Acute and Emergency Dermatology

Question 1

What is Erythroderma?

Answer 1

• A descriptive term rather than a diagnosis

- “Any inflammatory skin disease affecting >90% of total skin surface”

Question 2

What are the different causes of Erythroderma?

Answer 2

• Psoriasis
• Eczema
• Drugs
• Cutaneous Lymphoma
• Hereditary disorders
• Unknown

Question 3

What are the principles of management of Erythroderma?

Answer 3

• Appropriate setting: ?ITU or Burns unit
• Remove any offending drugs
• Careful fluid balance
• Good nutrition
• Temperature regulation
• Emollients (50:50 liquid paraffin:white soft paraffin)
• Oral and eye care
• Anticipate and treat infection
• > low-threshold for treatment of infection
• Manage itch
• Disease-specific therapy
• > treat underlying cause

Question 4

What are the different clinical presentations of drug reactions?

Answer 4

Mild:
- Morbilliform Exanthem

Severe:
- Erythroderma

• Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN)
• Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

Question 5

Which drugs are most likely to cause drug reactions?

Answer 5

• Abx.
• Anti-convulsants (aka. anti-epileptics)
• Allopurinol
• NSAIDs

Question 6

What are the clinical features of SJS?

Answer 6

• 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
• > (ie. eyes, nose, genitals)

Question 7

What are the clinical features of TEN?

Answer 7

• Often presents with prodromal febrile illness
• Ulceration of mucous membranes
• Rash:
• > macular, purpuric, blistering
• > rapidly becomes confluent
• > sloughing off large areas of epidermis: “desquamation” >30% BSA
• > Nikolsky’s sign +ve

Question 8

What is the management of SJS and TEN?

Answer 8

• Identify and stop culprit drug ASAP

- Supportive Therapy
?possible ITU for TEN-end of the spectrum

Question 9

What is SCORTEN?

Answer 9

• Predictor of mortality for pts presenting with TEN
• > 0-1 = >3.2%
• > 5 or more = >90% mortality

Question 10

What are the long-term complications of SJS and TEN?

Answer 10

• Pigmentary skin changes
• Scarring
• Eye disease and blindness
• Nail and hair loss
• Joint contractures

Question 11

What is Erythema Multiforme?

Answer 11

• HS reaction usually triggered by infection

- Most commonly HSV

Question 12

What are the clinical features of Erythema Multiforme?

Answer 12

• Abrupt onset of up to 100s of lesions over 24hrs
• Palms and soles
• Mucosal surfaces

Evolve over 72hrs:

• > Pink macules, become elevated and may blister in the centre
• > “Target” lesions

Question 13

What are the clinical features of DRESS?

Answer 13

• Onset 2-8 weeks after drug exposure
• Fever and widespread rash
• Eosinophilia and deranged liver function
• Lymphadenopathy
• +/- other organ involvement

Question 14

What is the management of DRESS?

Answer 14

• Stop causative drug
• Symptomatic and supportive
• Systemic steroids
• +/- immunosuppression or immunoglobulins

Question 15

What is the pathophysiology of Pemphigoid?

Answer 15

• Abs directed at dermo-epidermal junction (DEEP)
• Intact epidermis forms the roof of the blister
• Blisters are usually tense and intact (bullae, vesicles)

Question 16

What is the pathophysiology of Pemphigus?

Answer 16

• Antibodies targeted at desmosomes (erosions)

SUPERFICIAL

Question 17

What are the clinical features of Pemphigus?

Answer 17

• Uncommon
• Middle-aged pts
• V fragile blisters - may not be seen intact
• usually affects mucous membranes
• Pts may be v unwell if extensive

Question 18

How is diagnosis of Pemphigus + Pemphigoid made?

Answer 18

Immunofluorescence biopsy

Question 19

What is the treatment of Pemphigus?

Answer 19

• Systemic steroids
• Dress erosions
• Supportive therapies

Question 20

What are the clinical features of Pemphigoid?

Answer 20

• Common
• Elderly pts.
• Blisters often intact, tense
• Even if extensive, pts are fairly well systemically

Question 21

What is the treatment of Pemphigoid?

Answer 21

• Topical steroids (if localised)

- Systemic steroids (if diffuse)

Question 22

What are the causes of Erythrodermic and Pustular Psoriasis?

Answer 22

• Can occur w/o a prev. history of Psoriasis
• Infection
• Sudden withdrawal or oral or potent topical steroids

Question 23

What are the clinical features of Erythrodermic and Pustular Psoriasis?

Answer 23

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

Question 24

What is the treatment of Erythrodermic and Pustular Psoriasis?

Answer 24

• Exclude underlying infection, bland emollient, avoid steroids
• Often requires initiation of systemic therapy
• > (psoriasis therapy ie. immunosuppressant, sometimes biologic therapy)

Question 25

What is Eczema Herpeticum?

Answer 25

Disseminated Herpes Virus infection on a background of poorly controlled Eczema

Question 26

What are the clinical features of Eczema Herpeticum?

Answer 26

• Monomorphic blisters and “punched out” erosions (quite a lot if them!)
• > generally painful, not itchy
• Fever and Lethargy

Question 27

What is the management of Eczema Herpeticum?

Answer 27

• Aciclovir
• Mild topical steroid (for eczema)
• Treat secondary infection
• Ophthalmology input if peri-ocular disease
• In adults: consider underlying immunocompromisation

Question 28

What is the pathophysiology of Saphylococcal Scalded Skin syndrome?

Answer 28

• Initial Staph. infection

- Produces a toxin which targets Desmoglein 1 (causes the cells to peel apart)

Question 29

What are the clinical features of Staphylococcal Scalded Skin syndrome?

Answer 29

• Common in children, can also occur in immunocompromised adults
• Diffuse erythematous rash with skin tenderness
• More prominent in flexures
• Blistering and desquamation follows
• Fever and irritability

Question 30

What is the management of Staphylococcal Scalded Skin syndrome?

Answer 30

• Requires admission for IV abx initially and supportive care
• Generally resolves over 5-7 days with treatment

Question 31

What are the clinical features of Urticaria?

Answer 31

• Weal, Wheal or Hive:
• > central swelling of variable size, surrounded by erythema - dermal oedema
• > itching, sometimes burning (histamine release into dermis)
• > fleeting nature, duration: 1-24hrs
• Angioedema:
• > deeper swelling of the skin or mucous membranes

Question 32

What causes Acute Urticaria?

Answer 32

• <6 week history*
• Idiopathic (majority)
• Infection (viral)
• Drugs (IgE mediated)
• Food (IgE mediated)

Question 33

What is the treatment of Acute Urticaria?

Answer 33

• <6 week history*
• oral anti-histamine
• if severe: oral steroids
• avoid opiates and NSAIDs if possible (exacerbate urticaria)

Question 34

What causes Chronic Urticaria?

Answer 34

• > 6 week history*
• Autoimmune/Idiopathic (majority)
• Physical
• > (ie. cold (ice cube on skin), friction, heat, drawing on yourself)
• Vasculitic
• Rarely Type 1 HS reaction!!*

Question 35

What is first-line treatment for Acute Urticaria?

Answer 35

• > 6 week history*
• oral anti-histamine
• no place for oral steroids*