Acute and emergency dermatology

Question 1

What severe illness can result if the skin is unable to act as a mechanical barrier to infection

Answer 1

Sepsis

Question 2

What acute illness can result if the skin is unable to regulate body temperature

Answer 2

Hypo/Hyperthermia

Question 3

What can result if the skin is unable to maintain fluid or electrolyte balance (3)

Answer 3

Protein and fluid loss
Renal impairment
Peripheral vasodilation

Question 4

What is Erythroderma?

Answer 4

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

A descriptive term rather than a diagnosis

Question 5

Causes of Erythroderma (6)

Answer 5

Psoriasis 
Eczema 
Drugs
Cutaneous Lymphoma
Hereditary disorders
Unknown

Question 6

Drug induced skin reactions

Answer 6

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

Question 7

What is Stevens Johnson syndrome?

Answer 7

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

Question 8

What is Toxic Epidermal necrolysis?

Answer 8

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

Question 9

Clinical features of SJS

Answer 9

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

Question 10

What is Nikolsky’s sign?

Answer 10

Whole epidermis becomes necrotic and slides off

cleavage in the skin at the dermal-epidermal junction.

Question 11

Management of SJS or TEN

Answer 11

Identify and stop culprit drug as soon as possible
Supportive therapy

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

Question 12

Prognosis of SJS and TEN

Answer 12

SJS mortality up to 10%

TEN mortality up to 30%

Question 13

What is the SCORTEN scale?

Answer 13

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%

Question 14

What factors does SCORTEN take into consideration

Answer 14

Age >40
Malignancy
Heart rate >120
Initial epidermal detachment >10%
Serum urea >10
Serum glucose >14
Serum bicarbonate <20

Question 15

Long term complications of SJS/TEN (5)

Answer 15

Pigmentary skin changes - melanocytes don't regenerate to same level
Scarring
Eye disease and blindness
Nail and hair loss
Joint contactures

Question 16

What is Erythema multiforme?

Answer 16

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

Question 17

What does DRESS mean?

Answer 17

Drug Reaction with Eosinophilia and Systemic Symptoms

Question 18

Describe what a Drug Reaction with Eosinophilia and Systemic Symptoms is?

Answer 18

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

Question 19

Clinical features of Pemphigus

Answer 19

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

Question 20

Pemphigoid

Answer 20

Pemphigus is less common. It affects middle aged patients > elderly

Blisters are very fragile

Question 21

What is the difference between pemphigus and pemphigoid

Answer 21

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

Question 22

Clinical features of Pemphigoid

Answer 22

Blisters often intact and tense

Even if extensive, patients are fairly well systemically

Question 23

Common causes of erythrodermic psoriasis/pustular psoriasis

Answer 23

Infection

Sudden withdrawal of oral steroids or potent topical steroid

Question 24

How do Erythrodermic psoriais and Pustular Psoriasis present

Answer 24

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

Question 25

What is Eczema Herpeticum

Answer 25

Disseminated (widespread) herpes virus infection on a background of poorly controlled eczema

HSV barrier dysfunction

Monomorphic blisters and “punched out” erosions - Generally painful, not itchy

Fever and lethargy

Treat with aciclovir and mild topical steroid if required to treat eczema

Question 26

Staphylococcal Scalded Skin Syndrome

Answer 26

Common in children, can occur in immunocompromised adults

Initial Staph. infection - toxin attacks joints in skin which makes skin fall off

Diffuse erythematous rash with skin tenderness - blistering + peeling - Staphylococcus produces toxin which targets Desmoglein 1

Fever and irritability

Require admission for IV antibiotics initially and supportive care

Generally resolves over 5-7 days with treatment

Question 27

What is desquamation?

Answer 27

Skin peeling

Question 28

What is Urticaria?

Answer 28

Weal, wheal or Hive => central swelling of variable size surrounded by erythema. Dermal oedema. (nettle sting etc)

Itching, sometimes burning. fleeting nature, duration: 1- 24 hours

Angioedema =>
Deeper swelling of the skin or mucous membranes (below the dermis)

Question 29

Acute Urticaria causes (4)

Answer 29

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

Question 30

Treatment for acute urticaria <6 weeks

Answer 30

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 31

Causes of chronic urticaria >6 weeks

Answer 31

Autoimmune/idiopathic 60%

Physical - heat/pressure 35%

Vasculitic 5%

rarely a type 1 hypersensitivity reaction (IgE)

Question 32

Treatment/management of chronic urticaria

Answer 32

1 - antihistamine

2 - higher dose of H1 antihistamine up to 4 x recommended dose or add in 2nd antihistamine

3 - consider a 2nd line agent, anti-leukotriene or, if angioedema is present use tranexamic acid

4 - consider an immunomodulant omalizumab, cyclosporine

Question 33

Important drugs used in chronic Urticaria - what type of drug is it

Answer 33

Omalizumab
Monoclonal antibody to IgE

Cyclosporine