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Dermatology > Emergency Dermatology > Flashcards

Emergency Dermatology Flashcards

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1
Q

What can skin failure lead too / all conditions

A 
2 bacterial infection 
Sepsis
Dehydration 
Electrolyte imbalance 
Hypo / hyperthermia 
Renal impairment 
Peripheral vasodilatation
Cardiac failure
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2
Q

What is pirnciple of management of dermatological emergencies

A 
Full supportive care - ABC of resus 
Withdrawal of any precipitating agent 
Fluid balance
Temp regulation
Emollients
Anticipate and treat infection
Management of any complications 
Specific Rx
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3
Q

What is erytheroderma and what can cause

A

An exfoliative erythematous dermatitis affecting >90% of body
Psoriasis
Eczema
Drugs - penicillins, cephalosporin, AED, allopurinol
Cutaneous lymphoma
Hereditary disorders
Abrupt steroid withdrawal in erythrodermis psoriasis

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4
Q

How does it present and what are complications

A 
Inflammed oedematous scaly skin 
Itchy 
Systemically unwell - LN / malaise 
Secondary infection 
Fluid loss and electrolyte imbalance
Hypothermia
High output cardiac failure
Capillary leak syndrome = most severe
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5
Q

What happens in erythodermis psoriasis

A

Progress to exfoliative phase
Plaques over whole body
Mild systemic upset

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6
Q

How do you manage erythroderma

A 
ITU / burns unit 
Remove offending drug / treat cause 
Fluid balance
Nutrition
Temp regulation
Emollient and wet wraps to maintain skin moisture 
Topical steroid may help relieve inflammation 
Oral and eye care 
Manage itch
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7
Q

What is urticaria

A

Weals / Hive’s
Acute <6 weeks
Chronic

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8
Q

What is pathophysiology behind / type of hypersensitivity

A

Type 1 - IgE if acute
Chronic less likely
Due to local increase in permeability of capillaries
Histamine from mast cell = major inflammatory mediator

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9
Q

How does it present

A

Central swelling - variable size that involves superficial dermis raising the epidermis
Surrounded by patchy erythematous rash
Associated dermal oedema / flushing of skin
Itching / burning as histamine released - ask if rash itchy
Usually lasts 1-24 Horus

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10
Q

What is associated with urticaria and where do they affect

A

Angiooedema

  • Deeper swelling involving dermis and SC tissue
  • Skin or muscle membranes so throat, tongue and lips

Anaphylaxis

  • Bronchospasm
  • Facial and laryngeal oedema
  • Hypotension
  • Can initially present with urticaria and angioedema
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11
Q

What causes acute urticaria

A 
Idiopathic in 50%
Allergy stimulating release of mast cell contents = most common  
Food 
Insect bites
Chemicals - latex 
Viral or parasitic infection
Drugs - ask if any new drug etc (NSAID, ACEI, opiates, thiazide, phenytoin) 
Autoimmune 
Vacinations
Hereditary angioedema in some cases
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12
Q

How do you treat acute urticaria and associations if occur

A

Consider trigger and withdraw - opiate / NSAID
Oral anti-histamine 3x daily = mainstay
Corticosteroid if severe urticaria or angioedema + PPI
Treat as anaphylaxis if obstruction

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13
Q

What are complications

A

Urticaria = no complications

Asphyxia, cardiac arrest and death if angiodema / anaphylaxis

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14
Q

What causes chronic urticaria

A

Autoimmune disease where Ab target mast cells
Physical trauma
Vasculitis

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15
Q

How do you Rx

A

Anti-histamine
May need higher dose or 2nd
Consider Immunomodulant / biologic
Limited use of steroids

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16
Q

What should you consider if angiodema present

A

Anti-leukotriene

Tranexamic acid

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17
Q

Types of anti-histamine

A

Chlorophenamine = sedating
May have anti-muscarinic properties
Certrizine = non-sedating

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18
Q

When do drug reactions commonly begin

A

1-2 weeks after drug

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19
Q

What is mild drug reaction

A

Morbilliform exanthema
Macular red lesions
2-10mm but join up
Erythema multiform

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20
Q

What are severe drug reactions

A

Erythroderma
SJS - <10%
TEN >30%
DRESS

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21
Q

What are common drugs that cause / infection

A 
Drugs = main cause 
Antibiotics - penicillin
Anti-convulsants - phenytoin / carbamazepine 
Sulphonamides 
Allopurinol
NSAID
Infection 
HSV
Mycoplasma 
CMV
HIV
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22
Q

What is SJS

A

Severe variant of erythema multiforme (<1 mucosal)
Mucocutaneous necrosis with 2+ mucosal sites involved
Skin involvement may be limited or extensive

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23
Q

How does it present

A 
May have prodromal febrile illness 
Maculopapular rash <10% of skin surface 
Target lesions
Blisters 
Mouth / genital / eye ulceration 
Cause greyish white membrane 
Fever
Malaise
Arhtralgia
Histopathology = epidermal necrosis
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24
Q

How does TEN usually present

A

Prodromal febrile illness
Extensive skin and mucous membrane invovlement
Ulceration mucous membrane
May start macular or purpuric
Then blister
Become confluent >30% BSA
Leads to large loss of epidermis - desquamation
Systemically UNWELL
Nikolsky +ve - blisters form when rub back and forth
Histopathology = full thickness necrosis with detachment

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25
Q

Prognosis of TENS and SJS

A

Very serious

High mortality from sepsis / electrolyte imabalcen and multi-organ failure

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26
Q

How do you manage TEN / SJS

A 
Early recognition and help 
ITU
Stop culprit drug
Full supportive care 
Nutrition
Anti-septic
Analgesia
Opthamology input
IV IG = 1st line
Role of biologics / immunosuppression / steroid
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27
Q

What score to measure mortality

A

SCORTEN

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28
Q

What does it look at

A 
Age
Malignancy
HR
Initial epidermal detachment >10%
Urea >10
Glucose >14
Bicarb <20
29
Q

What are complications

A 
Secondary bacterial infection 
Sepsis 
Multi-organ failure
Electrolyte imbalance 
Pigmentary skin change
Scarring
Eye disease - blindness
Nail and hair loss
Joint contractures
30
Q

What is DRESS

A

Drug reaction with eosinophilia and systemic symptoms

31
Q

What happens

A 
2-8 weeks after drug
Fever
Widespread rash
Eosinophilia 
Deranged liver function
Lymphadenopathy
32
Q

How do you Rx

A

Stop drug
Systemic steroid
Immunosuppression / Ig

33
Q

What is pemphigus vulgaris

A

Autoimmune disease where Ab at desmosomes within epidermis cause dermis and epidermis to stick together and causing epidermal intra-epidermal split
Desmoglein 3
Tends to affect middle age

34
Q

What does it lead too

A 
Flaccid blisters
Rupture easily
Form erosion and crust 
Typically painful 
Common at face, axillae and groin 
Mucosal ulceration common which can proceed skin 
NOT itchy
Nikolsky's sign 
Patient very unwell
If mucosal involvement = vulgaris
Worse involvement
35
Q

How do you Dx

A

Biopsy shows acanthylsis

36
Q

How do you Rx

A 
Wound dressing 
Monitor for infection
Good oral care 
High dose oral steroid
Immunosuppression
- Methotrexate 
- Azathioprine
- Cyclophosphamide
- MMF
37
Q

What is bullous pemphigoid

A

More common condition presenting in the elderly

Autoimmune where Ab directed at derma-epidermal junction causing sub-peridermal split and blister

38
Q

What can it be a sign of

A

Underlying malignancy

39
Q

What are the features

A 
Intact epidermis forms roof of blister 
Itchy before blister
Blister = tense and intact
Erythematous base 
Do not break
Can be haemorrhagic 
Trunk and upper limb
Heal without scarring
Patient well
NO mucosal involvement
40
Q

How do you Dx

A

Bloods
Biopsy
CXR for malignancy

41
Q

How do you Rx

A

Wound dressing where required
Topical steroid if local
Oral steroid
Combination steroid / Ax / immunosuppression
Immunosuppression - not great if underlying cancer

42
Q

What is erythema multiforme

A

Acute self-limiting hypersensitivity reaction triggered by

  • HSV = most common
  • Mycoplasma pneumonia
  • Drugs
  • SLE / sarcoid
  • Malignancy
43
Q

What drugs

A

Penicillin
OCP
NSAID

44
Q

What happens

A 
Abrupt onset of 100s of lesions over 24-72 hours
Initially back of hands and feet
Then torso
Mucosal surfaces absent or LIMITED TO ONE surface 
Widespread itchy erythematous rash 
Target lesion 
Symmetrical with central blister
Pink macule becomes elevated
May blister
Occasional pruritus
Severe form = SJS / TEN
May have associated fever, arthralgia, stomatitis
45
Q

How do you Rx

A 
Self limiting
A form of SJS so early recognition important 
Resolve over 2-6 weeks 
Treat underlying cause
If underlying cause not known 
- CXR to look for pneumonia 
If severe may need admission for IV fluid, analgesia and steroid
Steroid for itch remains controversial
46
Q

What is eczema herpeticum

A

Disseminatd HSV infection on background of atopic eczema or less commonly other skin conditions

47
Q

What are the features and what are complications

A 
Widespread eruption 
Extensive crusted papule 
Monomorphic blisters + vesicles 
Punched out erosion
Painful
NOT itchy but can be 
Systemically unwell - fever, lethargy

Secondary infection
Herpes hepatitis
Encephalitis
DIC

48
Q

How do you Rx

A

Acyclovir - oral or IV
Mild steroid for eczema
Ophthalmology review if near eyes
Ax if bacterial secondary infection

49
Q

What should you consider if happens in a adults

A

Underlying immunosuppression e.g. HIV

50
Q

What causes generalised pustular psoriasis

A

Infection
Sudden withdrawal of steroids
Can occur without psoriasis

51
Q

What are features

A

Rapid development of generalised erythema + pustules
Fever
Elevated WCC

52
Q

How do you Rx

A

Avoid steroid in psoriasis patient
Systemic therapy
Treat infection

53
Q

What is staph scaled skin syndrome and who is it common in

A

S.Aureus produces toxin which targets desmoglein 1 and causes skin to break down
Children
Immunocompromised adults

54
Q

What are features

A 
Hx of staph infection initial 
Develops within hours - days 
Worse over face, neck, groin 
Diffuse erythematous rash
VERY PAINFUL
Scald like skin appearance followed by large flaccid bullae 
Blisters / bullae form 
Intra-epidermal blistering 
Nikolsky +ve - rubbing skin causes it to peal 
Desqaumation
Systemically unwell - Fever / Irritability
Recovery within 5-7 days
55
Q

How do you Rx

A 
Admit
IV Ax
Analgesia 
Fluid balance as prone to dehydration 
Usually make a full recovery without scarring
56
Q

What is necrotising fasciitis

A

Rapidly spreading infection of deep fascia with secondary tissue necrosis
Infection may not be noticeable on skin initially as affecting deep structures

57
Q

What causes

A

Group A strep

58
Q

What are RF

A

Abdo surgery
DM
Malignancy

59
Q

How does it present

A

SEVERE pain
Erythematous, blistering and necrotic skin
Swelling
Systemically unwell with fever and tachycardia+ hypo
After 3-4 days necrotic change occurs - rash swells and becomes dark purple with blisters
Presence of crepitus

60
Q

What does crepitus suggest

A

Subcutaneous emphysema as gas in the tissue

61
Q

What may X-ray show

A

Presence of gas (absence does not exclude)

62
Q

How do you manage

A 
ABCDE
Bloods 
VBG - lactate + metabolic acidosis 
Urgent referral for surgical debridement
IV Ax
Transfer to ITU
63
Q

What should you beware of

A

Pain out of proportion even if no skin involvement yet

64
Q

What are the 3 types

A 
Type 1 = poymicrobial 
- DM and elderly 
Type 2 = flesh eating (strep pyogenes) 
- Most common and can occur in healthy 
Type 3 = clostridium 
- Post op or IVDU
65
Q

What is Fournier gangrene

A

NF affecting perineal area

High mortality

66
Q

Wh is no pain a bad sign

A

Means that necrosis has destoyed peripheral nerves

Unlikely to improve with Ax

67
Q

What are complications

A

Amputtion

Death

68
Q

What are DDX

A

Cellulitis - minimal systemic toxicity

Cutaneous anthrax - IVDU / animal contact and tends to be painless pruritic papule that go on to necrose

Dermatology (12 decks)

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