Dermatological Emergencies Flashcards
What are the normal skin functions?
Mechanical barrier to infections
Temperature regulation
Fluid and electrolyte balance
Vitamin D synthesis
Sensation
What is Acute Skin Failure?
Loss of normal temperature control
Inability to prevent loss of fluid, electrolytes and protein
Loss of normal “barrier function”
What are the consequences of acute skin failure?
Peripheral vasodilation (can occasionally lead to cardiac failure)
Poor temperature regulation
- Hypothermia
- Fever (+/- infection)
Increased fluid losses
Protein loss
Infection
What are the principles of acute skin failure management?
- Appropraite setting (?ITU or burns unit)
- Remove any offending drugs
- Careful fluid balance
- Good nutrition
- Temperature regulation
- Emollients
- Oral and eye care
- Anticipate and treat infection
- Disease specific therapy; treat underlying cause
What is erythroderma?
Descriptive term rather than a diagnosis
Any inflammatory skin disease affecting >90% of body surface area
What are the common causes of erythroderma?
Psoriasis
Eczema
Drugs (almost any)
- Anticonvulsants
- Antibiotics
- Lithium
Cutaneous Lymphomas
Other
- Pityriases rubra pilaris
- Hereditary Disorders
What types of of cutaneous drug reactions may occur?
Mild
-Drug exanthems
Severe
- Erythroderma
- Stevens Johnson Syndrome/ Toxic Epidermal Necrosis
- Dress syndrome
How common are cutaneous drug reactions?
Common
-2-3% of inpatients
Can occur after any drug
Whar is Stevens johnson Syndrome
Stevens–Johnson syndrome, a form of toxic epidermal necrolysis, is a life-threatening skin condition, in which cell death causes the epidermis to separate from the dermis. The syndrome is thought to be a hypersensitivity complex that affects the skin and the mucous membranes. The most well-known causes are certain medications (such as lamotrigine), but it can also be due to infections, or more rarely, cancers.
What are the signs and symptoms of Stevens-Johnson Syndrome?
SJS usually begins with fever, malaise and arthralgia, which is commonly misdiagnosed and therefore treated with antibiotics.
Rash
- Macropapular, target lesions, blisters
- Erosions covering
What is the relation between Stevens Johnson Syndrome and Toxic Epidermal Necrolysis?
2 conditions which are thought to form part of the same spectrum
Very rare conditions
What are the signs and symptoms of Toxic Epidernal Necrolysis?
Often presents with prodromal febrile illness
Ulceration of mucous membranes
Rash
- May start as macular, purpuric or blistering
- Rapidly becomes confluent
- Sloughing off of large areas of epidermis “desquamation”
- Nikolsky’s sign may be positive
How is prognosis in SJS/TENS determined?
SCORTEN
Age >40 Malignancy Tachycardia >120bpm Epidermal detachment >10% Serum urea >10mmol/L Serum glucose >14mmol/L Bicarbonate
What does the predicted mortality with SCORTEN vary between?
0-1 = 3.2% 2 = 12.1% 3 = 35.3% 4 = 58.3% >/=5 = 90%
How do you manage SJS/TEN?
Identify and remove culprit drug ASAP
Supportive therapy
Specific therapies:
- ?High dose steroids
- ?IV immunoglobulins
- ?Anti-TNF therapy
- ?Ciclosporin
What are the long term complications of SJS/TEN?
Pigmentary skin changes
Skin scarring
Genital scarring
Joint contractures
Nail loss/ hair loss
Eye disease and blindness
What does DRESS syndrome mean?
Drug Reaction with Eosinophilia and Systemic Symptoms
What are the features of DRESS syndrome?
Fever
Rash - morbilliform; erythrodermic; blistering; pustular
Blood eosinophilia
Lymphadenopathy
What other organ systems may DRESS syndrome effect?
Liver dysfunction
Renal dysfunction
Haematological - oesinophilia, thrombocytopenia, anaemia
rarely GI, cardiac or respiratory involvement
What is the management of DRESS syndrome?
Withdraw offending drug
- Allopurinol
- Anticonvulsants
- NSAIDs
- Antibiotics
General skin care, emollients, dressings
Supportive care if skin failure
High dose corticosteroids in severe cases
What is Pemphigus?
Blistering disorder
Autoimmune disorder
Antibody (IgG) to desmosomes in epidermis
Loss of cell adhesion leads to splitting of epidermis -> blisters
Blisters very fragile
What are the clinical features of pemphigus?
Skin- flaccid blisters, rupture very easily
Intact blisters may not be seen
Common sites = face, axillae, groins
Nikolsky’s sign may be positive
Commonly affects mucous membranes
- Ill defined erosions in mouth
- Can also affect eyes, nose and genital areas
What is Nikolsky’s sign?
Pressure applied to skin and top layer will easily peel off.
Like rubbing glue off your hands
What is pemphigoid?
Antibodies directed at demo-epidermal junction
Intact epidermis forms roof of blister
Blisters are usually tense and intact
Is pemphigus or pemphigoid more common?
Pemphigoid
What demographic do pemphigus and pemphigoid effect?
Pemphigus = middle ages patients
Pemphigoid = elderly patients
What is the difference between pemphigus and pemphigoid blisters?
Pemphigus = blisters very fragile- may not be seen intact
Pemphigoid = blisters often intact and tense
How are mucous membranes effected in pemphigus and pemphigoid?
Mucous membranes effected in pemphigus but not pemphigoid
How well are patients with pemphigus and pemphigoid?
Pemphigus - patients may be very unwell if extensive
Pemphigoid - even if extensive, patients are fairly well systemically
How do you treat pemphigus and pemphigoid?
Pemphigus = systemic steroids
Phemphigoid = topical steroids may be sufficient if localised; systemic usually required if diffuse
What is pustular psoriasis?
Develops rapidly; patient can be extremely unwell
Generalised erythema followed by development of clusters of tiny pustules
Patient may or may not have a history of chronic plaque psoriasis
Fever (often without infection), malaise, tachycardia, increased WCC
How do you treat pustular psoriasis?
Admit, preferably to dermatology ward
Blood cultures- treat any superimposed infection
Emollients
Avoid topical steroids!
Consider systemic treatment e.g. retinoids, methotrexate, biologics
What is eczema Herpeticum?
Disseminated herpes virus infection on a background of atopic eczema
More common in children
HSV-1 more common
Multiple small vesicles develop, initially overlying eczematous skin, then becoming disseminated
What is the treatment for eczema herpeticum?
Send swab for viral culture
Treat weith systemic antivirals (e.g. aciclovir 200mg 5x/ day)
Consider superimposed bacterial infection
Try to avoid topical steroids
Opthalmology input if eye involvement
What is staphylococcal scalded skin syndrome?
Fairly common in children
Starts with a staphylococcal infection (e.g. impetigo, throat, nose, mouth)
Staphylococcus produces a toxin which causes splitting of the epidermis and widespread desquamation.
Can occur in immunocompromised adults
What are the clinical features of staphylococcal scalded skin syndrome?
Preceding staph infection (may be subclinical)
Diffuse erythematous rash with skin tenderness
More prominent in flexures
Blistering and desquamination follows
May occur at sites of minor trauma
What is the treatment for staphylococcus scalded skin syndrome?
Antibiotics (good idea to cover staph and strep)
Topical antibiotic preparations (e.g. Bactroban)
Wound care
Fluid rehydration
Most children are not too systemically unwell
