8. Dermatological Emergencies

Question 1

Answer 1

= The rash is most likely a drug reaction.

Question 2

Answer 2

= IM adrenaline should be given immediately

Question 3

Answer 3

= The rash is likely to be the first sign of toxic epidermal necrolysis or Steven-Johnsons syndrome.

Question 4

Answer 4

= Sending the patient home with a course of oral antibiotics.

Question 5

Answer 5

= Psoriasis is a common cause of erythroderma.

Question 6

SJS & TEN
- What are they?
- Aetiology: most commonly implicated drugs? (6)
- Clinical features?

Answer 6

Aetiology - the most commonly implicated drugs are:
1. Co-trimoxazole
2. Lamotrigine
3. Carbamezepine
4. Phenytoin
5. Allopurinol
6. Piroxicam and Meloxicam

Question 7

SJS & TEN
- Sequelae? (6)
- Management and prognosis?

Answer 7

Sequelae - Patients may experience severe ocular complications, severe pigment alteration, sicca syndrome, hair loss, and mucosal scarring leading to vaginal stenosis, and oesophageal stricture.

Question 8

Erythema Multiforme
- What is it?
- Aetiology?
- Clinical features?
- Diagnosis?
- Management & Prognosis?

Answer 8

Diagnosis: EM has a very characteristic histopathology. The diagnosis can be confirmed with skin biopsy if necessary.

Management & Prognosis:
- Although major EM can cause significant morbidity, it is not a systemic disease and is not life-threatening.
- The illness lasts about two weeks, and patients survive with supportive care.

Question 9

What is DRESS?
- 7 Drugs that might cause it?
- 6 Clinical features?
- Management & Prognosis?

Answer 9

Management & Prognosis
- Treatment is with oral prednisolone.
- The condition may last many weeks.
- Mortality is about 10% and usually occurs from hepatitis, colitis, or myocarditis.

Question 10

What is Uncomplicated Urticaria?

Answer 10

Question 11

What is Urticaria with Angiodema?

Answer 11

Question 12

Urticaria
- Aetiology?
- Differential diagnoses?

Answer 12

Differential Diagnoses
- Unlike many other rashes, urticaria is transient and migratory.
- In contrast to urticaria, vasculitis typically appears purpuric and leaves bruises. Urticaria and erythema multiforme can both have targetoid lesions, but erythema multiforme does not migrate.
- The differential diagnosis of angiodema includes erythema nodosum, cellulitis, and drug eruptions; however, these lesions are not migratory.

Question 13

Management of Urticaria
- Acute? (3)
- Chronic: 5 Investigations? Medication?

Answer 13

Question 14

What is Anaphylaxis?

Answer 14

Question 15

Outline the Manageent of Anaphylaxis.
- Adrenaline dose? How often?

Answer 15

Question 16

Erythroderma
- What is it?
- Aetiology?
- Clinical features?

Answer 16

Erythroderma describes any skin disease that involves 90% or more of the body surface area. Such skin diseases are usually inflammatory, erythematous, and scaly.

Question 17

Erythroderma
- Approach to erythroderma?
- Management?

Answer 17

Question 18

Vasculitis
- Introduction: What is it? Tell-tale appearance?
- Aetiology: Adults? Children? Infections?

Answer 18

Question 19

Vasculitis
- 4 Subgroups?
- Clinical features of Small vessel vasculitis?

Answer 19

Vasculitis can be divided into a number of subgroups. The most important are:
1. Small vessel vasculitis
2. Small & medium sized “mixed” vessel vasculitis
3. Medium sized vessel vasculitis
3. Large vessel vasculitis (usually do not have cutaneous manifestations and not discussed here).

Question 20

Small vessel vasculitis
- 4 Examples & Their Clinical features?

Answer 20

Small Vessel Vasculitis - Examples:
1. Acute meningococcaemia
2. Acute haemorrhagic oedema
3. IgA mediated vasculitis: Henoch-Schonlein purpura
4. Urticarial vasculitis

Question 21

Vasculitis
- Clinical features of Medium Vessel Vasculitis: Most common disease?
- Clinical features of Mixed Vessel Vasculitis?

Answer 21

Question 22

Vasculitis
- Approach to the management: Determine diagnosis & Extent of Involvement?
- Treatment?

Answer 22

Question 23

Management of Acute Meningococcaemia?

Answer 23

Question 24

What is Toxic Shock?
- Clinical Features?
- Management?

Answer 24

Management of Toxic Shock
- This condition is an emergency.
- Patients should be admitted to a high dependency area and monitored closely. Many require transfer to ICU.
- Anti-staphylococcal antibiotics should be immediately commenced: IV flucloxacillin, or a cephalosporin for penicillin allergic patients.
- Volume replacement and inotropic support may be required.
- Patients may benefit from IVIG treatment.

Question 25

**Kawasaki Disease** - What is it? - Clinical Features?

Answer 25

**Kawasaki Disease** - It affects children aged 5 years and under. - It is a multisystem vasculitis with cutaneous, mucosal, and systemic manifestations. - The most sinister association of this condition is coronary artery lesions in about 20% of cases. If left untreated, this can lead to coronary aneurysm, thrombosis, myocardial infarction, and death.

Question 26

Management of Kawasaki Disease? (6)

Answer 26

Question 27

**Differentiating Kawasaki Disease and Toxic Shock Syndrome.** - Children under 5? - Presentation? - Blood tests - Supportive features? - Treatment?

Answer 27

Question 28

**Staphylococcal Scalded Skin Syndrome** - What is it? - Clinical Features? - Management?

Answer 28

**Management** - If recognised early, oral anti-staphylococcal antibiotics abort the condition. - Once it is fully expressed, children may be to be admitted to hospital for pain relief and IV antibiotics.

Question 29

**What are Rapidly Growing Haemangiomas of Infancy?** - 8 Indications for Urgent Referral (to dermatologist or paediatrician)?

Answer 29

Question 30

**Patients with Multiple Blisters or Pustules** - Causes? - 5 Infective Conditions that can cause this?

Answer 30

Question 31

**Allergic Reactions** - Clinical Features?

Answer 31

Question 32

Management of Severe Contact Dermatitis?

Answer 32

Question 33

**What is Pustular Psoriasis?** - Management?

Answer 33

**Management** - Patients require hospital admission and an urgent referral to dermatology. - They require bed rest, wet dressings, and systemic treatment with cyclosporine or a retinoid.

Question 34

**Immunobullous Diseases** - What are they? - Clinical Features? - Management?

Answer 34

Question 35

What is Pompholyx?

Answer 35

Question 36

**Eczema Herpeticum** - Clinical features? - Complications? - Management?

Answer 36

Question 37

**Necrotising Fasciitis** - What is it? - Clinical features? - Management?

Answer 37

Question 38

**Skin Biopsy** - Information to the pathologist? (5) - 7 General principles in selecting a biopsy site? - Transport media?

Answer 38

**Biopsy Site - General principles in selecting a biopsy site**: 1. Select a recent lesion. 2. Select a typical lesion. 3. Avoid areas of ulceration and excoriation. 4. If taking a biopsy of an ulcer, take an edge of the ulcer and include normal skin. 5. If taking biopsy of a tumour, take a central part. 6. If taking a biopsy of a vesicular rash, attempt to take a whole vesicle. 7. As a skin biopsy leaves a scar, avoid cosmetically sensitive areas if possible.

Question 39

Management of Drug Eruption - 4 Steps?

Answer 39

Question 40

When should you suspect a severe drug reaction? How will you make the diagnosis?

Answer 40

Question 41

**Severe Drug Reaction** - Management? - Prevention?

Answer 41

Question 42

Outline the timing between drugs and reaction for different drugs?

Answer 42

Question 43

Which drugs cause rashes?

Answer 43

Question 44

**What is the most common type of drug reaction?** - Which drugs? - Differential diagnosis? - Onset? - Prognosis?

Answer 44

Question 45

- What is the second most common type of drug reaction? - Are Vasculitic drug reactions common? - 5 Mechanisms of purpura due to drugs?

Answer 45

Question 46

Which drugs cause Phototoxic and Photoallergic Drug reactions?

Answer 46

Question 47

**Which drugs cause Pustular Drug Reactions: AGEP?** - Onset? - Prognosis?

Answer 47

Question 48

**Which drugs cause Fixed Drug Eruptions?** - Onset? - Differential dianoses? - Prognosis?

Answer 48

Question 49

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Question 50

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Question 51

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Question 52

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Question 53

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Question 54

Answer 54

= She is likely to be allergic to amoxicillin. This should be ceased.

Question 55

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Question 56

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Question 57

Answer 57

= She has urticaria secondary to a viral infection

Question 58

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Question 59

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Question 60

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Question 61

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Question 62

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