Acute Dermal infections Flashcards
This deck covers the most common acute presenting dermatological conditions and how to manage them:
- Erythroderma
- Stevens Johnson Syndrome (SJS)
- Toxic Epidermal Necrolysis (TEN)
- Erythema Multiforme
- DRESS
- Pemphigus
- Pemphigoid
- Erythrodermic Psoriasis & Pustular Psoriasis
- Eczema Herpeticum
- Staphylococcal Scalded Skin Syndrome
- Urticaria
How do we manage any acute dermatological condition? [8]
Remove any offending drugs Balance fluids Good nutrition Temperature Regulation Emollient Oral/Eye Care Manage symptoms (mainly itching) Anticipate/treat infections
What do we use for an emollient? [2]
1:1 ratio
Liquid Paraffin : White Soft Paraffin
What is erythroderma? [2]
A description rather than a condition
Its any inflammatory skin disease affecting >90% of the skin
What can cause erythroderma? [5]
Psoriasis Drug Reactions Eczema Cutaneous lymphoma Hereditary disorders
What are Stevens Johnson Syndrome and Toxic Epidermal Necrolysis?
What are they both secondary to?
Main clinical feature?
SJS/TEN are a spectrum of disease.
They are secondary to certain drugs.
Most notable for epidermal detachment
Presentation: SJS [3]
Causes - name 4 drugs
- Vague URT symptoms: 2-3d after starting drug and 2d before rash
- Mucocutaenous necrosis with AT LEAST 2 SITES (conjunctivae, oral cavity, labia, urethra)
- Limited (<10%) skin involvement: painful erythematous macules evolve into target lesion
Causes:
- Sulphonamides
- Anti epileptics
- Penicillin
- NSAIDs
Presentation: TEN [3]
Causes - name 6 drugs
- Flu-like prodrome
- Skin involvement >30% body surface: widespread painful dusky erythema, then necrosis of large sheets of epidermis
- Severe mucosal necrosis
Causes:
- Sulphonamides
- Anti epileptics
- Penicillin
- NSAIDs
- Cephalosporins
- Allopurinol
How do SJS/TEN differ? [1]
In SJS <10% of the skin detaches
In TEN >30% detaches.
What is Nikolsky’s Sign?
What is the clinical significance of a positive sign?
Using a pencil eraser twisted against the skin to elicit blister formation,
If +ve a blister will form within a minute or so, indicating blister-forming disease such as SJS/TEN or Pemphigus
How would you handle SJS/TEN? [2]
Identify the causative drug and remove it.
Along with standard supportive therapy
What are the complications of SJS/TEN? [5]
Sepsis Pigment changes, Scarring Eye disease/blindness Nail/hair loss Contractures
How do we asses the severity of a SJS/TEN case?
Outline supportive therapy for both SJS and TEN [4]
The Scorten Score predicts mortality
Supportive care
- Admission to ITU, HDU, Burns unit
- IV fluids, IVIg
- Avoid topical/systemic steroids
- Relieve and protect skin but don’t debride
What is included in the Scorten Score? [7]
- Age >40
- Serum Glc > 14
- Serum Urea > 10
- Serum Bicarb <20
- Malignancy
- HR >120
- Initial epidermal detachment >10%
Patient presents with a 24 hour history of 100s of pink macules (target lesions) forming and blistering. Starting at their distal limbs (particularly palms and soles), what do they have?
Describe these pink macule in further detail [2]
Erythema Multiforme
Target lesions:
target lesions with three concentric colours (dark red, pale pink, bright red); progress from macules to papules and plaques
Etiology erythema multiforme [2]
A hypersensitivity reaction to certain infections.
Mainly HSV and mycoplasma pneumoniae.
The patient presents with fever, a widespread rash and lymphadenopathy. On bloods the LFTs are deranged and Eosinophils raised. What is it? [3]
DRESS
aka Drug Reaction with Eosinophils and Systemic Symptoms
Occurs 2-8 weeks after exposure to certain meds
How do we treat DRESS? [3]
- Stop the offending drug
- Symptomatic and supportive therapy
- Systemic steroid +/- immunosuppression or Immunoglobulins if necessary
What is the difference between pemphigus and pemphigoid [4]
Give 2 examples of each
Pemphigoid: autoab’s against antigens between dermis and epidermis causing SUB-EPIDERMAL SPLIT
Pemphigus: autoantibodies against antigens between dermis and epidermis desmosomes causing INTRA-EPIDERMAL SPLIT
- Bullous Pemphigoid
- Pemphigus Vulgaris
How does Pemphigus Vulgaris present? [4]
Flaccid, easily ruptured blisters with erosions and crusts that are often painful
Axilla, face, groin
Mucous membrane erosion (mouth/nose/genitalia/eyes)
Nikolsky’s Sign
How does Bullous Pemphigoid present? [2]
Tense fluid filled blisters on erythematous base that are often itchy.
On trunk and limbs
What are the main differences between Pemphigus and Pemphigoid in terms of extra dermal involvement and epidemiology?
Pemphigus is rarer, affects the middle aged and causes systemic unwellness (plus the fragile blisters)
Pemphigoid is more common, affects the elderly and patients are generally systemically well.
How do we treat Pemphigus and pemphigoid?
General: wound dressings, supportive therapy, monitor for infection, good oral care for pemphigoid
Bullous pemphigoid:
- Topical steroids for localized
- Widespread: oral steroids, tetracycline + nicotinamide, immunosuppression
Pemphigus vulgaris:
- High dose steroids
- Immunosuppression
What are erythrodermic and pustular psoriasis?
Types of psoriasis caused by sudden steroid withdrawal and infection
How do Erythrodermic & Pustular Psoriasis present? [3]
Fever
Rapid onset of erythema +/- pustule clusters
Elevated WCC
How would you manage erythrodermic and pustular psoriasis? [4]
Systemic Therapy: UVB phototherapy Steroid sparing immunosuppressants Avoid steroids Rule out underlying infection Bland emollient
A patient with eczema presents with monomorphic blisters, painful “punched out” erosions, fever & lethargy. what do you suspect? [2]
Eczema Herpeticum
A disseminated Herpes infection on top of poorly controlled eczema
A patient comes in having had a diffuse erythematous rash with tenderness that progressed to blistering and desquamation. They’re also febrile and irritable, what do we expect? [1]
Underlying pathology [2]
Staphylococcal Scalded Skin Syndrome
A staph infection has released toxins targeting Demoglein 1 causing blisters and epidermal detachment
Perioral crusting, scald like skin appearance followed by large flaccid bullae that develops hours-days, worse over face neck axillae or groins
How do we treat a patient with Staph Scalded Skin SYndrome? [2]
Supportive care
Abx: IV fluclox, fusidic acid, erythromycin or ceftriaxone
Presentation of urticaria [3]
A central swelling surrounded by erythema, may itch or burn.
Individual swellings are fleeting, dissapearing within 1-24 hours
Often comes with angioedema (A deeper swelling of soft tissues)
What causes urticaria?
Give 3 acute causes, 4 chronic causes
Acute:
- 50% idiopathic
- 40% infection
- 10% IgE mediated (Drugs & food)
Chronic:
- 60% autoimmune
- 35% physical
- 5% vasculitis
- Rarely Type 1 Hypersensitivity
How would you treat a case of acute (<6wks) urticaria? [3]
- Oral Antihistamine
- ~Short course of oral steroids if severe
- Avoid Opiates/NSAIDs
How would you treat a case of Chronic (>6wks) Urticaria? [4]
Identify and avoid the triggers.
1) Antihistamine
2) Increased dose of antihistamine
3) Anti-leukotriene
4) Immunomodulant e.g. Omalizumab
External triggers of chronic urticaria
Dermographism - rubbing/stroking skin
Cold contact - air or water
Solar
Angioedema
Presentation and management [2]
Tongue and lip swelling
Mx: CCS
Anaphylaxis signs [3]
Bronchospasm
Facial and laryngeal edema
Hypotension
Nec Fasc RF [2], presentation [3]
RF:
- abdo surgery
- medical co-morbidities (DM, malignancy)
Sy/Si:
- severe pain, erythematous, blistering and necrotic skin
- systemically unwell with fever and tachycardia
- crepitus (subcutaneous emphysema)
Nec Fasc
Ix
Mx [2]
Prog
Ix: XR shows soft tissue gas Mx: - urgent surgical debridement - IV abx Pro: up to 70% mortality
