Acute and emergency dermatology Flashcards
Dermatology emergencies, oh no! what do we do?! in this we will find out
What are the consequences of skin failure?
• Sepsis • Hypo- and Hyperthermia • Protein and fluid loss • Renal impairment • Peripheral vasodilation ○ Can occasionally lead to cardiac failure
What is erythroderma?
- A descriptive term rather than a diagnosis
- “Any inflammatory skin disease affecting >90% of total skin surface”
What are the causes of erythroderma?
- Psoriasis
- Eczema
- Drugs
- Cutaneous Lymphoma
- Hereditary disorders
What are the principles of management of erythroderma?
- Appropriate setting - ?ITU or burns unit
- Remove any offending drugs
- Careful fluid balance
- Good nutrition (want avoid any low albumin)
- Temperature regulation
- Emollients – 50:50 Liquid Paraffin : White Soft Paraffin
- Oral and eye care
- Anticipate and treat infection
- Manage itch
- Disease specific therapy; treat underlying cause
Explain Steven Johnson syndrome/ toxic epidermal necrolysis
- 2 conditions which are thought to form part of the same spectrum
- Rare
- 1-2/million/year (SJS)
- 0.4-1.2/million/year (TEN)
- Secondary to drugs
- Antibiotics
- Anticonvulsants
- Allopurinol
- NSAIDs
- Can be delayed onset
What are the clinical features of Steven Johnson syndrome?
- Fever, malaise, arthralgia
- Rash
- Maculopapular, target lesions, blisters
- Erosions covering <10% of skin surface
- Mouth ulceration
- Greyish white membrane
- Hemorrhagic crusting
- Ulceration of other mucous membranes
What are the clinical features of toxic epidermal necrolysis?
- Often presents with prodromal febrile illness
- 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
What is the management of SJS and TEN?
- Identify and stop culprit drug as soon as possible
- Supportive therapy
- Don't know how effective but... ?High dose steroids ?IV immunoglobulins ?Anti-TNF therapy ?Ciclosporin
What are the long term complications of SJS and TEN?
- Pigmentary skin changes
- Scarring
- Eye disease and blindness
- Nail and hair loss
- Joint contractures
What is the aetiology of drug reaction with eosinophilia and systemic symptoms (DRESS)?
- Incidence estimated between 1 in 1000-10,000
- Mortality up to 10%
What are the clinical signs of DRESS?
- Onset 2-8 weeks after drug exposure
- Fever and widespread rash
- Eosinophilia and deranged liver function
- Lymphadenopathy
- +/- other organ involvement
What is the management of DRESS?
- Stop causative drug
- Symptomatic and supportive
- Systemic steroids (usually oral prednisolone)
- +/- Immunosuppression or immunoglobulins
What are the clinical features of pemphigus?
- Antibodies targeted at desmosomes
- Skin: flaccid blisters, rupture very easily
- Intact blisters may not be seen
- Common sites: face, axillae, groins
- Nikolsky’s sign may be +ve
- Commonly affects mucous membranes
- Ill defined erosions in mouth
- Can also affect eyes, nose and genital areas
Explain pemphygoid
- Antibodies directed at dermo-epidermal junction
- Intact epidermis forms roof of blister
- Blisters are usually tense and intact
What’s the difference between pemphigus and pemphigoid?
Pemphigus
- Uncommon
- Middle aged patients
- Blisters very fragile (may not be seen intact)
- Mucous membranes usually affected
- Patients may be very unwell if extensive
- Treatment: systemic steroids, dress erosions, supportive therapies
Pemphigoid
- Common
- Elderly patients
- Blisters often intact and tense
- Even if extensive, patients are fairly well systemically
- Topical steroids may be sufficient if localised; systemic usually required if diffuse
