Acute and emergency dermatology Flashcards
What severe illness can result if the skin is unable to act as a mechanical barrier to infection
Sepsis
What acute illness can result if the skin is unable to regulate body temperature
Hypo/Hyperthermia
What can result if the skin is unable to maintain fluid or electrolyte balance (3)
Protein and fluid loss
Renal impairment
Peripheral vasodilation
What is Erythroderma?
“Any inflammatory skin disease affecting >90% of total skin surface”
A descriptive term rather than a diagnosis
Causes of Erythroderma (6)
Psoriasis Eczema Drugs Cutaneous Lymphoma Hereditary disorders Unknown
Drug induced skin reactions
Common esp if patient has no previous dermatological history
Commonly occur 1-2 weeks after drug
Mild - Morbilliform exanthem
Severe - Erythroderma, Stevens Johnson Syndrome/Toxic epidermal necrolysis, DRESS
What is Stevens Johnson syndrome?
A rare, serious disorder of your skin and mucous membranes.
It’s usually a hypersensitivity reaction to a medication or an infection.
Often, it begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters.9 Mar 2018
What is Toxic Epidermal necrolysis?
More severe than Stevens johnson syndrome but though to form part of the same spectrum of disease
Severe skin peeling and blistering >30% of body
Secondary to drugs - antibiotics, anticonvulsants, NSAIDs
The peeling progresses quickly, resulting in large raw areas that may ooze or weep
Nikolsky’s sign may be positive
Clinical features of SJS
Fever, malaise, arthralgia (joint pain)
Rash - Maculopapular, target lesions (2 colours), blisters
Erosions covering <10% of skin surface
Mouth ulceration - Greyish white membrane, Haemorrhagic crusting
Ulceration of other mucous membranes
What is Nikolsky’s sign?
Whole epidermis becomes necrotic and slides off
cleavage in the skin at the dermal-epidermal junction.
Management of SJS or TEN
Identify and stop culprit drug as soon as possible
Supportive therapy
?High dose steroids
?IV immunoglobulins
?Anti-TNF therapy
?Ciclosporin
Prognosis of SJS and TEN
SJS mortality up to 10%
TEN mortality up to 30%
What is the SCORTEN scale?
Toxic Epidermal Necrolysis-specific severity of illness score. Helps to identify what stage patient is at and decide on management
0-5
0-1 = >3.2% mortality
5 or more = >90%
What factors does SCORTEN take into consideration
Age >40 Malignancy Heart rate >120 Initial epidermal detachment >10% Serum urea >10 Serum glucose >14 Serum bicarbonate <20
Long term complications of SJS/TEN (5)
Pigmentary skin changes - melanocytes don't regenerate to same level Scarring Eye disease and blindness Nail and hair loss Joint contactures
What is Erythema multiforme?
Hypersensitivity reaction usually triggered by viral infection - Most commonly HSV, then Mycoplasma pneumonia
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 that may blister in centre
Self-limiting - resolves over 2 weeks
Treat underlying cause
What does DRESS mean?
Drug Reaction with Eosinophilia and Systemic Symptoms
Describe what a Drug Reaction with Eosinophilia and Systemic Symptoms is?
DRESS is a rare, potentially life-threatening, drug-induced hypersensitivity reaction
Onset up to 2 months after drug exposure
Fever and widespread rash
Eosinophil count quite high but this would be later on also deranged liver function
Lymphadenopathy
+/- other organ involvement
treated with systemic steroids and maybe imunosuppression or immunoglobulins
Clinical features of Pemphigus
Antibodies targeted at desmosomes - dermo-epidermal junction - between cells
Skin – flaccid blisters, rupture very easily
Intact blisters may not be seen
Commonly affects mucous membranes - ill defined erosions in mouth
Common sites – face, axillae, groins
Nikolsky’s sign may be +ve
Patient may be very unwell if extensive
Pemphigoid
Pemphigus is less common. It affects middle aged patients > elderly
Blisters are very fragile
What is the difference between pemphigus and pemphigoid
Pemphigus affects the outer epidermis layer only and causes lesions and blisters that are easily ruptured.
Pemphigoid affects a lower layer of the skin, between the epidermis and the dermis. It is more common. Epidermis is still in tact - strong blisters
Clinical features of Pemphigoid
Blisters often intact and tense
Even if extensive, patients are fairly well systemically
Common causes of erythrodermic psoriasis/pustular psoriasis
Infection
Sudden withdrawal of oral steroids or potent topical steroid
How do Erythrodermic psoriais and Pustular Psoriasis present
Rapid development of generalised erythema, +/- clusters of pustules, Hyperkeratonic skin
Fever, elevated WCC
Exclude underlying infection, bland emollient, avoid steroids
Often require initiation of systemic therapy
