DERMATOLOGICAL EMERGENCIES. DR. Ian Hoyle MBBS DIP IMC RCS (Ed), DA (UK),FRACGP,FACRRM,DIP DERM(Wales) TASMANIAN SKIN AND BODY CENTRE

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1 DERMATOLOGICAL EMERGENCIES DR. Ian Hoyle MBBS DIP IMC RCS (Ed), DA (UK),FRACGP,FACRRM,DIP DERM(Wales) TASMANIAN SKIN AND BODY CENTRE

2 Dermatological Emergencies INFECTIONS ERYTHRODERMA DRUG ERUPTIONS STEVENS-JOHNSON SYNDROME AND TOXIC EPIDERMAL NECROLYSIS BLISTERING DISORDERS NEUTROPHILIC DERMATOSES URTICARIA AND ANGIOEDEMA

3 INFECTIONS - CELLULITIS

4 ERYSIPELAS

5 ECZEMA HERPETICUM

6 Herpes Zoster

7 PERIANAL ABCESS

8 MENINGOCOCCUS

9 Petechial rash with meningitis

10 NECROTISING FASCIITIS

11 NECROTISING FASCIITIS Serious bacterial infection of soft tissues and fascia Type 1 polymicrobial Type 2 streptococcus Type 3 gas gangrene clostridia

12 CLINICAL FEATURES Usually starts as a minor injury Worsening pain at the site of injury Flu like symptoms Dehydration Purple rash at site of injury Large dark marks forming blisters Wound starts to die and blackens due to necrosis Severe pain Toxic shock

13 MANAGEMENT ICU/HDU IV Antibiotics Surgical Debridement Fluid balance Renal and cardiovascular support Hyperbaric Oxygen Consideration of Intravenous Immunoglobulins 25% mortality

14 NECROTISING FASCIITIS

15 ERYTHEMA MULTIFORME

16 CAUSES OF ERYTHEMA MULTIFORME HERPES SIMPLEX AND ZOSTER VIRUSES MANY OTHER VIRUSES EG CMV HEPATITIS HIV DRUG ERUPTION (< 10 % )

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19 CLINICAL FEATURES EM minor Usually preceded by infection such as cold sore or vaccination Targetoid rash, mild fever and malaise 1-3 weeks EM major rare, usually drug induced, more common withhiv Mucosal eruptions and blisters lips,oropharynx,genetalia,conjunctivi Fever and collapse

20 MANAGEMENT MINOR Symptomatic treatment topical steroids, antihistamines Anti virals for recurrent attacks MAJOR HDU - fluids, mouth care, avoid oral steroids

21 SEXUALLY TRANSMITTED DISEASE PRIMARY SYPHILIS SECONDARY SYPHILIS

22 BURNS

23 CLASSIFICATION OF BURNS FIRST DEGREE SECOND DEGREE

24 BURNS THIRD DEGREE FOURTH DEGREE

25 RULE OF 9 S

26 ERYTHRODERMA Redness and scaling of almost all of the entire surface of the skin

27 Causes of erythroderma Drug eruption

28 Overwhelming Sepsis Staph scalded skin

29 Eczema

30 PSORIASIS

31 ERYTHRODERMIC MYCOSIS FUNGOIDES

32 PITYRIASIS RUBRA PILARIS

33 HIV

34 RED MAN (WOMAN) SYNDROME

35 INTERNAL MALIGNANCY

36 Complications of Erythroderma Secondary Infections Loss of Thermoregulation High output Heart Failure Fluid and Electrolyte imbalance Renal Failure Hypoalbuminaemia

37 MANAGEMENT Wet dressings Manage fluid balance and temperature Anti biotics Antihistamines Aggressively Treat Underlying Condition

38 DRUG ERUPTIONS

39 ANY DRUG CAN CAUSE ANY RASH ANTIBIOTICS NON STEROIDAL ANTI INFLAMMATORIES ASPIRIN PARACETEMOL ACE INHIBITORS SEDATIVES EG BENZODIAZAPINES BARBITURATES ALLOPURINOL 3% OF ALL ADMISSIONS HAVE A DRUG INDUCED RASH

40 Generalised Morbilliform Rash

41 Drug induced erythema multiforme

42 Fixed Drug Eruption

43 Fixed drug Eruption

44 STEVENS JOHNSON SYNDROME AND TOXIC EPIDERMAL NECROLYSIS POTENTIALLY FATAL REACTION TO A DRUG thought to be a variation of the same condition Fever, cough,sore throat,runny nose,conjunctivitis,flu like aches and pains Evolving tender red skin rash- macules,targets and /or blisters Prominent Mucosal involvement eyes, lips, oropharynx, genital area Skin Desquamation with TEN >30% of Body SA

45 STEVENS-JOHNSON Usually due to drugs esp. sulphonomides nasaids,allopurinol,anticonvulsants May present as generalised rash or erythema multiforme

46 STEVENS JOHNSON SYNDROME Mucosal involvement

47 Stevens - Johnson CONJUNCTIVITIS

48 STEVENS-JOHNSON BLISTERS

49 TOXIC EPIDERMAL NECROLYSIS

50 TEN

51 TEN

52 MANAGEMENT OF SJS AND TEN Cessation of the suspected drug HDU/ICU Fluid and electrolyte management Temperature control Analgesia IV or Nasogastric nutrition Skin,eye and mouth care Physiotherapy to maintain joint movement and prevent pneumonia Treatment of secondary Infection Steroids contraversial Anticoagulation

53 SYSTEMIC DISEASE Systemic lupus Subacute lupus

54 Sytemic disease scleroderma

55 Systemic disease Dermatomyositis

56 Internal Malignancy Erythema gyratum repens Leser trelat syndrome

57 BLISTERING SKIN DISEASE SUBCORNEAL-very thin and fragile Impetigo,miliaria,sss

58 BLISTERING SKIN DISEASE Intra epidermal thin roof ruptures easily- eczema,varicella, pemphigus

59 BLISTERING SKIN DISEASE Subepidermal- Tense roof- Bullous pemphigoid,dermatitis herpetiformis,ten

60 BLISTERING SKIN DISODERS Bullous Pemphigoid

61 PEMPHIGUS

62 DERMATITIS HERPETIFORMIS

63 COELIAC DISEASE

64 EPIDERMOLYSIS BULLOSA

65 PEMPHIGUS GESTATIONIS

66 BULLOUS IMPETIGO

67 BURNS

68 NEUTROPHILIC DERMATOSES SWEETS DISEASE PYODERMA GENGRENOSUM

69 NEUTROPHILIC DERMATOSES ACUTE FEBRILE NEUTROPHILIC DERMATOSES (SWEETS DISEASE) Juicy pseudovesicular plaques Fever,conjunctivitis,arthralgia Arise in association with Infection, Malignancy and Drugs Management-systemic steroids,topical steroids,dapsone Withdraw any causitive drugs

70 PYODERMA GANGRENOSUM Acute Ulceration with overhanging purple or black necrotic edges Common on Lower legs Heals with cribriform scarring Associated with Inflammatory Bowel Disease,Haematological Malignancies and Rheumatoid Arthritis Management-Treat underlying disease,occlusive dressings,topical calcineurin,tetracycline antibiotics,ciclosporin

71 PYODERMA GANGRENOSUM

72 SWEET S DISEASE

73 URTICARIA AND ANGIOEDEMA Acute Lasts a few hours to six weeks eg infection, food, drugs. Sometimes associated with angioedema Chronic- Lasts for > six weeks, sometimes life longconsidered an autoimmune disease in most cases.

74 URTICARIA AND ANGIOEDEMA

75 DERMOGRAPHISM

76 ANGIOEDEMA

77 URTICARIA AND ANGIOEDEMA Management Treat Underlying cause Cooling moisturisers such as Aqueous cream with 1 % menthol Topical steroids Betamethasone Oral antihistamines Pulsed Oral steroids Immunosuppressant's - Ciclosporin

78 THANK YOU