Serious Rashes You Won t Want to Miss! Miriam Weinstein MD FRCPC (Paediatrics) FRCPC (Dermatology)

Transcription

1 Serious Rashes You Won t Want to Miss! Miriam Weinstein MD FRCPC (Paediatrics) FRCPC (Dermatology)

2 Good Resources for Clinical Derm Photos **This website currently under construction

3 Objectives Participants will be able to: Use morphologic and historical clues to identify and differentiate rashes Identify the major causes of bullous eruptions and use historical and morphologic clues to distinguish each from one another Discuss the varied morphologies of drug eruptions

4 Outline Approach to rashes Test your knowledge Morphologic groups of rashes Examples of differentiating rashes Summary

5 Approach to Rashes 1. Disease categories 2. Morphology

6 Disease Category Infectious Inflammatory Drug eruptions Toxin mediated Allergic Neoplastic Environmental

7 Morphologic Approach Describe what is seen Designate it to a morphologic category Differentiate the rashes in the DDx

8 Morphologic Approach Describe what is seen Designate it to a morphologic category Differentiate the rashes in the DDx Diagnose Deal with the problem (management!)

9 Morphologic Approach 1. Known (pattern recognition) 2. Unsure 3. Unkown

10 What to do if unsure or unknown? Need tools to sort out search literature ask a colleague dermatology referral trial of treatment if suspected diagnosis observe utilize visual literacy skills

11 What to do if unsure or unknown? Need tools to sort out search literature ask a colleague dermatology referral trial of treatment if suspected diagnosis observe utilize visual literacy skills

12 Visual Literacy Ability to read visual images and extract meaningful information from what is seen

13 Visual Literacy in Dermatology The ability to derive diagnostic interpretations form observed visual clues

14 Visual Literacy Not just looking.but observing! To observe incorporates: History Morphology Experience Knowledge

15 Clinical Skin Problem Known Unsure Unknown Develop DDx Manage Appropriately Visual Literacy Skills Try to refine Dx How? Visual Literacy Skills? Visual Literacy Skills

16 Morbilliform Eruptions Blanchable Erythematous Small flat macules Slightly raised papules May coalesce NO: scale, crust, vesicle, nodules

17 Morbilliform Eruptions Not to Miss Eruptions Travel related exanthems Kawasaki Disease GVHD Drug eruption Viral exanthem (measles) Mild Moderate Eruptions Common viral exanthems

18 Morbilliform Eruptions Travel related: Dengue Typhoid fever Early spotted fevers

19 Dengue Flaviviruses 4 serotypes: DEN1, DEN2, DEN3, DEN4 Immunity after infection is distinct to serotype Aedes aegypti mosquito transmits to humans Significant global increase

20 Dengue Fever Many parts of Mexico, Central and South America Many parts of Africa India

21 Dengue Fever Clinical Features (~ 3 12 days after bite) Fever Bone pain Pain with eye movements Joint/muscle aches Adenopathy Morbilliform eruption From extremities to central Spares face Palms and soles can be involved

22 Dengue fever Illness can last two weeks Symptomatic treatment Diagnosis: Isolating virus or viral DNA (PCR) Paired serology Prevention Mosquito avoidance strategies No vaccine

23 Dengue Hemorrhagic Fever Specific syndrome Usually 2 5 days after start of illness Usually on second exposure of different serotype Most common < 10 years old Leukopenia, thrombocytopenia,hemoconcentration Features: High fever Pneumonia, myocarditis Systemic circulatory collapse Hemmorhage Bleeding, bruising, petichiae, mucosal bleeding Mortality up to 30%

24 Typhoid fever Salmonella Typhi In blood and stool Shed in stool if ill & chronically in carriers Fecal oral spread In most developing countries Especially Asia, Africa, Latin America

25 Typhoid fever High fever and rose spots In 10% Discrete pink macules on trunk and abdomen during 2 nd week of illness Vaccination available can wane over time, may need booster

26 Kawasaki Disease: Diagnostic Criteria Fever for 5 days or more Plus 4 of: Bilateral conjunctivitis (no purulent) Changes of the lips and oral cavity Dry, fissures, crack, swelling, strawberry tongue Swelling of the cervical lymph nodes >1.5 cm Polymorphous exanthem of body Red and swollen palms and soles

27 Measles Cough Coryza Conjunctivitis Koplik s spots On day 3 7 morbilliform eruption Starts at head and face and spreads down Turns brownish and fine desquamation Fever that lasts more than 3 days into rash: Consider measles related complications

28 Measles Still accounts for 250,000 childhood deaths per year Still common in developing countries INCOMPLETE vaccination rates in developed countries must keep this disease in mind Spread: respiratory droplets Incubation 7 14 days Infectious from: 2 days before symptoms Until at least 5 days after the rash

29 Measles Treat complications Vitamin A Reduces blindness Reduces death rates by 50% Complications Pneumonia, encephalitis, otitis media Vaccine within 72 hours of contact May prevent developing disease Immunoglobulin May prevent disease If given within 6 days of contact For high risk patients

30 Papulosquamous Eruptions Erythematous purple Raised papules and/or plaques Sharply marginated Have scale Many different types of scale

31 Papulosquamous Eruptions Not to Miss Eruptions Neonatal Lupus Mild Moderate Eruptions Psoriasis Tinea corporis Nummular eczema Pityriasis rosea

32 Neonatal Lupus Discrete, round oval scaly papules Raccoon pattern Appears up to 6 weeks, resolve ~6 months Maternal antibodies cross placenta Anti Ro +/ Anti La Mother often asymptomatic 2% of exposed fetuses

33 Neonatal Lupus Can have associated heart disease Typically heart block (1 st, 2 nd, 3 rd ) Cardiomyopathy +/ Hepatic or Hematologic disease

34 Neonatal Lupus Cutaneous NL self resolves, may leave scar Importance is in recognizing this sign May predict cardiac NL in baby Marker for risk of cardiac NL in future baby

35 Neonatal Lupus Once baby diagnosed Work up including heme/liver parameters Mother should have Examination for rheumatologic disease Antibodies checked Followed during subsequent pregnancies Risk of next baby having NL elevated Cutaneous Heart Block Hepatic involvement/hematologic Izmirly et al, Arthritis and Rheumatism, April 2010

36 Dermatitic Eruptions Erythematous Macular and/or papular Often poorly marginated +/ scale +/ crust

37 Dermatitic Eruptions Not to Miss Eruptions Zinc deficiency Scabies Mild Moderate Eruptions Atopic dermatitis Irritant contact dermatitis Seborrheic dermatitis

38 Zinc Deficiency Etiology: Acrodermatitis enteropathica AR Affects intestinal absorption and transport of zinc Impaired zinc excretion in breast milk Clinical: Diarrhea Skin eruption: perioral, acral, diaper area +/- alopecia Irritability Collect blood in special tubes Rapid improvement with zinc supplement

39 Scabies Polymorphous eruption: Dermatitis Papules and pustules Acute eruption Palms/soles, web space, axillae, areola, umbilicus

40 Treatment of Scabies 1. Treat scabies 2. Treat close contacts 3. Environmental measures 4. Treat pruritus 5. Treat 2 0 infection from scratching

41 Treatment of scabies: Patients and Close Contacts Permethrin 5% cream most effective Infants: treat whole body Children & Adults: treat from neck down Leave on overnight and wash in am Re treat 1 week later Low side effect profile

42 Treatment of Scabies Environmental: Linen & clothing from last 3 days: launder Routine cleaning and vacuuming of house Pruritus Antihistamines Topical cortisones Itch may last weeks after scabies gone Secondary infection Topical or oral antibiotics

43 Vesicluar Eruptions Fluid filled (blood/pus/serum or combination) Some present as papules first Can present as open erosions/ulcer (de roofed) Can present as small crusts May have mixed morphology with above Usually well demarcated Can range from flaccid to tense

44 Vesicular Bullous Eruptions Not to Miss Eruptions Varicella Eczema Herpeticum Coxsackie Virus Poison Ivy (acute ACD) Immunobullous eruption Staph Scalded Skin SJS TEN Bullous Erythema Multifore Mild Moderate Eruptions Bullous impetigo Herpes labialis

45 Varicella Papules, crusts and vesicles May be very mild in vaccinated child Children can get zoster Post disease or post vaccine NOT a sign of immunodeficiency Don t tend to get post herpetic neuralgia

46 Eczema Herpeticum Widespread herpes in atopic derm patient Can be recurrent Often superinfected with bacteria Punched out erosions and vesicles Patient may have systemic symptoms

47 Eczema Herpeticum Management High index of suspicion for diagnosis Confirm with viral culture/pcr from lesion If unwell, <1 year, poor fluid intake, severe: Admit and treat with IV acyclovir If well, good fluid intake, good follow up Oral acyclovir for 10 days Add antibiotics if necessary Saline compresses help wound healing

48 Enanthem: Enterovirus: Hand foot mouth Vesicles rupture leaving erosions on red base buccal mucosa, tongue, palate, uvula, tonsils Painful causing anorexia and dehydration Exanthem: Gray white vesiculopustules/papules +/ erythema Palms, soles, dorsal hands & feet, buttocks, perineum

49 Hand Foot Mouth Disease New Manifestations Can cause much more substantial eruption More extensive than classic HFM Different morphologies: Vesicular>papular> petechial 2 Vesicular patterns Can produce an eczema coxsackium in pts with eczema Can look like eczema herpeticum Widespread vesicular eruption beyond palms and soles Pediatrics June 2013; 132(1): e149 e157

50 Hand Foot Mouth Disease New Manifestations Newer eruptions may be caused by serotype A6 classic HFM most commonly caused by A16 (CVA16): N America classic HFM most commonly caused by EV 71: Asia Nail abnormalities more common with A6 Work up: PCR and/or culture NP swab, viral skin swab, stool Self limited Supportive management Pediatrics June 2013; 132(1): e149 e157

51 Allergic Contact Dermatitis Acute Vesicular

52 Allergic Contact Dermatitis Different patterns: Plant based Nickel Topical active ingredients

53 Allergic Contact Dermatitis Plant based Poison ivy is prototype (poison oak, sumac) Acute, intensely itchy Bullous eruptions Crusting Often linear Extremities, face, genitals common

54 Allergic Contact Dermatitis Management Identify and eliminate allergen May need patch testing to determine Topical steroids for localized dermatitis 1% hydrocortisone for face, groin, folds 0.05% betamethasone valerate for body 0.1% betamethasone valerate for thick areas Poison Ivy or other severe, acute ACD 3 week tapering course of oral steroids

55 Autoimmune Bullous Diseases Rare group of bullous disorders Antibodies to key proteins in skin Proteins destroyed through immune system Integrity of skin lost creating blisters Many disorders each targeting a different protein Problems: Pain, infection, can have severe mucosal involvement Can have significant morbidity

56 Autoimmune Bullous Diseases Treatment is usually with high dose steroids to start Usually add steroid sparing agents Examples: Pemphigus vulgaris Pemphigus foliaceus Bullous pemphigoid Linear IgA disease

57 Staphlococcal Scalded Skin Syndrome Bullous eruption from S. aureus toxins Large, flaccid bullae Rupture easily Often present only with collarette of scale Pain is common Fever and systemic symptoms uncommon Axilla, groin: peeling, erythema Face (crusts around mouth, eyes)

58 Staph Scalded Skin Treatment Swab possible sites for Staph Eyes, peri-rectal, nares, umbilicus, pustules Intravenous Cloxacillin Some will add Clindamycin (anti-toxin) Pain control Compresses to healing skin Switch to oral when well

59 SJS-TEN Spectrum with different degrees of severity SJS: <30% BSA involved with bullae TEN: >30% BSA involved with bullae Mucous membranes involved Almost always caused by drugs Steroids not usually used Treatment: IVIG or Cyclosporin

60 Bullous Erythema Multiforme Atypical targets With central vesicle Vesicles without targets Discrete lesions Erosions and crusts Mucous membranes involved Mycoplasma most common identified cause

61 Bullous Erythema Multiforme Management Admit for management Check for Mycoplasma Consider starting Abx for mycoplasma Ophtho and derm consult Oral care Systemic steroids often needed Wound care

62 History Bacterial Folliculitis Staph Aureus Acute eruption No pruritus Usually systemically well Physical Exam Perifollicular red papules and pustules Any hair bearing area

63 Hot Tub Folliculitis (Pseudomonos) History Acute eruption No pruritus Often painful History of exposure Usually systemically well Physical Exam Perifollicular red papules and pustules Usually lower limbs and buttocks

64 Hot tub folliculitis Pseudomonas folliculitis From hot tubs, pools, water slides etc. Risk factors: High water temperature Turbulence Aeration Heavy bather load Low chlorine levels

65 Hot tub folliculitis Treatment: Self resolves Can persist for several weeks Can be recurrent Topical steroids may WORSEN eruption Prevention: chlorine levels at 0.5mg/l and maintain ph between 7.2 and 7.8

66 Papular Eruptions Solid papules or plaques Flesh, pink, red, purple Vary in degree of infiltration Appear to sit on skin (vs. nodules in skin) Usually no scale or crust

67 Papular Eruptions Not to Miss Eruptions Erythema Multiforme Urticaria Urticaria Multiforme Arthropod bites Mild Moderate Eruptions Molluscum Verrucae

68 Distinguishing EM from Erythema Migrans Erythema Multiforme Erythema Migrans Most common cause Herpes simplex virus Lyme Disease Target lesions Multiple Solitary (usually) Expanding lesion(s) rare typical Mucosal involvement often none Recurrent Often Unlikely

69 Lyme Disease Borrelia burgdorferi (spirochete) Transmitted by Ixodes tick Transmission rare in 1 st 24h of attachment Transmission high after 48h of attachment Clinical stages: Primary: erythema migrans +/ systemic (~60%) Secondary: after above ends, 5 6 months Tertiary: ~7 months after infection (skin/internal) Untreated: Heart, rheum, neuro problems

70 Erythema Migrans 7 days after tick bite (2 28) at bite site Target lesions Often asymptomatic and unnoticed Gone by 1 month alone or 2 3 days (Tx d) Multi focal erythema migrans Can be seen in early disseminated Lyme disease

71 Erythema Migrans History Exposure (relevant travel)? Tick removed +/ mild systemic symptoms Expanding target lesion Physical exam Target lesion (usually solitary) Examine joint, cardiac, neuro and general

72 Lyme Disease Primarily a clinical diagnosis Serology Culturing Borrelia low yeild but unequivocal PCR (synovial or CSF fluid) Prevention Typical arthropod avoidance measures Treatment Doxycycline (only >9), amoxicillin, cefuroxime Oral antibiotics: days IV antibiotics: days (systemic disease) 200mg doxy within 72h of tick bite may reduce risk LD

73 Urticaria Wheals from transient dermal edema No scale and they leave no marks Often targetoid ; rarely true target lesions Each lesion last no more than 48 hours Crops can recur intermittently Chronic Urticaria: Crops last > 6 weeks Giant urticaria: serpiginous border with central clearing

74 Urticaria Many cases are idiopathic Viral illness is a common cause Food allergy is an uncommon cause IgE mediated drug eruption Other rare causes: Cholinergic urticaria Cold urticaria Exercise induced urticaria

75 Urticaria Management Acute: If think food: eliminate food & refer to allergy If viral: reassure, antihistamines, symptomatic If idiopathic: reassure, antihistamines Epipen if anaphylaxis symptoms Chronic: Above measures Consider workup in select patients Workup based on history and exam No standard workup

76 Arthropod Bites Hard to distinguish arthropod based on lesion Lesions often grouped 2 3 (can be many groups) Usually excoriated papule Can have urticarial wheal surrounding Common causes: mosquitoes, fleas, bedbugs

77 Arthropod Bites Management Prevention Avoid mosquito avoidance measures No standing water Avoid outside at dawn/dusk Insect repellent (follow CPS guidelines) Have pets checked and treated for fleas Treatment Antihistamines Topical corticosteroids Cool compresses

78 Petechial/Purpuric Eruptions Non blanchable Red purple Small large non palpable macules/patches Can get palpable purpura Usually suggests vasculitis

79 Petechial Eruptions Not to Miss Travel related: Spotted fevers Viral hemorrhagic fevers Non travel related: Henoch Schonlein Purpura ITP Vasculitis Meningococcemia Mild Moderate Eruptions Petechiae 2 0 to scratch, cough Bruising from minor injury PPGSS (Papular purpuric glove and socks syndrome) Progressive pigmentary purpura

80 Rickettsial Disease Intracellular parasites with endothelial cell as target Many different rickettsia in different parts of world Divided into: Spotted fevers Typhus group (variation of above) Transmitted via infected ticks and other arthropods Worldwide distribution Necrotic eschars in some tache noire Eschar at bite site with surrounding inflammation

81 Spotted fevers Different parts of the world Different rickettsia types Tick bite transmits rickettsia to blood and disseminates Risk of spotted fever depends on: Prevelenace of rickettsial infected ticks in given area Abundance of ticks Affinity of tick for human Tick needs attachement for at least 6 hours Asymptomatic so not usually recalaled

82 Rocky Mountain Spotted Fever Incubation 6 8 days Flu like syndrome High fever, non specific general symptoms Rash (90%): 2 4 days after fever Red macules at wrists/ankles Becomes papular then petechiae Spreads centrally Trunk, palms, soles Multi organ involvement Long term sequelae possible

83 Spotted fevers All similar to RMSF Varying degrees of eschar Rare (RMSF) 50% of lesions (eg., African tick bite fever) Diagnosis: Non specific lab changes Histology not that helpful Serology Can t differentiate between the rickettsiae Rise in titres during second week of illness Culture, PCR, immunohistochemistry: special labs

84 Spotted fevers Treatment Empiric therapy must be started before serology confirmed Doxycycline 200 q12 for 2 7 days Data suggests dental staining NOT an issue <8 Prophylactic Abx after tick bite NOT helpful Avoid tick infested areas in given country Volovitz et al 2007

85 Typhus group Mites or fleas are vectors Usually eschar at bite site generalized flu like symptoms maculopaoulr and petichial rash Epidemic typhus: Spread by body lice Parts of Africa, S. America Scrub typhus R. tsutsugamushi Endemic in South East Asia Dx: serology Tx: doxycycline or tetracycline

86 Viral Hemorrhagic Fevers Several distinct families of viruses arenaviruses, filoviruses, bunyaviruses, flaviviruses Severe multisystem disease Shock, bleeding, multiorgan failure Vascular damage Hemorrhage often major feature Reside in animal host or arthropod vector Some can spread human human Ebola, Marburg, Lassa South America and Africa Treatment: symptomatic Ribavirin has been tried

87 Viral Hemorrhagic Fevers Mucocutaneous findings Non specific Macular eruption Flushing Petechiae (axillary especially) Hemmorhage Accompanied by severe systemic signs

88 Dengue Hemorrhagic Fever Specific syndrome Usually 2 5 days after start of illness Usually on second exposure of different serotype Most common < 10 years old Leukopenia, thrombocytopenia,hemoconcentration Features: High fever Pneumonia, myocarditis Systemic circulatory collapse Hemorrhage Bleeding, bruising, petechiae, mucosal bleeding Mortality up to 30%

89 Erythema Multiforme Urticaria Erythema Migrans Arthropod bite Tinea Corporis True Target YES Rare YES Rare No Associations HSV +/ Viral illness Often None None None Pruritus Rare YES NO YES NO Exposure HSV +/ Viral Illness Tick bite; travel Outside, pets, travel Known contact; Tinea Capitis Distribution Acral Prominent Widespread Usually solitary Grouped (2 3) One many

90 Summary Use visual clues Use historical clues Distinguish red flags from red herrings

91 Summary Describe what is seen Designate it to a morphologic category Differentiate the rashes in the DDx Diagnose Deal with the problem (management!)

92 Maculopapular Papulosquamous Dermatitic Vesicular Papular Purpuric/Petechial

93 Vesicular Bullous Eruptions Not to Miss Eruptions Varicella Eczema Herpeticum Coxsackie Virus Poison Ivy (acute ACD) Immunobullous eruption Staph Scalded Skin SJS TEN Bullous Erythema Multifore Mild Moderate Eruptions Bullous impetigo Herpes labialis