Emergency and Acute Dermatology

Question 1

What are the major groups of acute skin reactions?

Answer 1

Drug reactions
Toxic epidermal necrolysis
Stevens Johnson Syndrome
Erythema Multiforme 
Urticaria 
Vasculitis 
Erythroderma

Question 2

What are the different types of skin drug reactions?

Answer 2

Maculopapular
Urticaria
Morbilliform - looks like measles 
Papulosqaumous - looks liek psoriasis 
Photo-toxic - rash in the distribution of sun exposure
Pustular 
Lichenoid
Fixed drug rash
Bullous
Itch (no rash)

Question 3

Which drugs most commonly cause acute skin changes?

Answer 3

Antibiotics (penicillins, trimethoprim)
NSAIDs
Chemotherapeutic agents
Psychotropic - chlorpromazine 
Anti-epileptic - lamitrigine, carbamaz
Cardiac

Question 4

Describe a morbilliform rash and common causes of it.

Answer 4

Looks like measles
Blanches when you press on it
Macular - flat
Itchy
Often a reaction to penicillin

Question 5

Describe a urticaric rash and common causes of it.

Answer 5

(Hives)
Red
Raised bumps
Itchy/burning/stinging 
Angiooedema 
Often a reaction to ACE inhibitors

Question 6

What is meant by a photo-toxic drug reaction?

Answer 6

Rash is caused by drugs but only appears after exposure to sunlight

• quinine
• bendroflumethiazide

Question 7

Describe a pustular drug reaction.

Answer 7

Lots of pustules (inflamed, pus filled lumps) appear on the surface of the skin
Widespread (unlike acne)
Commonly caused by antibiotics

Question 8

Describe a Lichenoid rash.

Answer 8

Looks similar to the Lichen planus rash

• purple discolourations
• itchy
• fades to leave hyperpigmentation

Question 9

What are some of the triggers of vasculitis?

Answer 9

Infection
Drugs
Connective tissue disease (e.g. RA)

Question 10

How can you check for systemic vasculitis?

- not just the blood vessels and the skin that are inflamed

Answer 10

Renal blood pressure

Urinalysis

Question 11

Given that a vasculitis rash looks like a meningococcal rash, how can you tell the difference between the two diseases?

Answer 11

The person is less systemically unwell in vasculitis

Question 12

Describe a drug induced psoariasiform reacion.

Answer 12

Psoriasis like rash
- well demarcated pink erythema
- hyperkeratosis
Sudden onset
No family history
Commonly on Lithium and beta-blockers
Foot is a common place

Question 13

Describe a fixed drug reaction.

Answer 13

Exactly the same rash appears in exactly the same place every time the patient takes a specific drug
- paracetamol is common

Question 14

Name two drug induced blistering disorders.

Answer 14

Steven Johnson Syndrome

Toxic epidermal necrolysis

Question 15

Name two autoimmune blistering conditions.

Answer 15

Reaction to glue makeup that holds the skin toegther (this is destroyed so the skin splits and blisters)
Bullous pemphigoid
Bullous pemphigus

Question 16

What is the most common clinical presentation of Steven Johnson Syndrome?

Answer 16

Mucositis - inflammation of the mucosa (lips and around the mouth)
If more than 10% of your skin is peeling, it’s probably not SJS (-> toxic epidermal necrolysis)

Question 17

Why is Toxic Epidermal Necrolysis a dermatological emergency, and how is it delt with?

Answer 17

50% mortality rate
- most severe mucous membrane involvement (>10% skin peeling)
- sudden onset 
- systemically ill 
Stop suspect drug

Question 18

What does a positive Nikolsky’s sign indicate?

Answer 18

Nikolsky’s sign
- when slight rubbing of the skin causes the top layer to come off
Indicates TEN (toxic epidermal necrolysis)

Question 19

Describe the skin changes seen in toxic epidermal necrolysis.

Answer 19

Peeling skin
Flat red rash
Blisters and sores on the mucous membrane

Question 20

How is toxic epidermal necrolysis managed?

Answer 20

Analgesia 
Fluid balance 
SCORTEN severity scale - risk of mortality
Treated like a burns patient
- Special mattress and sheets
- Infections control/prophylaxis
- Non adherent dressings
Urology, gynaecology and ophthalmology consults are required
- moisturisers

Question 21

Describe the appearance of staphylococcal scalded skin syndrome.

Answer 21

Red blistering skin
- looks like a burn or a scald 
- blisters rupture easily 
Widespread
Tissue paper wrinkling of the skin

Question 22

What is staphylococcal scalded skin syndrome?

Answer 22

Common in children
Not as systemically unwell as TEN
Skin peels off as a result as a toxigenic Staph infection releases epidermolytic toxins A and B

Question 23

How is staphylococcal scalded skin syndrome treated?

Answer 23

With antibiotics (probably flucloxacillin)

Question 24

Describe the appearance of erythema multiforme.

Answer 24

Skin eruption characterised by a typical target lesion

• round red/pink macules which become raised papules
• gradually enlarge to form plaques up to 1cm in diamete
• the centre may darken, blister and crust over

Question 25

What is the cause of erythema multiforme?

Answer 25

Self-limiting allergic reaction - often triggered by HSV or EBV - sometimes a drug trigger

Question 26

What symptoms indicate onset of erythema multiforme?

Answer 26

``` None Or mild - fever - chills - weakness - painful joints ```

Question 27

What are the difference between bullous pemphigoid and pemphigus skin blisters?

Answer 27

Pemphigoid - deep split in the skin Pemphigus - superficial split in the skin

Question 28

Name the different types of pemphigoid blisters.

Answer 28

Bullous pemphigoid Mucous membrane pemphigoid Paraneoplastic pemphigoid

Question 29

What disease is dermatitis herpetiformis an indicator of?

Answer 29

Coeliac disease

Question 30

Describe the appearance of the skin in pemphigus.

Answer 30

Blistering is small and thin | - they slough off and turn into sores

Question 31

How are immunobullous disorders treated?

Answer 31

``` Reducing the autoimmune reaction -oral steroids Steroid sparing immunosuppressants (azathioprine) Burst blisters Dressing and infection control Check for oral/mucosal involvement Screen for underlying malignancy - rare ```

Question 32

How is dermatitis herpetiformis treated?

Answer 32

Topical steroids (dampens local immune response) Gluten free diet Oral dapsone

Question 33

Where does dermatitis herpetiformis normally appear?

Answer 33

Elbows Knees Bottom

Question 34

What is the most common skin disorder to present to A&E?

Answer 34

Uritcaria

Question 35

Describe the skin changes seen in Urticaria.

Answer 35

``` Itchy wheals (hives) - raised patches of skin (oedmea) Scratch marks Lesions last less than 24 hours Non-scarring ```

Question 36

What are the time frames for acute and chronic urticaria?

Answer 36

Acute - if it goes away after less than 6 weeks | Chronic - if it is still present for more than 6 weeks

Question 37

What is the cause of urticaria?

Answer 37

``` Immune mediated type 1 allergic IgE response - doesn't quite progress to anaphylaxis Non-immune mediated - direct mast cell degranulation - e.g. opiates, contrast media, NSAIDs ```

Question 38

How is urticaria treated?

Answer 38

Antihistamines - high doses Steroids Immunosuppression Omiluzimab - anti IgE drug

Question 39

Name some causes of acute urticaria.

Answer 39

Viral infections Medications - NSAIDs, aspirin, ACE inhibitors Food and food additives Parasitic infections Physical stimulants - cold, pressure, solar, cholingeric, aquagenic

Question 40

What is pressure urticaria?

Answer 40

Urticaria that is elciated by pressing down on the skin - Dermographism Wheal and flare reaction

Question 41

Describe the skin changes seen in erythroderma.

Answer 41

Not a condition, just a description of the skin | - red skin from head to toe (80-90% of surface area)

Question 42

What are the most common causes of erythroderma?

Answer 42

Psoriasis Eczema Drug reaction Cutaneous lymphoma - rare

Question 43

How is erythroderma treated?

Answer 43

Treat the underlying skin disorder Supportive - fluid and temperature balance - moisturisers