32. Cutaneous Skin Reactions Flashcards by Meghan May

Dx?

Erythema Multiforme

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Viral infections that cause Erythema Multiforme

HSV (50%)

Mycoplasms

Other viral

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Drugs that cause Erythema Multiform

less then 10%

NSAIDs

Sulftas

Antipileptics

Antibiotics

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What clinical features do I see with Erythema Multiform?

Arise after the HSV lesions have crusted and formed

See abrupt onset of target lesions

Common on hands, feet, and acral

Prodrome is rare and non-toxic

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What the heck is this?

Oral involvment of Erythema Multiforme

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Recommended tx for this patient?

suspect Erytherma Multiforme

Tx with topical steriods and pain managment if mild

If severe mucosal involvment prednisone is option (controversial) and get consult with opthomology!

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42 yo woman presents with eruption for one day… started off as small macules on the chest and over the course of the day has worsended to most of her body.

Rahs is itchy and painful. Pt has hx of bipolar and started lamotrigine 2 weeks ago with no know drug allergies.

NO facial edema or lymphadenopahty. Dx?

Exanthematous Drug Eruption

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Describe what Exanthematous drug eruption looks like

innumerable pink
macules coalescing into
patches on the head, trunk,
and extremities.

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Most common Drug reaction:

Occurs mostly with what types of drugs:

• AKA morbilliform drug rash
• Most common drug reaction
– Can occur with any drug
– Most common: antibiotics, anticonvulsants

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What type of hypersensitivity is Exanthematous Drug Eruption?

• Idiosyncratic delayed (type IV) immune
reaction

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Clinical Feature of Exanthematous Drug Eruption

Color/characteristic

Location

Other signs:

• Numerous pink macules and barely palpable
papules
• Starts on the face and trunk, then spreads to
extremities
• Pruritic
• Fever and mucosal involvement are typically
absent

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What is the Course of Disease for Exanthematous Drug Eruption?

Onset
– 2-14 days after starting medication
– Subsequent occurrences have faster onset
– Can start even after finishing treatment (e.g.
antibiotic)

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Patient started new drug about a week ago. Now presentes with numerous pink macules and barely palpable paplues. Started on her face and trunk and spread to extemeties. It is itchy with a lack of mucosal involvement and no fever. What is the recommended tx for patient?

Exanthematous Drug eruption

Discontinue culprit drug if possible
• Supportive care for pruritus
– Oral antihistamines
– Topical corticosteroids
• Resolution
– Spontaneously resolves in 1-2 weeks
– Can resolve even with continuation of drug

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The rash is itchy but not painful. She has had fever up to 38.9°C. She has a history of bipolar disorder and was started on lamotrigine 4 weeks ago. She has no known drug allergies. facial edema and bilateral cervical
lymphadenopathy on exam. She has innumerable pink macules coalescing into patches on the head, trunk, and extremities. Dx?

DRESS

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What labs do we expect to see in patient with DRESS?

CBC: (2 things)

Liver Panel: (3)

Blood urea nitrogen and creatinine: (1)

– WBC normal
• 15% eosinophils (↑)
– H/H and platelets normal
• Liver panel
– AST 126 (↑) and ALT 208 (↑)
– Alk phos and bilirubin normal
• Blood urea nitrogen and creatinine normal

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How is DRESS different then Exanthematous Drug Eruption

Type IV hypersensitivity
• More common in adults
• Later onset 2-8 weeks after drug initiation

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Most common medications that cause DRESS

– Anti-epileptics
– Sulfonamides
– Minocycline
– Allopurinol
– Anti-retrovirals

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What clinical features do we look for in a patient with DRESS?

Cutaneous involvement
– Most commonly morbilliform
– Other cutaneous patterns sometimes seen
• Facial edema
• Lymphadenopathy
• Fever

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Common organ involvement in DRESS

Most common organs involved
– Liver: elevated transaminases
– Hematologic: eosinophilia, atypical lymphocytes
– Kidney: mild nephritis

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If a pt has liver involvment in their DRESS, what would we expect to see clinically?

Morbilliform eruption with ascites
and jaundice from liver
involvement.

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Recommended Tx for mild DRESS

• Identify and stop the culprit drug
• Mild cases treated with supportive care
– Topical corticosteroids
– Oral antihistamines

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Recommended tx for severe DRESS?

Severe cases
– Systemic corticosteroids
– May require hospitalization

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Long term affects we can see with DRESS

• Autoimmune diseases may develop later
– Autoimmune thyroiditis
– Diabetes mellitus
– Autoimmune hemolytic anemia

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Pt has DRESS and wants to know if this is really serious as well as how long it will take to get better.. What should we tell them to expect?

10% mortality rate despite treatment
Slow resolution over weeks or months

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28-year-old man presents with a skin eruption that started yesterday and has progressively worsened to cover most of his body. The lesions seem to be coming and going and changing shape. He had URI symptoms starting 3 days ago and has been taking phenylephrine for nasal congestion and dextromethorphan for cough suppression. He has no known food allergies, but he did eat shrimp for dinner 4 nights ago. DX

Uticaria

Pathology of Uticaria What chemokines are involved? What type of hypersensitivity is it?

– Release of histamine, bradykinin, leukotriene C4, prostaglandin D2, and other vasoactive substances from mast cells and basophils – Most commonly type I IgE-mediated

Most case of Uticaria are:

idiopathic • Most commonly identified cause is URI • Other causes – Other infections – Drug allergies – Food allergies

Classic lesion in uticaria is a: How long will it last?

wheal • Individual lesions last • Very pruritic • Can last up to 6 weeks

Oh god... What has happened to this patient??

Angioedema ---Anaphyalaxsis; can see shortness of breath, uticaria, lightheaded and confusion, wheezing and shortness of breath, stridor, fast or slow HR

Tx options for non-severe Uticaria?

Anti-histamines – Non-sedating H1 antihistamines • Loratadine • Cetirizine • Fexofenadine – Sedating H1 antihistamines • Diphenhydramine • Hydroxyzine

These two meds are what type of med and used to Tx? • Diphenhydramine • Hydroxyzine

– Sedating H1 antihistamines for non severe uticaria

What meds would we think of using for more severe uticaria?

Prednisone

A 55-year-old woman complains of a rash on her body starting this morning. She also has noticed ulcers on her lips and oral mucosa. Prior to the start of the rash, she had 4 days of fever and flu-like symptoms. Dx

Steven Johnson Syndrome

SJS is what type of reaction?

Hyersensitivity

Caues of SJS?

Infection – Viral – Mycoplasma • Medications – NSAIDs – Sulfa drugs – Allopurinol – Antiepileptics – Antibiotics – Anti-retrovirals • Malignancy • Idiopathic

Drugs that can cause SJS

– NSAIDs – Sulfa drugs – Allopurinol – Antiepileptic

Associated risk factors for SJS

Female • Genetic susceptibility (HLA types) • HIV patients • SLE patients • Malignancy

• Occurs 1-14 days prior to cutaneous eruption • Flu-like illness – Fever, malaise – Pharyngitis, rhinitis, cough – Headache – Myalgias, arthralgias – Anorexia, nausea, vomiting

Prodrome

What are the Clinical Features of SJS?

Starts as painful red macules and patches • Rapidly evolves into blistering and necrosis • Affects skin and mucosa (ocular, nasal, oral, and/or genital)

What transition do we expect to see from Day 1 to Day 2 with SJS?

Rapidly evolves from pink macules to bullae

Acute systems of SJS

Acute – Dehydration – Malnutrition – Pneumonitis/pneumonia – GI bleeding – Sepsis

What are the long term complications of SJS?

Mucocutaneous scarring • Blindness • Strictures • Sicca syndrome

What tx would you recommend for this pt?

SJS: Requires inpatient hospital care with multidisciplinary approach • Discontinue drugs • Maintain fluid and electrolyte balance • Pain management • Medical therapy controversial – Systemic corticosteroids – IVIG

A 38-year-old woman presents with palpable purpura on the legs for the past 2 months. The lesions cause burning pain but no other symptoms. A skin biopsy shows neutrophils and other inflammatory cells surrounding the small vessels of the skin.

Vasculitis

What is vasculitis and how is it classified?

Inflammation and destruction of blood vessels • Classified by size of involved vessel

Also called hypersensitivity vasculitis • Small vessel vasculitis of the skin with predominately neutrophils • Affects children and adults • Approximately equal males and females

Leukocytoclastic Vasculitis

What patient population is usually affected by leukocytosis vasculitis?

* Affects children and adults * Approximately equal males and females

What infections can cause leukocytoclastic vasculitis?

Infections – Upper respiratory infection – Group A streptococcal infection – Hepatitis B and C – HIV

What Drugs can cause leukocytosis vasculitis?

Drugs – Antibiotics – NSAIDs

50% of Vasculitis is:

Idiopathic

What Are Causes of Leukocytosis Vasculitis besides infections and drugs?

• Autoimmune diseases – Rheumatoid arthritis – Systemic lupus erythematosus – Inflammatory bowel disease • Malignancy

If we see this in leukocytosis vasculitis, what are we concerned with?

• Systemic involvement may be present – Fever – Joint pain and swelling – GI bleeding – Renal involvement – Cardiopulmonary involvement

Prognosis of Leukocytosis Vasculitis?

Good prognosis if skin-limited – Self-resolves in most – Chronic relapsing course in some • Can be potentially fatal if systemic involvement

Pt has horrible case of Leukocytosis vasculitis... What is our Tx

Treatment for more severe cases – Systemic corticosteroids – Colchicine – Dapsone – Immunosuppressives (methotrexate, azathioprine, cyclosporine, etc.)

Pt presets with palpable purpura on her legs that itch. There are some neutrophils and inflammatory cells surrounding blood vessels

Treat underlying cause if present • Supportive care for mild cases – Rest and elevation – Analgesicsp

What systemic involvement do we worry about in a pt with leukocytosis vasculitis?

Systemic involvement may be present – Fever – Joint pain and swelling – GI bleeding – Renal involvement – Cardiopulmonary involvement

Pt has this purpura rash for the past two months that is painful. Dx and Treatement?

Good prognosis if skin-limited – Self-resolves in most – Chronic relapsing course in some • Can be potentially fatal if systemic involvement

4 year old boy with cutaneous eruption for the past 3 days. Started on the legs and buttocks and has spread to the face and trunk. Mildly itchy.

Henoch-Schonlein Purpura

Henoch-Schonlein Purpura is what type of disease?

Subtype of leukocytoclastic vasculitis

Who is most susceptible to Henoch-Schonlein purpura?

children – Peak 2-11 years old • More common in males – 2:1 male:female

Inflammation around and thrombi within the vessels and Neutrophils and neutrophilic debris

Henoch-Schonlein Purpura

Hallmark skin findings in HSP?

Hallmark skin findings = palpable purpura on buttocks and legs • Can have purpura elsewhere too (face and arms)

Most common causes of HSP

Amoxicillin B. Mononucleosis **C. Streptococcus pyogenes upper respiratory infection** D. Escherichia coli urinary tract infection E. HIV infection

What is our MOST most common cause of Henoch Schonlein purpura

Streptococcus pyogenes upper respiratory infection Strep and other URIs are most common but many drugs, infections, and vaccines implicated.

What is a common association of HSP

Abdominal pain

What systemic involvement is expected in HSP

Arthritis and arthralgias • Gastrointestinal – Nausea, vomiting, abdominal pain – GI bleeding – Intussusception • Nephritis • Rare: testes, lungs, heart, brain

How long will you skin be all purpur like if you h ave HSP?

Skin eruption resolves over 2-4 weeks

Up to 6 months after getting HSP, what do we need to be worried about?

• Nephritis can develop up to 6 months later, even after skin eruption has resolved • Systemic involvement can cause longer-lasting or permanent complications

palpable purpura on buttocks and legs and recently has a strep A infection... What is the tx?

Treatment – Supportive care for pruritus • Oral antihistamines • Topical corticosteroids – NSAIDs for pain – Prednisone for severe cases