Dermatology: Emergencies Flashcards
State some dermatological emergencies
- Eczema herpeticum
- Necrotising fasciitis
- Staphylococcal scalded skin syndrome
- Urticaria, angioedema & anaphylaxis
- Stevens-Johnson syndrome
- Toxic-epidermal necrolysis
- Erythroderma
For eczema herpeticum, discuss:
- What it is
- Who is it more commonly seen in
- Typical presentation
- Management
- Potential complications
- Skin infection caused by HSV 1 or 2
- More commonly seen in children with eczema
- Presentation of rash:
- Widespread
- Rapidly progressing
- Erythematous
- Painful
- ?itchy
- Vesicles containing pus (may see punched out ulcers if these have burst)
- Management:
- Aciclovir (mild or moderate may be treated with PO but severe treated with IV. **PASSMED says should be admitted for IV aciclovir)
- Complications:
- Potentially life-threatening
- Bacterial superinfection
For Staphylococcal scaled skin syndrome, discuss:
- What it is/cause
- Who it usually affects
- Presentation
- Potential consequences
- Management
- Skin infection with type of Staphylococcus that produces epidermolytic toxins that cause skin breakdown
- Children <5yrs
- Presentation:
- Start with generalised patches erythema on skin
- Skin then looks thin & wrinkled
- Formation of bullae
- Burst, leave sore erythematous skin below
- Nikolsky sign positive
- Systemic symptoms: fever, lethargy, irritability, dehydration
- Potential consequences: sepsis → death
- Management:
- Admission to hospital (under care dermatology)
- IV antibiotics
- Analgesia
- Close monitoring of fluid balance and electrolytes (and fluids if required)
*Resolves in ~5-7 days
What is necrotising fasciitis?
There are numerous types of necrotising fasciitis; explain difference and state which is more common
- Necrotising fasciitis is a rapidly spreading infection of deep fascia with secondary tissue necrosis
- Types:
- Type 1: polymicrobial with mixed anaerobes & aerobes (MOST COMMON)
- Type 2: monomicrobial- caused by group A haemolytic streptococcus/Streptococcus pyogenes
- Type 3: rare monomicrobial due to marine mircrobes
State some risk factors for necrotising fasciitis
- Compromised skin integrity: recent trauma, burns or soft tissue infection
- Diabetes mellitus
- Particularly if on SGLT2 inhibitors
- Immunosuppression
- IV drug use
- Abdominal surgery
What site is most commonly affected by necrotising fasciitis?
Perineum (Fournier’s gangrene- necrotising fasciitis affecting genitals and perineal area)
Describe typical presentation of necrotising fasciitis
- Acute onset
- Severe pain
- Erythema
- Swelling
- Blistering
- Systemical unwell
- Necrotic skin (late sign)
- Crepitus (subcutaneous emphysema) (late sign)
Discuss the management of necrotising fasciitis
What is the mortality?
Urgent admission to hospital:
- Urgent surgical debridement (may even need amputation)
- IV abx
Average mortality= 10-40% (BMJ)
What is SJS/TEN?
SJS and TEN are considered two ends of spectrum of severe epidermolytic adverse cutanous drug reactions.
- SJS <10% body surface area involved
- TEN >30% of body surface involved
*(when in-between 10 and 30% conditions overlap)
Incidence of SJS/TEN is higher in what patients?
HIV positive patients
Drugs are the most common cause of SJS/TEN (infections are occasionally reported as the sole cause); state some common drugs that cause SJS/TEN
- Allopurinol
- Sulphonamides
- Antibiotics (penicillin’s)
- Anticonvulsants (lamotrigine, carbamazepine, phenytoin)
- NSAIDS (oxicam-type)
Discuss the clinical features of SJS/TEN
- Onset within 2 months of commencing causative drug
- Painful, dusky erythema with blisters & erosions
- Rapidly progress into confluent erythema with sheet-like epidermal detachment
- Nickolsky sign (epidermis detached by mechanical pressure)
- Mucosal involvement (more common in SJS [at least 2 mucosal sites] than in TEN)
- Systemically unwell (fever, tachycardia etc..)
Diagnosis of SJS/TEN is made clinically, but how is it confirmed?
Biopsy
Discuss the management of SJS/TEN
Need early recognition and admission to hospital:
- Stop causative drug
- Supportive care best delivered in ICU or burns unit (e.g. fluids, electrolyte management, wound managemet)
- Analgesia
- IV immunoglobulins
- Ophthalmology review for eye involvement
Discuss the mortality of SJS and TEN
- SJS= 5-12%
- TEN= >30%
Death often due to sepsis, electrolyte imbalance or multi-system organ failure
What is erythroderma (also called exfoliative dermatitis)?
State some potential causes
Describe typical presentation
- Rash affecting at least 90% of skin surface (also called exfoliative dermatitis; ‘exfoliative’ describes the skin peeling which is found
- Causes:
- Previous skin disease (eczema, psoriasis)
- Drugs (e.g. sulphonamides, allopurinol, pencillin)
- Lymphoma
- Idiopathic
- Presentation:
- Inflamed, oedematous, scaly skin
- Lymphadenopathy common
- Systemically unwell
