Dermatologic Emergencies

Question 1

Henoch-Scholein Purpura

Path:

S/Sx:

Dx:

Tx:

Answer 1

Henoch-Scholein Purpura

Path: Bacterial or viral infection -> deposition of IgA immune complexes in vasculature -> Vasculitis -> Hemorrhages -> Purpura

S/Sx:

• HA, arthralgias, N/V
• Ecchymosis, petechiae, non-blanchable rash
• Painful lesion +/- edema

Dx: Monitor renal function

Tx:

• Steroids
• Rheumatology consult
• Complication: Renal failure

Question 2

Hypersensitivity Vasculitis

Path:

S/Sx:

Dx:

Tx:

Answer 2

Hypersensitivity Vasculitis

Path: Drug rxn (allopurinol, cephalosporin, PCN, famciclovir, phenytoin, sulfonamide, thiazide, warfarin) or post-infectious (but not immune complex mediated like HSP)

S/Sx: Fever, malaise, arthralgias

Dx: Clinical

Tx: Prednisone, colchicine, dapsone (if severe)

Question 3

Purpura Fulminans

Path:

S/Sx:

Answer 3

Purpura Fulminans

Path: Post-infectious (or idiopathic) DIC / coagulopathy

S/Sx: Large areas of non-blanchable ecchymosis

Question 4

Meningococcemia

Path:

S/Sx:

Answer 4

Meningococcemia

Path: Neisseria meningitides infection or disseminated gonorrhea infection

S/Sx:

• Fever, malaise, arthralgias, myalgias
• Petechial vs maculopapular non-blanchable rash
• Starts on distal hands/wrists -> progresses proximally
• Late finding: palpable lesions

Question 5

Rocky Mountain Spotted Fever

Path:

S/Sx:

Dx:

Tx:

Answer 5

Rocky Mountain Spotted Fever

Path: 2-14d s/p tick bite

S/Sx:

• Fever, malaise, HA
• Rash to wrists, palms, ankles, soles
• Rash progresses to trunk

Dx: Antibody titer

Tx: Empiric doxycycline (don’t want until Ab titer results if suspicion high)

Question 6

DRESS

Path:

S/Sx:

Dx:

Tx:

Answer 6

DRESS

Path: Allopurinol, phenytoin/antiepileptic, Zosyn, sulfa, Bactrim -> Drug eruption with eosinophilia and systemic symptoms

S/Sx:

• Raised erythematous rash (measles like) on face and trunk
• Severe with facial & limb edema
• Can lead to organ failure

Dx: Monitor chemistry, liver, kidney function

Tx: Steroids and supportive care

Question 7

Erythema Multiforme

Path:

S/Sx:

Dx:

Tx:

Answer 7

Erythema Multiforme

Path: Hypersensitivity reaction to virus or drug

S/Sx:

• Minor: skin -> self-resolves
• Major: Mucous membranes - life threatening

Dx: Clinical

Tx: Fluids, analgesics, wound care, treat underlying cause

Question 8

Syphilis

Path:

S/Sx:

Tx:

Answer 8

Syphilis

Path: Treponema pallidum infection

S/Sx:

• Primary: Chancre
• Secondary: Fever, malaise, generalized pruritic macular rash on palms/feet

Tx: PCN

Question 9

Necrotizing Fasciitis

Path:

S/Sx:

Tx:

Answer 9

Necrotizing Fasciitis

Path: Polymicrobial with hx immunocompromise

S/Sx: Intense pain out of proportion to exam and beyond visible infection

Tx: Surgical emergency -> abx and debridement

Question 10

Bullous Pemphigoid

Path:

S/Sx:

Tx:

Answer 10

Bullous Pemphigoid

Path: IgG autoantibodies

S/Sx: Tense bullae

Tx: Topical / PO steroids, wound care, +/- methotrexate

Question 11

Pemphigus Vulgaris

Path:

S/Sx:

Tx:

Answer 11

Pemphigus Vulgaris

Path: Autoantibodies

S/Sx: Large, flaccid bullae

Tx: Oral steroids +/- IVIG

Question 12

Herpes Zoster Virus

Path:

S/Sx:

Tx:

Answer 12

Herpes Zoster Virus

Path: VZV reactivation

S/Sx: Painful shingles

Tx: If >2 dermatomes affected, admit for IV antivirals and treat for chronic neuropathic pain

Question 13

Stevens Johnson Syndrome/TENS

Path:

S/Sx:

Tx:

Answer 13

Stevens Johnson Syndrome/TENS

Path: Severe drug reaction

S/Sx:

• SJS <10% BSA; TENS >30% BSA
• Fever with (+) Nikolsky sign

Tx:

• Fluid resuscitation
• Wound care
• Symptomatic analgesia
• D/c causative agent
• Transfer to burn center

Question 14

Toxic Shock Syndrome

Path:

S/Sx:

Tx:

Answer 14

Toxic Shock Syndrome

Path: Staph or strep

S/Sx: Fever, (-) Nikolsky sign

Tx: Abx, IVIG, remove offending agent

Question 15

Staph Scalded Skin Syndrome

Path:

S/Sx:

Tx:

Answer 15

Staph Scalded Skin Syndrome

Path: Staph aureus

S/Sx: Fever, (+) Nikolsky sign

Tx: Nafcillin (vs. vanc), wound care, IV fluids

Question 16

Erythema Nodosum

Path:

S/Sx:

Tx:

Answer 16

Erythema Nodosum

Path: Autoimmune / IBD / RA

S/Sx: Painful nodule under skin; cellulitis-like

Tx: Treat underlying autoimmune disorder

Question 17

Pyoderma Gangrenosum

Path:

S/Sx:

Tx:

Answer 17

Pyoderma Gangrenosum

Path: Autoimmune / IBD / RA

S/Sx: Necrotic open ulcer with extreme pain

Tx: Abx, wound care, Steroids

Question 18

Venous Stasis Dermatitis

Path:

S/S:

Tx:

Answer 18

Venous Stasis Dermatitis

Path: Chronic venous insufficiency

S/S: Cellulitis-like, but afebrile; chronic

Tx: Avoid abx