Acute and Emergency Dermatology

Question 1

what is the consequence of mechanical barrier to infection failing?

Answer 1

sepsis

Question 2

what are the consequences of temperature regulatioin failing?

Answer 2

Hypo- and Hyper- thermia

Question 3

what are the consequences of fluid and electrolyte balance failing?

Answer 3

Protein and fluid loss
Renal impairment
Peripheral vasodilation

Question 4

what are the causes of erythroderma?

Answer 4

Psoriasis
Eczema
Drugs
Cutaneous Lymphoma
Hereditary disorders
Unknown

Question 5

what are the principles of management?

Answer 5

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
Manage itch
Disease specific therapy; treat underlying cause

Question 6

what could a mild drug reaction be?

Answer 6

Morbilliform exanthem

Question 7

what could severe reactions be?

Answer 7

Erythroderma, Stevens Johnson Syndrome/Toxic epidermal necrolysis, DRESS

Question 8

what are clinical features of stevens johnson syndrome?

Answer 8

Fever, malaise, arthralgia
Rash

Mouth ulceration
Greyish white membrane
Haemorrhagic crusting

Ulceration of other mucous membranes

Question 9

what does toxic epidermal necrolysis present with?

Answer 9

prodromal febrile illness
Ulceration of mucous membranes
Rash

Question 10

what is the management of toxic epidermal necrolysis?

Answer 10

Identify and stop culprit drug as soon as possible
Supportive therapy

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

Question 11

what are long term complications?

Answer 11

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

Question 12

what is Erythema Multiforme

Answer 12

Hypersensitivity reaction usually triggered by infection

Most commonly HSV, then Mycoplasma pneumonia

Question 13

what are the symptoms of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

Answer 13

Fever and widespread rash

Question 14

what are the clinical features of DRESS?

Answer 14

Eosinophilia and deranged liver function
Lymphadenopathy
+/- other organ involvement

Question 15

whatare the clinical features of pemphigus?

Answer 15

Antibodies targeted at desmosomes
Skin – flaccid blisters, rupture very easily
Intact blisters may not be seen
Commonly affects mucous membranes
Ill defined erosions in mouth
Can also affect eyes, nose and genital areas

Question 16

where are common sites for pemphigus?

Answer 16

face, axillae, groins

Question 17

whats the difference between pemphigus and pemphigoid?

Answer 17

pemphigus-
Uncommon
Middle aged patients
Blisters very fragile – may not be seen intact
Mucous membranes usually affected
Patients may be very unwell if extensive
Treat with 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

Question 18

how would you treat pemphigus?

Answer 18

systemic steroids. Dress erosions. Supportive therapies

Question 19

how would you treat pemphigoid?

Answer 19

Topical steroids may be sufficient if localised; systemic usually required if diffuse

Question 20

what are the common causes of Erythrodermic psoriais and Pustular Psoriasis

Answer 20

infection and sudden withdrawel of oral steroids or potent topical steroid

Question 21

what are symptoms of Erythrodermic psoriais and Pustular Psoriasis

Answer 21

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

Question 22

what is Eczema Herpeticum

Answer 22

Disseminated herpes virus infection on a background of poorly controlled eczema

Question 23

what is the treatment of Eczema Herpeticum

Answer 23

Aciclovir
Mild topical steroid if required to treat eczema
Treat secondary infection
Ophthalmology input if peri-ocular disease

Question 24

what organism is responsible for Staphylococcal Scalded Skin Syndrome

Answer 24

staph. aureus

Question 25

wht is the treatment of Staphylococcal Scalded Skin Syndrome

Answer 25

Require admission for IV antibiotics initially and supportive care

Question 26

what is urticaria?

Answer 26

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- 24 hours

Question 27

what is Angioedema

Answer 27

Deeper swelling of the skin or mucous membranes

Question 28

what are the causes of acute urticaria?

Answer 28

Idiopathic
50%
Infection, usually viral
40%
Drugs, IgE mediated
9%
Food, IgE mediated 
1%

Question 29

what is the treatment for acute urticaria?

Answer 29

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 30

what are the causes of chronic urticaria?

Answer 30

Autoimmune/Idiopathic
60%
Physical
35%
Vasculitic
5%

Question 31

what is the management of chronic urticaria?

Answer 31

Omalizumab
Monoclonal antibody to IgE, mechanism of action unknown
Recently licensed for use in chronic spontaneous urticaria
300mg S/C ever 4 weeks
£6000 per year per patient