Concentrate on Descriptors. An Approach to Skin Diseases in the ER
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1 Concentrate on Descriptors An Approach to Skin Diseases in the ER Toby Maurer, MD University of California, San Francisco Vasculitis-leaky blood vessels Targetoid lesions-round lesions with blue or red center Urticaria-hives Redness Blisters-clear fluid that may become murky Pustules-murky small fluid filled lesions Infestations For each descriptor, think about following etiologies Infection Drug Reactions Connective tissue disease Rheumatologic/Blistering Diseases Leukemia/Lymphoma 1
2 Leaky blood vessels Vasculitis Multiple purple papules/macules Usually legs, arms +/- fever, +/- edema Infection, drugs, connective tissue dz, leukemia/lymphoma Vasculitis: Infection Meningococcemia Strep Staph (endocarditis) Hepatitis A, B, C TB Vasculitis: Infection Nuchal rigidity/neuro changes Murmur CBC, Pharyngeal cx, ASO titer, Bl cx X 3, Hep screen, Chest X-Ray skin biopsy helpful to confirm 2
3 Vasculitis: Drugs Any antibiotics Any medications Vasculitis: Connective Tissue Disease Lupus/Dermatomyositis Rheumatoid Arthritis Cryoglobulinemia Henoch-Schonlein (+/- GI and renal) 3
4 Vasculitis: Connective Tissue Disease Joint aches, photosensitivity ANA, ESR, Fe Rheumatoid factor, Hep C and cryoglobulins Vasculitis: Leukemia/Lymphoma CBC/smear Chest X-Ray Vasculitis Nutritional: Scurvy-lack of vit C Older person-eating toast and tea Psychiatric pt Look for bruising, GI bleeds, corkscrew hair Get Vit C level and replace vit c Biopsy helpful 4
5 Treatment of Vasculitis Look for and treat underlying disease Check Urinalysis for red cells If asymptomatic-reassure If symptomatic (pain, swelling, joint aches, red cells in urine): bedrest, antihistamines, colchicine (0.6 mg bid), Prednisone 5
6 Targetoid Lesions (Erythema Multiforme) Round lesions with dusky blue centers Usually painful Often on palms, soles, knees, elbows +/- blisters Infection, drug, connective tissue dz, leukemia/lymph Targetoid Lesions: Infection (Reaction pattern to infection) Herpes Simplex Previous history Recent outbreak of orolabial/genital HSV Cx if there is a primary lesion Mycoplasma: dry cough Persons under 21 +/- blisters Titers, chest x-ray, start IV, erythro 6
7 Targetoid Lesions: Drugs Septra most common Targetoid Lesions: Treatment Discontinue offending drug Prednisone controversial Helpful in HSV driven EM Persons with recurrent EM Prophylax with ACV 400 mg tid 7
8 Urticaria Wheals that come and go within 24 hr periods Pruritic Infection, drugs, connective tissue dz, leukemia/lymphoma Urticaria: Infection Strep-sinusitis, teeth, pharynx (cx s and ASO titer) Viral 8
9 Any Aspirin Others: Urticaria: Drugs Food products Nuts, shellfish, citrus fruit CBC Urticaria: Leukemia/Lymphoma Chest X-Ray Blisters Acute Urticaria from any cause can last 6 weeks Chronic urticaria: 2-7 years If you can find cause, treat it Avoid Prednisone if possible Non-sedating antihistamines by day Allegra, Claritin, Zyrtec Sedating antihistamines by night Benadryl, Atarax, Doxepin Clear fluid underneath Infection, drugs, connective tissue dz, leukemia/lymphoma 9
10 Blisters: Infection Sometimes fluid is murky(=pustulobullous lesion) Herpes Zoster - Shingles Dermatomal, painful Patients may have pain before blister appears 10
11 Blisters: Treatment ACV 800 mg 5 x s/day Famvir 500mg tid Valacyclovir 1000 tid begin within 48 hrs of onset of blister. Any time in immunosuppressed host Pain control NSAIDS/Tylenol Neurontin: 100 mg tid Elavil: 25 mg qhs or q 8 hrs Prednisone: no role Staph: Bullous Impetigo (+) bacteria in blisters Tx: antibiotics 11
12 Staph scalded skin Toxin mediated reaction to staph (from skin, heart, ears, etc.) Big blisters Painful red skin underneath NO BACTERIA IN BLISTERS Search for source Tx source with antibiotics Comfort care for skin (burn unit) Blisters: Drug Bullous Drug Reaction Septra, antiseizure medications History and biopsy diagnosis 12
13 Blisters: Drug Toxic Epidermal Necrolysis Sheets of skin desquamating Biopsy (frozen section) helpful to distinguish between staph scalded skin and drug Prednisone controversial IVIg being used 13
14 Pressure Necrosis Blister with strange borders Usually in person found down for long period of time Check CK and creatinine Area will slough off 14
15 Blisters: Connective Tissue Diseases Blistering Diseases: Bullous Pemphigus and Pemphigoid mid-size to large blisters Often in the elderly Biopsy diagnosis and consultation Can be life threatening Start Prednisone 15
16 Blisters: Connective Tissue Diseases Blisters in or around umbilicus in pregnancy Bx to rule out herpes gestationis Monitor fetus May need Prednisone Total Body Redness Infection, drugs, leukemia, lymphoma Infection Toxin medicated staph/strep EBV CMV Total Body Redness: Drug Drug Hypersensitivity Syndrome Allopurinol Dapsone Antiseizure medications Septra Nevirapine/Sustiva/Abacavir (+) fever (+) lymphadenopathy Check kidneys, check liver +/- Prednisone 16
17 Total Body Redness: Leukemia/Lymphoma T-cell lymphoma of the skin Biopsy in order to rule out mimickers: atopic derm, psoriasis, drug reaction CBC, chest x-ray Pustules: Drugs Acute generalized Exanthematous Pustulosis Small pustules in intertriginous areas +/- fever Increase WBC Penicillin, cephalosporins, Erythromycin, antiseizure medications Biopsy diagnosis to rule out pustular psoriasis Treat with Prednisone 17
18 Pustular Psoriasis Usually in persons with a history of psoriasis Can see in pregnancy High output state Patients need to be cooled down in the hospital Topical steroids +/- methotrexate or Acitretin Do not treat with Prednisone Infestations Scabies Papules/pustules Web spaces Genitalia Scapula Periumbilical Breasts Scabies prep. to make diagnosis 18
19 Infestations Treatment Permethrin 5% (Elimite) 2 applications 1 week apart Clothing instructions Concomitant treatment of intimates (even if not itching) itch continues x3 weeks, give patient TAC and antihistamine for comfort Infestations Body Lice Live in clothing Feces make the patient itch Excoriations upper back and seam lines Get rid of clothes Do not need to treat patient with Kwell or Elimite 19
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