Dermatological Emergencies Flashcards
What are some functions of the skin?
Mechanical barrier to infection Temperature regulation Fluid and electrolyte balance Vitamin D synthesis Sensation
What is the definition of acute skin failure?
A loss of normal temperature control, an inability to prevent excessive fluid, electrolyte and protein loss, as well as the loss of its normal barrier function
What is a potential consequence of acute skin failure with regard to systemic circulation?
It can cause peripheral vasodilation and may rarely lead to cardiac failure
What are some general consequences of acute skin failure?
Increased fluid loss
Protein loss
Poor temperature regulation
Infection
What is erythroderma?
Reddening of the skin - a descriptive term rather than a diagnosis - it is any inflammatory skin disease affecting more than 90% of the body surface area
Give some common causes of erythroderma
Psoriasis
Eczema
Most classes of drugs
Cutaneous lymphomas
What is a common, mild skin manifestation caused by adverse drug reaction?
Drug exanthems
What are some severe skin manifestations of drug reactions?
Erythroderma
Stevens Johnson Syndrome
What is another name for Stevens Johnson Syndrome? What are these conditions?
Toxic Epidermal Necrosis
2 conditions which from part of the same rare spectrum which cause fever, malaise, arthralgia and ulceration of mucous membranes, in particular the mouth
What is the most common cause of Stevens Johnson Syndrome?
It is usually secondary to drugs and can be delayed in onset
Antibiotics
NSAIDs
Anticonvulsants
What are the clinical features of Stevens Johnson Syndrome?
Fever Malaise Arthralgia Rash -'target lesions', blisters Severe mouth lacerations with a greyish white membrane and haemorrhagic crusting Red painful eyes
What kind of skin lesions can be seen in Stevens Johnson Syndrome?
Macropapular rash
Targetoid rash
Greyish white memraned mucal ulceration
How can Toxic Epidermal Necrosis sometimes differ from Stevens Johnson Syndrome?
Often presents with a prodromal febrile illness
Its rash rapidly becomes confluent and sloughing off of large areas of the epidermis ‘desquamation’ occur
What clinical sign may be positive in Toxic Epidermal Necrosis?
Nikolsky’s sign
What are the management principles for TEN?
Identify and remove culprit drug!
Supportive Therapy
Specific therapies might include high dose steroids, IV immunoglobulins, anti-TNF therapy, ciclosporin
Give some long term complications that occur as a result of TEN
Pigmentary skin changes Skin scarring Genital scarring Joint contractures Nail loss/hair loss Eye disease and blindness
What is DRESS syndrome?
Drug Reaction with Eosinophilia and Systemic Symptoms
What is the mortality rate for DRESS syndrome?
Up to 10%
What are the clinical features of DRESS syndrome?
Fever
Rash - multiform, erythrodermic, blistering, pustular
BLOOD EOSINOPHILIA
Lymphadenopathy
What are some systemic consequences of DRESS syndrome?
Liver dysfunction
Renal dysfunction
Haematological - eosinophilia, thrombocytopaenia, anaemia
Rarely - GI, cardiac or resp involvement
What is the management for DRESS syndrome?
Withdraw offending drug - often Allopurinol, anticovulsants, NSAIDs or antibiotics
Genral skin care, emollients, dressings
Supportive care if skin failure
High dose corticosteroids in severe cases
What type of skin condition is pemphigus?
A blistering disorder
What is the basic pathophysiology of pemphigus?
Autoimmune disorder where IgG antibodies against desmosomes in the epidermis are produced, leading to a loss of cell adhesion and splitting of the epidermis which causes blistering which are very fragile
What type of hisopathological technique can be used to identify pemphigus?
Immunoflourescence
What are the clinical features of pemphigus?
Skin - flaccid blisters which rupture very easily - intact blisters may not be seen!
Commonly affects face, axxilae and groin
Nikolsky’s sign may be positive
Commonly affects mucous membranes, ill defined erosions in the mouth aooear and can also affect the eyes, nose and genital areas
What is pemphigoid?
An antibody mediated disease which affects the dermo-epidermal junction. Deeper than pemphigus, the intact epidermis fomrs the root of the blister
Visually, what is the main difference between pemphigus and pemphigoid? Why?
Pemphigus if far more superficial, the blisters will likely be burst and affecting the epidermis. Intact blisters may not be seen and if present will be flaccid and highly fragile
Pemphigoid is deeper and blisters are usually tense and intact
Pemphigus affects the epidermis whereas pemphigoid affects the dermo-epidermal junction and is therefore less superficial
Which differing age groups do pemphigus vs pemphigoid usually affect?
Pemphigus usually affects middle aged patients
Pemphigoid affects the elderly in the main
Are pemphigus and pemphigoid common?
Pemphigus is uncommon
Pemphigoid is common
What are the treatments for pemphigus and pemphigoid?
Pemphigus must be treated with systemic steroids
Pemphigoid may be treatable with topical steroids or systemis ones if severe
DO NOT ASSUME THAT BECAUSE PEMHIGOID IS DEEPER THAN PEMPHIGUS IT IS MORE DANGEROUS
Outline pustular psoriasis
Generalised erythema followed by clusters of tiny pustules
Develops rapidly and the patent may be extremely unwell
Patient may not have a history of chronic plaque psoriasis
What are the clinical signs which often accompany pustular psoriasis?
Fever - often without infection
Malaise
Tachycardia
Increased WCC
What is the treatment for pustular psoriasis?
Admit, preferably to a dermatology ward
Blood cultures and treat for any superimposed infections
Emollients
Avoid topical steroids!
Consider systemic treatments e,g, retinoids, methotrexate, biologics
What is eczema herpeticum?
A disseminated herpes virus infection on the back of atopic eczema, more common in children. Multiple small vesicles develop, initially overlying eczematous skin and them becoming disseminated
Which strand of herpes simplex virus most commonly caused eczema herpeticum?
HS-1
What is the treatment for eczema herpeticum?
Send a swab for viral culture
Treat with systemic antivirals e.g. aciclovir 200mg 5x/day
Consider superimposed bacterial infection
Try to avoid topical steroids
Ophthalmology input in eye involvement
What is staphylococcal scalded skin syndrome?
A condition which starts with a staphylococcal infection e.g. impetigo, throat, nose, mouth
The staph produces a toxin which causes splitting of the epidermis and widespread desquamation
More common in children but can occur in immunocompromised adults
What are the clinical features of SSSS?
Preeceding staph infection - may be subclinical
Diffuse erythmatous rash with skin tenderness
More prominent in flexures
Blistering and desquamation follows
May occur at the site of minor trauma
What is the treatment for SSSS?
Antibiotics - good idea to cover staph and strep
Topical antibiotic preparations e.g. Bactroban
Wound care
Fluid rehab
(Most children are not too systemically unwell)
What are the basic principles of management of skin failure which broadly apply regardless of the cause?
Good fluid and electrolyte balance
Temperature regulation
Emollients
Anticipate and treat infection
