Dermatologic Emergencies Sept 2014
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1 Dermatologic Emergencies Sept 2014 SJS YES MUCOSAL INVOLVEMENT MCC drugs >> HSV TARGET LESIONS, +NIKOLSKY, painful Prodromal flu-like symptoms <10% BSA Tx: remove trigger, supportive, admit TEN YES MUCOSAL INVOLVEMENT MCC drugs (sulfa) TARGET LESIONS, +NIKOLSKY, painful Prodromal flu-like symptoms >30%BSA Tx: remove trigger, supportive, admit SSSS NO MUCOSAL INVOLVEMENT Kids <6 years old +NIKOLSKY, painful erythema, flaccid bullae Tx: Nafcillin/Dicloxacillin NO steroids Nec Fasc S/S: pain out of proportion, hemorrhagic bullae, crepitance, rapid progression, dirty dishwater discharge Tx: surgery, clindamycin Type 1 bacteria = polymicrobial (DM) Type 2 bacteria = GAS/MRSA 1
2 URTICARIA TRANSIENT lesions (<24 hours) Pruritic,edematous plaques, NOT symmetric Tx: remove trigger, supportive, recognize anaphylaxis (epinephrine +/- glucagon) ERYTHEMA MULTIFORME FIXED lesions NO MUCOSAL INVOLVEMENT Hallmark = TARGET lesions, SYMMETRIC Palms/Soles Tx: remove trigger, supportive ROCKY MOUNTAIN SPOTTED FEVER Rickettsia ricketsii via ticks (MC southeast US) Blanching maculopapular rash (palpable) Starts wrists/ankles spreads centrally Tx: Doxycycline (high mortality if NOT treated) PEMPHIGUS VULGARIS Older adult/elderly Flaccid bullae break easily & crust YES MUCOSAL INVOLVEMENT POSITIVE NIKOLSKY Tx: steroids PemphiguS = Superficial BULLOUS PEMPHIGOID PemphigoiD = Deeper Elderly TENSE/FIRM bullae NO MUCOSAL INVOLVEMENT NEGATIVE NIKOLSKY Tx: steroids 2
3 MENINGOCOCCEMIA College, military barracks Evolving petechiae purpura, very ill/shock (purpura fulminans) Tx: ceftriaxone, resuscitation INFECTIONS TOXIC SHOCK SYNDROME Fever + Hypotension + Erythroderma 3 organ systems involved Desquamating erythroderma YES MUCOSAL INVOLVEMENT Trigger: tampon, surgical wounds Tx: remove source, broad-spec antibiotics DISSEMINATED GONOCOCCEMIA Assoc with tenosynovitis, septic arthritis Erythematous/hemorrhagic papules pustules/vesicles with necrotic center (gun metal gray); total lesions Dx: culture genital/throat Tx: ceftriaxone IMPETIGO CHILDREN Facial vesicles rupture honey crust CONTAGIOUS Tx: TOPICAL mupirocin (small area) vs SYSTEMIC cephalexin (more extensive) (Bullous impetigo = flaccid bullae) ERYSIPELAS Sharply demarcated cellulitis with raised borders Strep (GAS) Tx: antibiotics 3
4 CANDIDA Babies (diaper rash); Adults (intertriginous areas); HIV/chemo (oral thrush) Moist red macules/scaly rim, peripheral satelitte lesions Tx: ORAL nystatin (thrush); TOPICAL azoles and keep dry (rash) TINEA Sharply marginated, annular scaly lesions with central clearing; pruritic Corporis (ringworm); Crura (jock itch); Pedis (foot); Capitis (scalp); Unguium (nail) Tx: TOPICAL azoles for everything (except scalp, nails) HERPES SIMPLEX Vesicular clusters with painful erosions HSV1 (1 mouth) = MC children HSV2 (2 genitals) Tx: acyclovir HERPES ZOSTER (shingles) UNILATERAL dermatome Prodromal pain grouped vesicles Elderly/immunocompromised HUTCHINSON SIGN (herpes ophthalmicus) RAMSAY-HUNT syndrome (CN 7/8 palsy) Tx: self-limiting, acyclovir HUMAN PAPILLOMA VIRUS Anogenital warts Cauliflower-like, PAINLESS Tx: referral; sexually transmitted Vaccine available 4
5 MOLLUSCUM CONTAGIOSUM Dome-shaped fleshy papule Central umbilication Children (daycare), Adult (STD), think HIV Tx: benign, self-limited, refer SCABIES Interdigital web space, intertriginous areas Extreme pruritis Tx = permethrin cream, ivermectin oral Norweigan scabies (immunocompromised) PEDICULOSIS (lice) Erythematous macules/wheals Extreme pruritis Kids (head lice); Adults (body lice) Tx: permethrin cream now and in 1wk Nits/lice = + Woodʼs lamp DERMATITIS ATOPIC DERMATITIS Children <5 years old, h/o asthma/atopy Flexural areas: dry, pruritic skin; lichenified Tx: emollients, topical steroids PSORIASIS Silvery scale/plaque Extensor areas; nail pitting/color changes Tx: emollients, keratolytics, topical steroids 5
6 SEBORRHEIC DERMATITIS Yellow greasy or dry white scales (dandruff) Infants (cradle cap); Adults (scalp/eyebrow/forehead/ear/axilla/groin) Think HIV in adults Tx: topical antifungals, keratolytics, steroids CONTACT DERMATITIS DISCRETE rash (papules/vesicles/bullae) Contact trigger: direct irritant vs allergic rxn Tx: remove trigger, steroids (3wks for poison oak/ivy) Irritant (chemical) or allergic (ivy) MALIGNANCIES BASAL CELL CARCINOMA Pink pearly papule with telangiectasia Sun-exposed areas (head/neck) Male >50 years old Tx: referral for biopsy SQUAMOUS CELL CARCINOMA ULCERATED center with firm-raised border Sun-exposed area (head/neck/arms) Tx: referral for biopsy MELANOMA ABCDE: Asymmetric, Borders (irregular), Color (mottled), Diameter (>6mm), Enlarged/ elevated Tx: referral for biopsy 6
7 KAPOSI SARCOMA Red/purple papule/plaque PAINLESS, nonpruritic MC oral lesion (palate/gingiva) HIV/AIDS Tx: treat HIV OTHERS HEMANGIOMA Infant/child HEAD >> trunk > ext Blanching ripe strawberry nodule 50% resolve by age 5years Tx: referral LIPOMA Well-circumscribed, mobile, painless Asymptomatic, normal overlying skin SLIPPAGE SIGN Tx: benign; referral for excision SEBACEOUS CYST Central punctum; cottage cheese discharge Asymptomatic although can be secondarily infected NO slippage sign Tx: benign; referral for excision DECUBITUS ULCER ICU, elderly, paraplegic Stage 1: intact skin w/ nonblanching erythema Stage 2: partial thickness loss of dermis Stage 3: full thickness loss exposing SQ fat Stage 4: exposed bone/tendon/muscle Tx: wound care, consultation as needed 7
8 ERYTHEMA NODOSUM PAINFUL red/violet nodules Looks like a bruise ANTERIOR TIBIA 20-50yo female Tx: supportive PITYRIASIS HERALD PATCH Christmas tree rash pattern to trunk; rash can be pruritic Prodromal flu-like illness Tx: self-limited 8
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