Peter J Green MD FRCPC Professor, Division of Dermatology Dalhousie University

2 Objectives 1. Review spectrum of cutaneous manifestations seen with inpatient population 2. Differentiate urgent and emergent presentations 3. Review therapeutic management of cutaneous diseases

3 Before we go on. If you say maculopapular. Dermatologist thinks two things: You mean a viral or drug eruption You frontin'

4 The drug rash

5 The set up Patient admitted to hospital for 4 plus weeks. Develops red, itchy rash all over No new soaps,?laundry detergent on sheets No new meds ( better be sure )

6 Key points: drug eruption Common, delayed hypersensitivity Symmetric, blanching erythema that progresses over days, sparing mucous membranes Common triggers in hospital will be antibiotics, cardiac meds, seizure meds Will not be : warfarin, tylenol, constipation meds, sleeping pills, opiates, iron Danger signs: mucous membranes, painful, sick patient, blistering AND/OR specific LABS

7 Key points Skin findings: new widespread, symmetric eruption with recent drug exposure Always go back at least 3 weeks to look for new med exposure Make a time line to clarify drugs vs skin findings

8 Don t. X. Start benadryl just because someone has a drug eruption X. Assume new skin findings in patient who started meds is a drug eruption X. Re-challenge patients to meds they report as true allergy

9 Do. Stop the suspected drug when possible Educate the patient about duration ( it gets more extensive before it gets better) Ask about previous exposures to same med Educate about re-exposure Know signs this is a serious drug eruption

10 Serious Drug Eruptions SJS/TEN Drug Hypersensitivity syndrome Acute generalized exanthematous pustulosis

11 SJS/TEN SJS and TEN probably a spectrum of severe blistering disease from drug exposure SJS/TEN - Widespread blisters predominant on the trunk and face, with underlying erythema and one or more mucous membrane erosions SJS/TEN overlap BUT may be separated based on 1. Clinical features/blistering pattern eg target vs sheet like 2. Percent of skin that is detached ie 10% vs 30%

12 When to suspect SJS/TEN Patient looks and feels sick Widespread rash with dusky areas plus fever Skin is painful rather than pruritic Separation of skin/blistering Mucous membrane involvement Recent DANGER drug exposure

13 Danger Drugs Allopurinol Anticonvulsants Phenytoin, lamotrigine, carbamezapine, phenobarbital Sulfa NSAIDs ( Oxicams) Antiretrovirals

14 Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University Admission After Clinical Diagnosis of SJS/TEN Admit to ICU or IMCU (under medicine) Discontinue offending drug Monitor respiratory status for possible airway intervention Establish IV access (through non-lesional skin if possible) and begin fluid resuscitation with crystalloids (burn protocol) Goals MAP > 65mmHg, CVP 8-12mmHg, urine output 0.5-1ml/kg/h Skin biopsy to confirm diagnosis (lesional skin) Reverse isolation in a heated environment with strict contact precautions Monitor CBC, electrolytes and extended electrolytes, liver function, creatinine, serum albumin, CRP/ESR, coagulation factors (transfuse as needed) Optimize pain management Calculate SCORTEN

15 Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University Medical Therapy First Line (order both therapies together) Cyclosporine 3 mg/kg/day PO/NG divided twice daily for 7-14 days (decrease to 1mg/kg/day divided BID if IV dosing) Monitor serum creatinine and blood pressure. Do baseline creatinine and repeat before the end of treatment. And Etanercept 50mg subcut x 1 Second Line IVIG 1-2g/kg/day for 3 days (For NS dosing: NSPBCP/IVIG-calculator.asp) Additional Therapy Corticosteroids 1mg/kg/day x 4 weeks, tapered over 3-6 months

16 Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University Wound Care Burn care dressings by RN trained for burn care (if possible) Careful patient handling to reduce shear forces on skin Chlorhexidine/saline (1:5000 dilution) compresses x 20 mins to skin daily Non-adherent dressings (petrolatum coated such as Jelonet) to denuded skin Avoid use of adhesive tapes Hydrous emollient application PRN once reepitheliaztion occurs Mucosal membrane care Chlorhexidine mouthwash QID Topical anesthetic or spray for buccal pain Petrolatum regularly to lips Foley catheter PRN

17 Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University Consultations to Consider Ophthalmology o For consideration of amniotic membrane transplantation in those with moderate to severe ocular involvement and topical therapies such as lubricants Gynecology/Urology o If significant mucosal membrane involvement Other Supportive Measures DVT prophylaxis Consider pan-culturing and broad spectrum antibiotics if indicated Nutrition supplementation through NG tube if necessary (hypercaloric, high protein diet) Physical therapy and mobilization when able

18 Drug Hypersensitivity When to suspect Syndrome Looks like a widespread drug eruption with erythema WITH FACIAL EDEMA Fever, lymphadenopathy, unwell patient Delayed onset after DANGER drug exposure ( 2-8 weeks) Atypical lymphocytosis, marked eosinophilia and/or other visceral involvement ( LIVER, KIDNEY, LUNG, HEART, THYROIDITIS)

19 DHS : Danger Drugs Anticonvulsants Minocycline Allopurinoal Azothioprine Dapsone Sulpha

20 Drug Hypersensitivity Syndrome STOP offending drug Supportive therapies Investigate/monitor visceral involvement Consider prednisone 1mg/kg Lung/heart. renal/liver less responsive

21 A case for you: Drug eruption or not

22 The set up 64 year old with DM admitted to hospital with toe pain and suspected left limb cellulitis, Xray of toe shows non specific changes, no osteomyelitis IV antibiotics ( vanco )started with improvement of cellulitis 5 days after admission, nurses ask about cream to use for worsening and painful yeast infection

23 What is the hallmark clinical finding?

24 Pustules

25 Acute Generalized Exanthematous Pustulosis Rapid appearance of fever, minute sterile pustules after antibiotic exposure (B-lactam, others) Often starts in intertriginous folds i.e. armpits, groin with more rapid spread Lasts for 1-2 weeks with progression towards desquamation ( peeling) Identify and D/C offending agent

26 AGEP: DIFF DX SJS/TEN DRESS Pustular psoriasis Staph scalded skin syndrome

27 And speaking of groins.

28 What about

29 Inverse Psoriasis

30 One offs test yourself

31 Case 1

32 New onset skin findings in someone admitted with asthma flare..

33 I would describe as A. Oslers nodes and Janeway lesions B. Target lesions C. Hemorrhagic vesicles and bullae D. Palpable purpura

34 I would diagnose A. Endocarditis B. Erythema multiforme from mycoplasma pneumonia C. Autoimmune bullous disease D. Vasculitis

35 I would describe as A. Oslers nodes and Janeway lesions B. Target lesions C. Hemorrhagic vesicles and bullae D. Palpable purpura

36 I would describe as A. Oslers nodes and Janeway lesions B. Target lesions C. Hemorrhagic vesicles and bullae D. Palpable purpura

37 I would diagnose A. Endocarditis B. Erythema multiforme from mycoplasma pneumonia C. Autoimmune bullous disease D. Vasculitis

38 I would diagnose A. Endocarditis B. Erythema multiforme from mycoplasma pneumonia C. Autoimmune bullous disease D. Vasculitis

39 Vasculitis and skin Small vessel Hypersensitivity ( drug, infection, CTD, meds) ANCA positive vasculitis Churg-Strauss, Granulomatous with polyangiitis, MPA Medium vessel Polyarteritis nodosa

40 Vasculitis Clinical finding of palpable purpura confirms vasculitis Laboratory investigations I start with : CBC, ANA, ANCA, cryoglobulins, hep B, hep C, BUN, Cr, urinalysis, IgG s, C3, C4, ESR

41 Case 2

42 Chest rash 6 weeks duration in patient with previous breast Ca

43 I would order A. Oral antiviral B. Topical steroid C. Cephalexin D. Skin punch biopsy

44 Metastatic inflammatory breast carcinoma

45 Take home point: consider metastatic disease of breast with persistent, localized skin findings

46 24 year old with Downs syndrome admitted with pneumonia- care giver mentions one year history of itch and rash

47 I would describe as A. Maculopapular B. Dry and scaly C. Generalized D. Crusted

48 I would describe as A. Maculopapular B. Dry and scaly C. Generalized D. Crusted

49 What is the hallmark clinical finding?

50 Crusting

51 What does this finding confirm?

52 Crusted ( Norweigan scabies)

53 Crusted scabies Severe infestation with 100 s of mites Highly contagious Usual scabies treatment with Topical 5% permethrin is insufficient 6% salicylic acid and multiple treatments with 5% permethrin Oral Ivermectin is best but hard to get CONTACTS AND CONTAINMENT!!

54 Case 3

55 56 year old female admitted for 6 days for investigations of TIA

56 New skin changes, unresponsive to Cephalexin over 48 hours

57 I would ask about A. Itch vs pain B. Culture and sensitivities for fluid swab C. Raynauds, photosensitivity, pleuritis/ pericarditis, arthritis D. Recent tick bite

58 I would ask about A. Itch vs pain B. Culture and sensitivities for fluid swab C. Raynauds, photosensitivity, pleuritis/ pericarditis, arthritis D. Recent tick bite

59 I would A. Switch to IV Cefazolin B. Switch to Doxycycline 100mg BID 21 days C. Treat with oral steroids D. D/C antibiotics, supportive therapy

60 I would A. Switch to IV Cefazolin B. Switch to Doxycycline 100mg BID 21 days C. Treat with oral steroids D. D/C antibiotics, supportive therapy

61 Allergic Contact Dermatitis

62 Allergic contact dermatitis Numerous sources in topical preparations, cosmetics, occupation etc eg Tea tree oil, vitamin E, Polysporin, adhesive, lidocaine, formaldehydes etc Range from eczematous to vesiculobullous Severe presentations resemble infections process Consider with well localized, ITCHY eruptions in a well patient who has failed to respond to antibiotics

63 Therapeutic hotline

64 Topical steroid Potency determined by vasoconstriction assay ( NOT percentage of molecule) Absorption greatest on thinnest skin, least on thickest : eyelid/genitals>palms and soles Ointments ( vaseline) more potent than creams ( white) Dry and scaly vs oozing, exudative

65 What to use PEDS: 1 % hydrocortisone cream or ointment ADULTS: FACE or FOLDS 1 % hydrocortisone cream or ointment ADULTS: BODY, EXTREMITIES Betamethasone valerate 0.1% OR triamcinolone acetonide 0.1% cream or ointment

66 Potency of steroids Mild potency 1%HC Medium ( 100X) BMV/TRIAMCINOLONE/MOMETASONE High BETAMETHASONE DIPROPRIONATE/FLUOCINOLIDE Ultrahigh ( 600X) CLOBETASOL

67 How much to apply? More than the pharmacist will tell them. Fingertip unit = 0.5 gms Two palm surfaces

68 Steroids: tips Fear of atrophy 1% HC will likely never cause atrophy, unless used under occlusion for prolonged period Choose base for AREA being treated e.g. ointments for hands/feet, lotions for scalp AVOID shotgun mixes of steroids/antibiotics/ antifungals eg: kenacomb/viaderm

69 Other complications of steroids

70 Perioral dermatitis Acneiform facial eruption, perioral with sparing of vermilion border Most common in children and adult females In adults, daily topical moisturizers implicated Topical steroids used to treat will create dependance, tolerance and escalation Treat with topical metronidazole/oral tetracyclines if moderate to severe

71 others

72 Questions