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Dermatological emergency rashes Flashcards

1
Q

What is toxic shock syndrome (TSS)?

A

Infection caused by bacterial (S. aureus or strep A) toxins that can result in multiorgan failure

TSS is associated with Toxic Shock Syndrome Toxin-1 (TSST-1)

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2
Q

What percentage of TSS cases are associated with tampon use?

A

~50%

TSS is more common in menstruating women

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3
Q

List non-menstruation associated causes of TSS.

A
  • Post-cesarean delivery
  • Endometritis
  • Mastitis
  • Wound/skin injections
  • Burns
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4
Q

What is the characteristic rash associated with TSS?

A

Erythematous, macular, scaly ‘sun-burn’ rash that later presents with desquamation in large sheets

Mostly distributed on palms and soles but can be diffuse over the whole body

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5
Q

What are some associated signs of TSS?

A
  • Red mouth
  • ‘Strawberry’ tongue
  • Sclera
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6
Q

What are the potential complications of TSS?

A
  • Acute Respiratory Distress Syndrome (ARDS)
  • Hypotension
  • Septic shock
  • Acute kidney injury (AKI)
  • Shock liver
  • Altered mental state
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7
Q

What are the diagnostic criteria for TSS?

A

Diagnosed based on specific criteria for staph or strep TSS

These criteria help differentiate TSS from other conditions

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8
Q

What is the initial management for TSS?

A
  • IV fluids
  • Antibiotics
  • Possibly IV immunoglobulins

Urgent diagnosis and treatment are crucial

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9
Q

What supportive therapies may be needed in TSS management?

A
  • Ventilation for ARDS
  • Dialysis for renal injuries
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10
Q

What is an important step in the management of TSS related to the primary cause?

A

Removal of the primary cause

This may include infected tampons, surgical drainage of abscesses, or debridement of necrotizing fasciitis

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11
Q

What is Staphylococcal Scalded Skin Syndrome (SSSS)?

A

A blistering skin disorder characterized by the detachment of the epidermis, caused by Staphylococcal epidermolytic toxins A, B, D (ETA, ETB, ETD).

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12
Q

Who is most affected by SSSS?

A

Children under 5 years old and immunocompromised adults.

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13
Q

What is the typical presentation of SSSS?

A

Erythematous, tender rash that originates at the face, groin, axillae, then diffuses over the body but spares palms and soles.

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14
Q

What does the ‘scalded’ appearance in SSSS indicate?

A

Bullae and desquamation occur within 48 hours (positive Nikolsky’s sign).

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15
Q

What regions are usually affected in SSSS?

A

Only skin involvement that usually favors intertriginous regions, with no mucosal involvement.

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16
Q

What are common clinical features of SSSS?

A

Perioral and nasolabial crusting.

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17
Q

How is SSSS diagnosed?

A

Clinical diagnosis with bacterial swabs from possible sites of infection and purulent cultures from the patient.

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18
Q

What additional tests are done to exclude staph carriage?

A

Bacterial swabs from groin, axillae, and nostrils of family members.

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19
Q

What is done to exclude Toxic Epidermal Necrolysis (TEN)?

A

Skin snip sample (cutting of a piece of desquamated skin).

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20
Q

What is the first-line management for SSSS?

A

Flucloxacillin for 7-10 days.

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21
Q

What are the second-line options for managing SSSS?

A

Clarithromycin, azithromycin, or erythromycin for 7-10 days.

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22
Q

What is necrotising fasciitis?

A

A subset of aggressive bacterial SSTIs that cause necrosis of the muscle fascia and subcutaneous tissues.

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23
Q

How is necrotising fasciitis transmitted?

A

It is transmitted after skin trauma (e.g., bite, IV drug use, cut) or idiopathic causes.

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24
Q

What are some causative organisms of necrotising fasciitis?

A

Streptococcus pyogenes, Group B and C streptococci, Vibrio vulnificus, Clostridium perfringens, Bacteroides fragilis.

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25
What is the typical presentation of necrotising fasciitis?
Erythematous area that rapidly spreads, with severe pain upon palpation beyond the erythema.
26
What are some systemic symptoms of necrotising fasciitis?
Fever, toxicity, which can lead to organ failure, shock, and death.
27
What are the key findings upon examination of necrotising fasciitis?
Bullae formation, necrosis, gangrene, and wooden-hard induration of subcutaneous tissues.
28
What is the investigation method for diagnosing necrotising fasciitis?
Excisional deep skin biopsy and culture for identifying the causative organisms.
29
What is the management approach for necrotising fasciitis?
Must be treated as a medical emergency with surgical debridement of necrotic tissue and antibiotics.
30
What antibiotics are commonly used for necrotising fasciitis?
Gentamicin and clindamycin.
31
What is eczema herpeticum?
A contagious disseminated infection caused by HSV that presents in patients with atopic dermatitis.
32
What is the presentation of eczema herpeticum?
Diffuse clusters of monomorphic (identical) vesiculopustular lesions that are umbilicated (new) or with crusting or punched-out erosions (old) in areas of pre-existing eczema.
33
What complications can arise from eczema herpeticum?
Eye involvement can present as herpetic keratoconjunctivitis and can lead to secondary bacterial infection which causes impetigo or cellulitis.
34
How is eczema herpeticum diagnosed?
Clinical diagnosis, viral culture, and Tzanck smear showing characteristic multinucleated syncytial giant cells and acantholytic cells.
35
What is a reliable lab test for identifying vesiculobullous skin lesions?
Tzanck smear is a reliable lab test to identify multiple types of vesiculobullous skin lesions.
36
What is the management for eczema herpeticum?
Urgently treated with antivirals, oral or topical antibiotics for secondary infection, and ophthalmology referral.
37
What is generalized pustular psoriasis?
A life-threatening form of psoriasis.
38
What is the presentation of generalized pustular psoriasis?
Widespread sheets of sterile pustules on erythematous skin, associated with pyrexia and haemodynamic instability.
39
What are the complications of generalized pustular psoriasis?
Complications include secondary bacterial infection, electrolyte disturbance, renal and liver impairment.
40
What is DRESS?
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe hypersensitivity reaction to a drug.
41
What drugs are most commonly associated with DRESS?
Most associated drugs include anticonvulsants (e.g., carbamazepine, phenobarbital), antiretrovirals (e.g., nevirapine), sulfonamide antibiotics, and allopurinol.
42
What is the initial presentation of DRESS?
Initially presents with facial and neck edema, usually followed by widespread lymphadenopathy.
43
What type of rash is associated with DRESS?
Widespread, maculopapular drug eruption with red papules, targetoid lesions, vesicles, and pustules, favoring the face, upper trunk, and extremities.
44
What can the rash in DRESS progress to?
The rash can progress to erythroderma.
45
How is DRESS diagnosed?
DRESS is diagnosed clinically.
46
What investigations are done for DRESS?
FBC, vital observations to check for fever, CRP, ESR, and a viral swab to rule out viral infection.
47
What is the management for DRESS?
Immediately withdraw all suspected offending drugs; should resolve within 2-6 weeks.
48
What is the first-line treatment for DRESS?
First-line treatment includes emollients and topical corticosteroids (e.g., prednisolone).
49
What is the second-line treatment for DRESS?
Second-line treatment includes systemic corticosteroids or IV methylprednisolone.
50
What is the third-line treatment for DRESS?
Third-line treatment includes immunosuppressants (e.g., ciclosporin, MMF, rituximab).
51
What is erythroderma?
Erythroderma is widespread and intense inflammatory reddening of the skin with associated severe itching and pain affecting >90% of the skin surface.
52
What is the initial presentation of erythroderma?
Initially presents as a maculopapular eruption that progresses to widespread erythema.
53
What are the symptoms associated with erythroderma?
Skin is tender and pruritic, leading to scaling and lichenification.
54
How is erythroderma diagnosed?
Erythroderma is diagnosed clinically.
55
What is the management for erythroderma?
Management includes emollients and mild-moderate topical steroids.
56
When should systemic steroids be used in erythroderma?
Systemic steroids should be used if the condition is severe.
57
What supportive care is needed for erythroderma?
IV fluids for dehydration and nutritional support, along with monitoring vital observations.
58
What are Stevens-Johnson syndrome (SJS), SUS/TEN overlap, and Toxic Epidermal Necrolysis (TEN)?
Febrile mucocutaneous drug reactions on the same spectrum.
59
What is the epidemiology of SJS and TEN?
Mostly associated with use of NSAIDs, anticonvulsants, sulfonamides. ## Footnote SJS is more common in children and young adults, while TEN is more common in middle-aged and old adults.
60
What are the stages of presentation for SJS and TEN?
1. Prodromal stage: fever, malaise, upper respiratory symptoms. 2. Cutaneous stage: Erythematous macules coalesce into large patches, then become bullae.
61
What happens to bullae in the cutaneous stage?
Bullae burst easily and cause skin desquamation, leaving painful erosions that resemble hot-water burn and are necrotic.
62
What are typical oral and ocular involvements in SJS and TEN?
Oral involvement: Upper and lower lips swollen and bright red with erosions and hemorrhagic crusting. Ocular involvement: Bilateral conjunctival injections.
63
What is the classification of SJS and TEN based on skin peeling?
SJS: Skin peeling on below 10% body surface area. SJS/TEN overlap: Skin peeling on 10-30% body surface area. TEN: Skin peeling on over 30% body surface area.
64
How is SJS and TEN diagnosed?
Clinical diagnosis. ## Footnote Kawasaki disease doesn't cause necrosis of mucosal surfaces or severe blistering, erosion, crusting.
65
What is the management for SJS and TEN?
Immediate withdrawal of offending drug and supportive care. Treat like severe burns.
66
What are some specific management strategies for SJS and TEN?
Don't manipulate intact or detached areas, keep detached areas covered with dressing until wound is closed. Frequent swabs from potentially infected areas, blood and urine cultures to monitor infection.
67
When should referral occur in the management of SJS and TEN?
Referral depending on organ involvement.

Clinical lectures: Yr2 (56 decks)

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