Dermatologic Conditions Flashcards
Approach to ED Dermatologic Conditions
- CC
- brief history- duration, rate of progression, location
- derm exam
- age-appropriate differential diagnosis
- additional concerns- associated complaints, meds, exposures, pertinent +/-
- evaluate systemic involvement
- dermatologic consultation if necessary
Dermatologic Exam
- type of lesion
- secondary changes to surface
- color
- shape
- arrangement
- distribution
DDx - Plantar surfaces
atopic dermatitis, candidiasis, eczema, ichthyosis
DDx - Sun exposure
sunburn, photosensitive drug eruption, photosensitive dermatitis,
SLE, viral exanthem, porphyria
DDx - Distal extremeties
viral exanthem, atopic/contact dermatitis, eczema, Rocky Mtn SF, gonococcemia
DDx - Front/Back of chest
pityriasis rosea, secondary syphilis, drug eruption, atopic/contact dermatitis, psoriasis
DDx - Clothing covered
(thorax and distal lower extremeties)
contact dermatitis, psoriasis, folliculitis
DDx - Acneform
(face and upper thorax)
acne, drug-induced acne, irritant dermatitis
<0.5cm, flat, level w/ skin
macule
Macule Conditions
- syphilis (secondary)
- miningococcemia (early)
- viral exanthema
- drug eruption
- vitiligo
- tinea versicolor - hyper (sun) / hypo (tan)
- nevus
- tattoo (ink)
- rheumatic fever
- toxic/infectious erythemas
- ecchymosis (external trauma)
- cellulitis (early)
<0.5cm, solid, elevated
papule
Papule Conditions
- molluscum
- dermatitis
- dermatitis
- erythema multiform
- acne
- basal cell carcinoma
- melanoma
- nevus
- warts
- skin tags
- atopic dermatitis
- urticaria
- eczema
- folliculitis
- insect bites
- vasculitis
- psoriasis
- scabies
- toxicodendron dermatitis- poison ivy, oak, sumac
- varicella (early)
- gonococcemia
papule >0.5cm, solid, elevated
plaque
Plaque Conditions
- pityriasis rosea
- syphilis (secondary)
- eczema
- tinea corporis and versicolor
- psoriasis
- seborrheic dermatitsi
- urticaria
>0.5cm dermal or SQ solid, elevated
nodule
Nodule Conditions
- erythema nodosum
- furuncle (carbuncle larger)
- lipoma
- warts
- basal cell, squamous cell, metastatic carcinoma
- melanoma
any size, white to pink, edematous papule or plaque lasting <24h
wheal
Wheal Conditions
- PPD test
- angioedema
- urticaria
- insect bites
- erythema multiforme
<0.5cm cavity filled w/ pus (purulent) or sterile
pustule
Pustule Conditions
- gonococcemia
- herpetic infection
- impetigo
- rosacea
- pyoderma gangrenosum (assoc. w/ UC and Crohn’s)
- acne
- folliculitis
- hidradenitis suppurativa
- psoriasis
<0.5cm blister containing clear fluid or blood
vesicle
Vesicle Conditions
- pemphigus vulgaris
- herpetic infection (herpes simplex, herpes zoster, varicella)
- impetigo
- Toxicodendron dermtitis- poison ivy, oak, sumac
- thermal burn (2nd degree)
- friction blister
- toxic epidermal necrolysis
>0.5cm blister containing fluid or blood
bulla
Bulla Conditions
- bullous impetigo
- bullous pemphigoid
- pemphigus vulgaris
- Toxicodendron dermatitis
- thermal burn
- friction blister
- toxic epidermal necrolysis
skin defect that extends into dermis or deeper
ulcer
Ulcer Conditions
- apthous lesions- tx w/ Kenalog or orabase dental cream
- chancre (primary syphilis, non-painful)
- stasis ulcer
- chancroid (painful)
- decubitus ulcer
- thermal or friction injury
- subacute or chronic ischemia
- malignancy
- primary blistering disorders- bullous pemphigoid/vulgaris
- brown recluse spider envenomation
- pyoderma gangrenosum
skin defect only in the dermis
erosion
Erosion Conditions
- candidiasis
- dermatophytic infection (tinea)
- eczema
- toxic epidermal necrolysis
- toxic-infectious erythemas
- erythema multiforme
- primary blistering disorders
- bullous pemphigoid
- pemphigus vulgaris
- brown recluse spider envenomation
dried blood/exudate on skin surface
crust
Crust Conditions
- eczema
- dermatophytic infection (tinea)
- impetigo
- contact dermatitis
- insect bite
flakes of stratum corneum
scales
Scale Conditions
- psoriasis
- xerosis (dry skin)
- pityriasis rosea
- toxic and infectious erythemas
- syphilis (secondary)
- dermatophytic infection (tinea)
- tinea versicolor
- thermal burn (first degree)
least potent, mild, upper mid-strength corticosteroids
- least: hydrocortisone
- mild: Triamcinolone (Kenalog) 0.025%
- mid-strength: Triamcinolone (Kenalog) 0.1%
Uses
- Superpotent
- Clobetasol (Temovate, Clobex) 0.05% cream or ointment
- Halobetasol (Halonate, Ultravate)
- Betamethasone (Diprolene)
- Potent
- Fluocinonide (Lidex, Vanos) 0.05% ointment
- Halcinonide (Halog) 0.1% cream
- Mometasone (Elocon) 0.1% ointment
- psoriasis
- eczema of hand (severe)
- poison ivy (severe)
- atopic dermatitis (severe)
Uses
- Upper mid-strength
- Betamethasone (Diprolene) 0.05% lotion
- Fluticasone (Cutivate) 0.005% ointment
- Triamcinolone (Kenalog) 0.1% ointment
- Mid-strength
* Mometasone (Elocon) 0.1%cream, lotion - Lower mid-strength
- Betamethasone (Diprolene) 0.1% cream
- Fluocinolone (Synalar) 0.025% cream
- Fluticasone (Cutivate) 0.05% cream
- atopic dematitis
- stasis dermatitis
- seborrheic dermatitis
- tinea
- scabies
- nonspecific dermatitis of face (severe)
Uses
- Mild
- Alclometasone (Alclovate) 0.05% cream or ointment
- Desonide (Desonate, Desocort) 0.05% cream
- Triamcinolone (Kenalog) 0.025% cream
- Least Potent
* Hydrocortisone 1% or 2.5% cream, lotion or ointment
- nonspecific dermatitis of face, eyelids, perineum
Evaluation of Wounds & Lacerations:
Symptoms
- pain
- swelling
- paresthesias
- muscle weakness (distal too)
Evaluation of Wounds & Lacerations:
Type of Force
- crush (blunt)
- shear (shart)
- bite
- puncture
Evaluation of Wounds & Lacerations:
Elements of Contamination
- time from injury to initial cleansing
- time from injury to presentation
- wound care prior to ED
- object causing injury
- cleanliness of body and environment at injury and afterward
Evaluation of Wounds & Lacerations:
Factors Resulting in Injury
- intentional vs. unintentional
- occupational vs. non-occupational
- assault or self-inflicted (for reporting)
Evaluation of Wounds & Lacerations:
Foreign Body Potential
- did the object break or shatter
- is there foreign body sensation
- was a portion of the object removed
Evaluation of Wounds & Lacerations:
Function
occupation and handedness (R/L)
Evaluation of Wounds & Lacerations:
Allergies
- anesthetics
- analgesics
- antibiotics
- latex
Evaluation of Wounds & Lacerations:
Medications
status of prior tetanus immunization
Evaluation of Wounds & Lacerations:
Chronic Medical Conditions
- increased risk of infection
- increased likelihood of poor wound healing
- DM
- clotting/bleeding disorders
Evaluation of Wounds & Lacerations:
Previous Scar Formation
hypertrophic scars or keloids
3 items of concern for wound care in ED
- cosmesis
- glue or steristrips in non-tension areas
- pain
- infection
Suture Types and Sizes
- Type
- dissovable: vicryl or catgut only for SQ
- Sizes
- 3.0-4.0
- thick skin, palm/soles, high tension
- 4.0-5.0
- most common, not for face
- 6.0
- nylon or prolene
- best for face
- MC simple interruupted
- 7.0
- difficult to see - eyelid only
- 3.0-4.0
Suture Removal Times
- face
- neck
- upper extremety
- hand
- chest
- back
- legs
- foot
- overlying joints
- tongue
- face: 3-4 (child), 3-5 (adult)
- neck: 2-3 (child), 3-4 (adult)
- upper extremity: 7-10
- hand: 10-14
- chest: 7-10
- back: 10-14
- legs: 8-10
- foot: 10-14
- joints: 10-14
- tongue: absorbable
Puncture Wound Care & Tx
uncomplicated, clean presenting <6 h
- superficial wound cleansing
- tetanus prophylaxis as indicated
high-risk pts. w/ plantar puncture
- Cephalosporing 1st gen -or-
- anti-staphylococcal Penicillin
through athletic shoes
- Ciprofloxacin PO
Tx of Bite Wounds
- dog: Augmentin 875mg BID x7d
(Clindamycin+Cipro if PCN allergy)
- cat: Augmentin
- human: Augmentin
- monkey: Acyclovir
- fish: Fouroquinolone
- wild/unknown: Rabies immunoglobulin + vac.
Reduction of Bacterial Isolates in Wound
(cleansing)
- hair removal (vaseline, shaving, clipping)
- irrigation: isotonic or tap water, 7-11 lbs psi
- 35mL syringe w/ 18ga angiocath
- zero wet on 65cc syringe
- Canyons wound irrigation system
- scrubbing (brush or sponge)
Cleanser Options
- normal saline (best)
- for skin around wound:
- hydrogen peroxide 1/2 strength
- pHisoHex detergent
- disinfectants
- providone-iodine
- shure-clens
- hibiclens
- debridement if all else fails
(when in doubt, wash or pick it out)
Indications for Tetanus Prophylaxis
- 3+ doses
- 5-10 years since last dose
- booster if not clean, minor wound
- >10 years since last dose
- booster for ALL wounds
- 5-10 years since last dose
- < 3 doses or uncertain
- clean, minor wound- booster
- all other- booster and immunoglobulin
Care of Traumatic Wounds
compulsive cleansing!
- remove dressing after 24h and cleanse, inspect (unless 4-5d or physician re-eval)
- daily cleansing and inspection (red, warm, swelling, drainage)
- adhesives- can shower but not bathe/swim
- antibiotics if
- human, cat, deep dog bite
- bite to hand
- open fractures
- exposed joints or tendons
Black Widow S/s and Tx
- S/s
- erythema and swelling in 20-60 min
- pain and cramps 20-40 min later
- rigid abdomen
- HTN, shock, coma, m. paralysis
- sx resolve in 2-3 days
- Tx
- Antivenin (Lyovac), benzos, opiates
- no allergy to horse serum
Brown Recluse S/s and Tx
- S/s
- “bullseye” pattern
- pain, myalgias, arthralgias, vomiting, seizures, hemolysis, renal failure
- Dapsone
- leukocyte inhibitor
- prevents progression of tissue necrosis
- must monitor pt for hemolysis and agranulocytosis
swelling of deeper dermal and SQ tissues
worse if mouth, tongue, lips, lower airway
Angioedema
(hereditary- <16 y/o vs. acquired- ACEI, NSAIDs)
EMERGENCY INERVENTION
- emergency airway protection
- fluids for shock
- O2 to keep pulse ox > 90%
- Epinephrine 0.1-0.5mg IM or SQ (.3 is good)
- H1 antihistamine- Benadryl 25mg IV/50mg IM
- Solumedrol 125mg IV q6h (or IM)
- consider: H2 blocker- Pepcid 20mg IV
- admit to ICU or monitor for sx return
- allergic- mast cell mediated
- 50% associated w/ angioedema
- transient edematous papule/plaque w/ peripheral erythema
Treatment
Urticaria (hives)
- identify and remove allergen
- antihistamine tx
- OTC
- Zyrtec 10mg qd, Allegra 180mg qd, Xyzal 5mg qd
- OTC
- Zantac 150mg bid, Pepcid 20mg bid
- Rx
- Vistaril (Atarax) 25mg q6h (6x more potent than Benedryl)
- OTC
- Short course corticosteroids
- Prednisone 20mg bid w/ food 5-7d and 9d taper
- papules, vesicles, bullae on erythematous base
- streaky, linear, intensely pruritic
Treatment
Contact Dermatitis
- good hx to ID irritant or allergen
- avoidance
- OCT- topical baths
- antihistamine- Zyrtec 10mg qd
- topical steroid cream
- Triamcinolone .05% bid x7d
- systemic steroids for poison ivy
- Prednisone 10mg #36 tabs, 80mg today then taper by 10mg until gone
- SoluMedrol 125mg IM
- Zanfel or Mean Green OTC soap
Characteristic locations such as suprapatellar or olecranon, may have palpable fluid collection
bursitis
Pruritus instead of pain, absence of fever, may have bulla, but patient is nontoxic in appearance.
contact dermatitis
Abscess may appear similar to cellulitis initially; eventual fluctuanceand purulent drainage
cutaneous abscess
Typically not associated with skin redness or fever
DVT
Temporal relation to new drug exposure, pruritus instead of pain, absence of fever
drug reaction
Pronounced pain with involved joint movement
gouty arthritis
Characteristic vesicles, dermatomal pattern
herpes zoster
Pronounced pain most at onset
insect sting
Rapid progression; triad of severe pain, swelling, and fever; pain out of proportion to exam; severe toxicity; hemorrhagic or bluish bullae; gas or crepitus; skin necrosis or extensive ecchymosis
necrotizing soft tissue infection
Deeper involvement, prolonged course, comorbidities
osteomyelitis
Typically not associated with fever, limited to venous path
superficial thrombophlebitis
Hypotension, multiorganinvolvement, severe toxicity
TSS
Tx of Abscess
- I&D at bedside (iodoform gauze pack if deep)
- antibiotics
- healthy w/ no systemic signs - NONE
- immuno. or mild systemic (cellulitis/fever)
- Bactrim DS PO bid 10d
- Doxycycline 100mg PO bid 10d (if sulfa allergy)
- Clindamycin 300-400mg PO 4xd 10d (hard on GI)
- deep wound culture to ID bacteria
- circle redness and have pt return if larger after 2 doses Bactrim
Tx of Abscess if
PO Abx Failure, severe dz, s/s of infection
- admit to hospital
- culture wound prior to starting abx
- start IV Vancomycin or Clindamycin
- suspect necrotizing fasciitis
Cellulitis / Erysipelas Cause and Tx
(deep tissue / superficial dermis)
Group A Strep, Strep pyogenes, Staph aureus
- mild (no systemic signs)
- no labs, discharge w/ PO abx
- Cephalexin 500mg qid 7d
- Dicloxacillin 250mg qid
- Clindamycin 450mg qid
- Erythromycin if PCN allergy
- Bactrim DS bid if MRSA
- moderate (mild-mod systemic signs)
- admit
- IV Pen G, Nafcillin, Vanco for MRSA
- severe (sepsis, deep, immuno)
- admit
- surgery consult for debridement
- blood cultures
- IV Vanco +
- Piperacillin-tazobactam
- Meropenem
- Imipenem-cilastatin
Celluliltis / Erysipelas ER Disposition
- healthy w/out systemic toxicity
- discharge w/ warnings for prompt return
- follow-up in 2-3 days
- mark skin for monitoring
- systemic response, extensive infection, cannot tolerate PO, unreliable
- inpatient therapy
- deep soft tissue infection or osteomyelitis
- admission
- surgical intervention
- IV abx
