4) Derm emergencies

Question 1

What is erythroderma?

Answer 1

involvement of over 90% of the skin with an inflammatory or neoplastic process. Essentially skin failure

Question 2

What diseases can cause erythroderma?

Answer 2

eczema, psoriasis, drug eruptions, skin lymphomas

Question 3

When it is associated with exfoliation what is it known as?

Answer 3

exfoliative dermatitis

Question 4

S+S of erythroderma?

Answer 4

warm to touch
itchy
scaling 2-6 days after redness
scalp may scale
LN may swell

Question 5

Complications of erythroderma?

Answer 5

loss of fluid, secondary infection, heat loss, catabolic state, high output CF

Question 6

what does biopsy show in erythroderma?

Answer 6

often unhelpful but important to rule out CTCL

Question 7

Management of erythroderma?

Answer 7

admit
supportive care, keep warm and watch for infection. Give supportive nutrition. Active treatment generally not required so bland emoliants are used. May manage depending on caue after initial stages

Question 8

What is staph scalded skin?

Answer 8

Red blistering rash that looks like a scald. Caused by the release of exotoxins A and B from gp II staph.

Question 9

WHat do the exotoxins do in staph scalded skin?

Answer 9

THey bind to desmoglein 1 and break it up so that the cells unstich

Question 10

What is another issue with all the toxin in staph scalded skin?

Answer 10

excreted by the kidney so can risk renal failure

Question 11

Who does staph scalded skin tend to happen in?

Answer 11

kids under 5, get lifelong abs to the toxins that make it v unlikely when older

Question 12

S + S of staph scalded skin?

Answer 12

usually fever, irritability, widespread redness
fluid filled blister form over a day or so
tissue paper wrinkling of skin, large blister in armpits and groin goes to everywhere

Question 13

What is nikolsky s sign?

Answer 13

gentle storkes of skin can cause exfoliation- top layer peels off in sheets

Question 14

Where do you tend to get blisters in neonates in staph scalded skin?

Answer 14

around the diaper area and umbilicus

Question 15

How do you diagnose staph scalded skin?

Answer 15

Hx and Ex, tzanck smear, biopy (damage at granular layer), bacterial culture

Question 16

treatment of staph scalded skin?

Answer 16

IV abx (fluclox), vanc if supect MRSA. supportive treatment, para, fluid balance, incubator for newborns

Question 17

What is TEN?

Answer 17

full thickness epidermal loss. SJS and TEN are now thought to be part of a spectrum. rare, acute potentially fatal skin reaction in which there is sheet like skin and mucosal loss.

Question 18

Who is TEN more common in?

Answer 18

slightly more in females, 100x more common in HIV

Question 19

What is the likely cause? what type of drugs are more likely to cause it?

Answer 19

Almost always drug reaction
sulphonamides,
penicillins, cephalosporins, chloramphenicol
anticonvulsant
allapurinol
nsaids/para

Question 20

What are the biochemical causes of TEN?

Answer 20

cytokines have been implicated including perfrin/granzyme, fas/fasL. and tnf a. granule mediated exocytosis via perforin and granzyme B also implicated

Question 21

CLincial hx of TEN?

Answer 21

Usually develops within the first week of abx, 2 months with anticonvulsant. prodromal urti preceeds. abrupt onset of red tender rash. Starts on trunk and spreads rapidly but rarely affects scalp, palm or soles.

Question 22

What are the lesions like in TEN?

Answer 22

macules
difuse erythema
targetoid
blisters- converge to form sheets of detachment

Question 23

Do you get mucosal involvemen in ten?

Answer 23

yes at least 2 and prominent/severe

Question 24

Complications of SJS/TEN?

Answer 24

10% mortality, 30% for TEN
infection
dehydration
ards
shock
dic

Question 25

Dx of sjs/ten?

Answer 25

SJS is diagnosed clinically and classified by skin detachment
elevated granulysin is predictive in early drug eruption
skin biopsy usually required
keratinocyte necrosis, full thickness epidermal necrosis, minimal inflammation

will be anaemic, neutropenia is a bad prognostic sign

Question 26

What is SCORTEN?

Answer 26

predictive of mortality

>40
malignancy
HR>120
detachment >10%
urea >10
glucose >14
bicarb>20 

more than 5 has a 90% mortality
1 has 3.2

Question 27

Difference between SJS and TEN

Answer 27

SJS- detachment < 10%

TEN- >30%

Question 28

DD of SJS/TEN?

Answer 28

SSSS
Erythema multiforme
mycoplasma
bullous sle
paraneoplastic pemphigus

Question 29

Management of SJS/TEN?

Answer 29

STOP DRUG, ADMIT TO ICU/BURNS
Supportive: fluid, temp, positive pressure, good nursing
topical antisepics (NOT SILVER)
care for eyes, mouth, catheter, abx if infection, vte prophylaxis

Question 30

systemic management for SJS/TEN?

Answer 30

controversial

IVIG inhibits apoptosis but nothing has been shown to be effective really and trials hard as nubers small