Acute and Emergency Dermatology Flashcards
1
Q
What % of body mass does skin make up in the average person?
A
10%
2
Q
Consequences of failure of the skin
A
Sepsis Hyper and hypo thermia Protein and fluid loss Renal impairment Peripheral vasodilation that can occasionally lead to cardiac failure
3
Q
Definition of erythroderma
A
Any inflammatory skin disease affecting > 90% of the total skin surface
4
Q
Causes of erythroderma
A
Psoriasis Eczema Drugs Cutaenous lymphoma Hereditary disorders
5
Q
Treatment of erythroderma
A
ITU / burns unit Remove any offending drugs Careful fluid balance Good nutrition Temp regulation Emollients - 50:50 liquid paraffin : white soft paraffin Oral and eye care Anticipate and treat infection Manage itch Treat underlying cause
6
Q
When do drug reactions commonly occur?
A
1 - 2 weeks after drug
Within 72 hours if rechallenged
7
Q
Mild drug reactions affecting the skin causes what?
A
Morbilliform exanthem
8
Q
Severe drug reactions affecting the skin causes what?
A
Erythroderma
Steven johnstons syndrome / toxic epidermal necrolysis
DRESS
9
Q
Which of SJS and TEN is less severe?
A
SJS
10
Q
What drugs can cause SJS and TENS?
A
Antibiotics
Anticonvulsants
Allopurinol
NSAIDs
11
Q
Presentation of SJS
A
Fever Malaise Arthralgia Rash - maculopapular - target lesions - blisters Mouth ulceration - greyish white membrane - haemorrhagic crusting Ulceration of other mucous membranes
12
Q
Definition of arthralgia
A
Joint pain
13
Q
Presentation of TEN
A
Prodromal febrile illness Ulceration of mucous membranes Rash - may start at macular, purpuric or blistering - rapidly becomes confluent - desquamation > 30% BSA Nikolsky's Sign may be +ve
14
Q
Definition of prodromal
A
Relating to or denoting the period between the appearance of initial symptoms and the full development of a rash and fever
15
Q
What is desquamation?
A
Sloughing off large areas of epidermis
16
Q
Definition of Nikolsky’s sign
A
Rub the skin and lose the skin surface over the area that you rub
17
Q
Treatment of SJS / TEN
A
Stop drug Supportive Possible - high dose steroids - IV immunoglobulins - anti TNF therapy - ciclosporin
18
Q
Mortality of SJS
A
10%
19
Q
Mortality of TEN
A
30%
20
Q
What scoring system is used for SJS / TEN?
A
SCROTEN
21
Q
What does SCROTEN look at?
A
Age > 40 Malignancy HR > 120 Initial epidermis detachment >1-% Serum urea >10 Serum glucose >14 Serum bicarbonate <20%
22
Q
Long term complications of SJS / TEN
A
Pigmentary skin changes Scarring Eye disease and blindness Nail and hair loss Joint contractures
23
Q
What is erythema multiforme?
A
Hypersensivity reaction usually triggered by infection.
Abrupt onset of up to 100s of lesions over 24 hours
24
Q
2 most common causes of erythema multiforme
A
HSV most common
Then mycoplasma pneumonia
25
Presentation of erythema multiforme
Abrupt onset of up to 100s of lesions over 24 hours
Distal -> proximal
Palms and soles
Mucosal surfaces (EM major)
Evolve over 72 hours
- pink macules, become elevated and may blister in the centre
- target lesions
26
How long does erythema multiforme take to resolve?
Over 2 weeks
27
What does DRESS stand for?
Drug Reaction with Eosinophilia and Systemic Symptoms
28
Mortality of DRESS
10%
29
When does DRESS occur?
Onset 2 - 8 weeks after drug exposure
30
Presentation of DRESS
```
Fever
Widespread rash
Eosinophilia
Deranged liver function
Lymphadenopathy
+/- other organ involvement
```
31
Treatment of DRESS
Stop causative drug
Symptomatic and supportive
Systemic steroids
+/- immunosuppression or immunoglobulins
32
Pathology of pemphigus
Antibodies targeted at desmosomes
33
Presentation of pemphigus
Flaccid blisters which rupture very easily
Intact blisters may not be seen
May be Nikolsky's sign +ve
34
Where do you get the lesions of pemphigus?
```
Face
Axillae
Groin
Mucous membranes
Ill defined erosions in mouth
```
35
Pathology of pemphigoid
Antibodies directed at dermo-epidermal junction
36
Presentation of pemphigoid
Intact epidermis forms the roof of the blister
| Blisters are usually tense and in tact
37
Who gets pemphigus?
Middle aged patients
38
How common is pemphigus?
Uncommon
39
Treatment of pemphigus
Systemic steroids
Dress erosions
Supportive therapies
40
How common is pemphigoid?
Common
41
Who gets pemphigoid?
Elderly
42
If extensive disease, how are pemphigus patients?
Very unwell
43
If extensive disease, how are pemphigoid patients?
Fairly well systematically
44
Treatment of pemphigoid patients
Topical steroids if localised
| Systemic if diffuse
45
Can erythrodermic psoriasis and pustular psoriasis occur if you haven't had psoriasis before?
Yes
46
Common causes of erythrodermic or pustular psoriasis
Infection
| Sudden withdrawal of oral steroids or potent topical steriod
47
Presentation of erythrodermic / pustular psoriasis
Rapid development of generalised erythema
+/- clusters of pustules
Fever
Elevated WCC
48
Treatment of erythrodermic / pustular psoriasis
Exclude underlying infection
Bland emollient
Avoid steroids
Systemic therapy Often needed
49
What is eczema herpeticum?
Disseminated herpes virus infection on a background of poorly controlled eczema
50
Presentation of eczema herpeticum
```
Monomorphic blisters and "punched out" erosions
Generally Painful
Not itchy
Fever
Lethargy
```
51
Treatment of eczema herpeticum
Aciclovir
Mild topical steroid if required to treat eczema
Treat secondary infection
Ophthalmology input if peri-ocular disease
52
If an adult and have eczema herpeticum, what should be considered?
Underlying immunocompromise
53
Who does staphylococcal scaled skin syndrome (SSSS) occur in?
Children
| Immunocompromised adults
54
Presentation of SSSS
```
Initial staph infection (may be subclinical)
Diffuse erythematous rash
Skin tenderness
More prominent in flexures
Blistering and desquamation follows
Fever
Irritability
```
55
Why does blistering and desquamation occur in SSSS?
Staphylococcus produces toxin which targets desmoglein 1
56
Treatment of SSSS
IV antibiotics
| Supportive care
57
How long does SSSS take to resolve with treatment?
5 - 7 days
58
Other names for urticaria
Weal
| Hives
59
What is urticaria?
Central swelling of variable size, surrounded by erythema
| Dermal oedema
60
Presentation of urticaria
Swellings surrounded by erythema
Itching
Sometimes burning
Fleeting nature
61
Duration of urticaria
1 - 24 hours
62
What is angioedema?
Deeper swelling of the skin or mucous membranes
63
Definition of acute urticaria
< 6 week history
64
Causes of acute urticaria
Idiopathic 50%
Infection, usually viral 40%
Drugs, IgE mediated 9%
Food, IgE mediated 1%
65
Treatment of acute urticaria
Oral antihistamine
66
What drugs exacerbate urticaria?
Opiates
| NSAIDs
67
Definition of chronic urticaria
> 6 week history
68
Causes of chronic urticaria
Autoimmune/idiopathic 60%
Physical 35%
Vasculitic 5%
Rarely type 1 hypersensitivity reaction
69
Treatment of chronic urticaria
Omalizumab
70
What is Omalizumab?
Monoclonal antibody to IgE
71
What complications are monitored for in an inpatient with erythroderma?
Dehydration
Infection
High output heart failure
72
Bullous pemphigoid vs pemphigus vulgaris
Bullous pemphigoid - NO mucosal involvement
| Pemphigus vulgaris - mucosal involvement
73
Children with new onset purpura need to be admitted and tested to exclude what two conditions?
ALL
| Meningococcal septicaemia
74
When should superficial dermal burns be referred to secondary care?
> 3% TBSA adults
> 2% TBSA children
Also if involve face, hands, feet, perineum, genitalia, any flexure, circumferential burns of the limbs, torso or neck
