Acute and Emergency Dermatology

Question 1

What are the consequences of failure of the skin?

Answer 1

–Sepsis

–Hypo- and Hyper- thermia

–Protein and fluid loss

–Renal impairment

–Peripheral vasodilation

•Can occasionally lead to cardiac failure

Question 2

What is erythroderma?

Answer 2

Any inflammatory disease affecting over 90% of the total skin surface

Question 3

What are the causes of erythroderma?

Answer 3

Psoriasis

Eczema

Drugs

Cutaneous lymphoma

Hereditary disorders

Question 4

What are the principles of management of erythroderma?

Answer 4

Remove offending drugs

Maintain fluid balance

Good nutrition

Ensure patient remains at suitable temperature

Emollients - 50:50 liquid paraffin: white soft paraffin

Oral and eye care

Anticipate and treat infection

Manage itch

Disease specific therapy; treat underlying cause (e.g - eczema, psoriasis, cutaneous lymphoma)

Question 5

When do drug reactions resulting in skin symptoms often occur?

Answer 5

Commonly 1-2 weeks after drug - within 72 hours if re-challenged

Question 6

What are the mild and severe forms of drug reactions?

Answer 6

Mild - morbilliform exanthem

Severe - Erythroderma, stevens johnson syndrome/toxic epidermal necrolysis, DRESS

Question 7

What causes the onset of Stevens johnson syndrome and toxic epidermal necrolysis?

Answer 7

Secondary to drugs -

–Antibiotics

–Anticonvulsants

–Allopurinol

–NSAIDs

Question 8

What are the clinical features of SJS?

Answer 8

•Fever, malaise, arthralgia

•Rash

–Maculopapular, target lesions, blisters

–Erosions covering <10% of skin surface

•Mouth ulceration

–Greyish white membrane

–Haemorrhagic crusting

•Ulceration of other mucous membranes

Question 9

What is the prodrome of TENS?

Answer 9

Febrile illness

Question 10

What is the clinical presentation of toxic epidermal necrolysis?

Answer 10

Ulceration of mucous membranes

Rash:

–May start as macular, purpuric or blistering

–Rapidly becomes confluent

–Sloughing off of large areas of epidermis – ‘desquamation’ > 30% BSA

–Nikolsky’s sign may be positive

Nikolsky sign is a skin finding in which the top layers of the skin slip away from the lower layers when slightly rubbed

Question 11

What is the management for TEN?

Answer 11

Identify and stop culprit drug as soon as possible

Supportive therapy

• ?High dose steroids
• ?IV immunoglobulins
• ?Anti-TNF therapy
• ?Ciclosporin

Question 12

What score is used to determine the prognosis of TEN?

Answer 12

SCORTEN

Question 13

What are the long term complications of TEN?

Answer 13

–Pigmentary skin changes

–Scarring

–Eye disease and blindness

–Nail and hair loss

–Joint contactures

Question 14

What is erythema multiform?

Answer 14

Abrupt onset of 100s of lesions over 24 hours - hypersensitivty reaction usually triggered by infection (HSV and mycoplasma pneumonia)

Question 15

Where are the lesions located in erythema multiforme?

Answer 15

Go from distal to proximal

Start at the palms and the soles

Includes mucosal surfaces

Question 16

What happens to the lesions over time?

Answer 16

They evolve over 72 hours - pink macules become elevated and may blister in the centre

Resolves over 2 weeks

Question 17

What does dress stand for?

Answer 17

Drug reaction with eosinophilia and systemic symptoms

Question 18

What is the onset of dress?

Answer 18

2-8 weeks after drug exposure

Question 19

What are the clinical featrures of DRESS?

Answer 19

Fever and widespread rash

Eosiniphilia and deranged liver function

Lymphadenopathy

Possible involvement of other organs

Question 20

What is the management for dress?

Answer 20

Stop causative drug

Treat symptoms

Systemic steroids

Possible immunosuppressants or immunoglobulins

Question 21

What causes pemphigus?

Answer 21

Antibodies targeted at desmosomes

Question 22

What are the clinical features of pemphigus?

Answer 22

Flaccid blisters which rupture very easily

Common sites for the blisters include the face, axillae, groins

Nikolsky’s sign may be positive

Commonly affects the mucous membranes, ill defined erosions in the mouth

Can also affect the eyes, nose and genital areas

Question 23

Where are antibodies directed in pemphigoid?

Answer 23

•Antibodies directed at dermo-epidermal junction

Question 24

Describe the blisters in pemphigoid

Answer 24

• Intact epidermis forms roof of blister
• Blisters are usually tense and intact

Question 25

What are the differences between pehigus and pemphigoid?

Answer 25

Question 26

What are the causes of erythrodermic psoriasis and pustular psoriasis?

Answer 26

Infection

Sudden withdrawal of oral steroids or potent topical steroid

Question 27

What are the clinical features of Erythrodermic psoriais and Pustular Psoriasis?

Answer 27

• Rapid development of generalised erythema, +/- clusters of pustules
• Fever, elevated WCC

Question 28

What is the management of erythrodermic psoriasis and pustular psoriasis?

Answer 28

Exclude underlying infection, blsnd emollient and avoid steriods

Often requires initiation of systemic therapy

Question 29

What causes eczema herpeticum?

Answer 29

•Disseminated herpes virus infection on a background of poorly controlled eczema

Question 30

What are the clinical features of eczema herpeticum?

Answer 30

•Monomorphic blisters and “punched out” erosions

–Generally painful, not itchy

•Fever and lethargy

Question 31

What is the treatment for eczema herpeticum?

Answer 31

Treatment dose aciclovir

Mild topical steroid if required to treat eczema

Treat secondary infection

Ophthalmology input if peri-occular disease

In adults consider underlying immunocompromise

Question 32

What is staphylococcal scalded skin syndrome?

Answer 32

Initial staph infection, may be subclinical (common in children, but can occur in immunocompromised adults)

Diffuse erythematous rash with skin tenderness

Prominent in flexures

Blistering and desquamation follows

Question 33

What is the disease process of staphylococcal scalded skin syndrome?

Answer 33

Staphylococcus produces a toxin which targets desmoglein 1

Question 34

Despite the rash and the blistering, what other symptoms does the patient have?

Answer 34

Fever and irritability

Question 35

What is the treatment for staphylococcal scalded skin syndrome?

Answer 35

Admission for IV antibiotics initially and supportive care

Generally resolves over 507 days with treatment

Question 36

What is urticaria?

Answer 36

–Central swelling of variable size, surrounded by erythema. Dermal oedema

Question 37

What causes the itching / brining feeling of urticaria?

Answer 37

Histamine release into the dermis

Question 38

What is the disease progression of urticaria?

Answer 38

–fleeting nature, duration: 1- 24 hours

Question 39

What is angioedema?

Answer 39

–Deeper swelling of the skin or mucous membranes

Question 40

What are the causes of acute urticaria?

Answer 40

Idiopathic

Infection (viral)

Drugs, IgE mediated

Food. IgE mediated

Question 41

What is the treatment for acute urticaria?

Answer 41

•Oral antihistamine

–Taken continuously

–Up to 4 x dose

• Short course of oral steroid may be of benefit if clear cause and this is removed
• Avoid opiates and NSAIDs if possible (exacerbate urticaria)

Question 42

What is the definition of chronic urticaria?

Answer 42

History of over 6 weeks

Question 43

What are the causes of chronic urticaria?

Answer 43

Autoimmune / idiopathic (60%)

Physical (35%)

Vasculitic (5%)

Rarely a type 1 hypersensitvity reaction

Question 44

What is the management of chronic urticaria?

Answer 44