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SPM- Dermatology > Emergency Dermatology > Flashcards

Emergency Dermatology Flashcards

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Dermatology Board Prep flashcards
1
Q

What are four true skin emergencies that require urgent dematological input?

A

Erythroderma
Toxic Epidermal Necrolysis
Angioedema
Acute Blistering disorders

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2
Q

What is erythroderma? What diseases can cause it?

A 
Widespread redness of the skin
Involvement of over 90% of the skin of an inflammatory or neoplastic disease. Examples include:
Psoriasis
Eczema
Drugs
Cutaneous T Cell Lymphoma
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3
Q

Why can erythroderma become life-threatening?

A

There is systemic upset leading to vasodilation, decreased blood pressure and tachycardia. Large amounts of heat are also lost.
This results in high output cardiac failure.

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4
Q

What are the signs of erythroderma?

A

Skin is warm to touch
Widespread redness affecting 90% or more of BSA
Itching
Eyelid swelling may result due to scratching
If due to psoriasis may have associated nail changes

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5
Q

What are some complications of erythroderma?

A 
Heat loss
Fluid loss
Electrolyte abnormalities
High-output heart failure
Risk of developing secondary skin infections such as impetigo and cellulitis
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6
Q

How is erythroderma diagnosed?

A

History and Examination
(Note nail changes associated with psoriasis, weeping associated with eczema)
Skin Biopsy if uncertain of cause and can investigate for cutaneous T-Cell Lymphoma

Bloods- Raised WCC, Eosinophilia (could indicate T-Cell Lymphoma), ESR, CRP, U&Es, Creatinine (Risk of AKI), LFTs

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7
Q

What is the treatment for erythroderma?

A

Admit
Discontinue unnecessary medications
Fluids and monitor fluid status
Wet wraps and emollients to maintain skin moisture
Antibiotics if any bacterial infection
Antihistamines- could reduce itch and sedation

Treat the cause- e.g. Oral steroids, methotrexate, ciclosporin, azathioprine, acitretin

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8
Q

What are some drugs that can cause erythroderma?

A

Sulfonamides
Allopurinol
Carbamazepine
Gold

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9
Q

What can cause acute blistering?

A 
Staph scalded skin syndrome
Toxic epidermal necrolysis
Immunobullous disease
Insect Bites
Eczema- e.g. Palmar-plantar pustular eczema
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10
Q

What is staphylococcal scalded skin syndrome?

A

Due to toxins produced by staphylococcus bacteria which cause red blistering that looks like a scald or burn

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11
Q

What are the toxins that are released in staphylococcal scalded skin syndrome called? What do they target?

A

Epidermolytic toxins A and B

They target the desmosomes- specifically desmoglein 1

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12
Q

Who is at risk of staphylococcal scalded skin syndrome?

A

Infants and young children

Anti-bodies develop during childhood that prevent this happening in adults

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13
Q

Neonates with what other comorbidity are at greater risk of staphylococcal scalded skin syndrome

A

Kidney disease- as the toxins are cleared through the kidneys and so reduced clearance increases levels of the toxins

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14
Q

What are the signs and symptoms of staphylococcal scalded skin syndrome?

A 
Blistering- fluid filled blisters burst
Intense redness
Raised temperature/ fever
Irritability
Raised WCC, CRP, ESR
Nikolsky sign- gentle strokes of the skin cause exfoliation
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15
Q

What might be done to diagnose staphylococcal scalded skin syndrome?

A 
History and examination
Urgent dermatology assessment 
Skin Biopsy
Bacterial Cultures- from skin, blood (at risk of sepsis), urine and umbilical cord sample in new-born baby
Tzanck Smear
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16
Q

What is the Tzanck smear used for?

A

To distinguish Steven-Johnsons Syndrome/TEN from Staphylococcal scalded skin syndrome.

Helps to differentiate the cause of a number of blistering skin conditions

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17
Q

What is the treatment for staphylococcal scalded skin syndrome?

A

Hospitalisation
IV Antibiotics- e.g. Flucloxacillin, Clindamycin, Vancomycin if MRSA
Paracetamol to reduce pain and fever
Intense monitoring for fluid balance

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18
Q

What is Steven-Johnsons Syndrome/ TEN? What is the difference between the two?

A

Immune mediated condition that cause blistering of the skin and mucosal membranes.

Toxic epidermal necrolysis is the more severe form.

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19
Q

What is the process resulting in Steven-Johnsons syndrome/TEN? What type of hypersensitivity reaction is seen?

A

Drug reaction where the drug metabolites causes cells to be recognised as foreign and so an immune response is generated against them. Skin and mucosa are affected.

It is a type IV hypersensitivity reaction- Cytotoxic T Cell Mediated

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20
Q

What is the difference between TEN and Steven-Johnson Syndrome?

A

Steven-Johnson’s- Less than 10% of the body affected
TEN- More than 30% of BSA affected

(Overlap at 10-30%)

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21
Q

What are some drugs that cause TEN/Steven- Johnsons Syndrome?

A

Anti-epileptics such as Carbamazepine, Lamotrigine, Phenytoin
Antibiotics such as Sulphonamides (cotrimoxazole), Penicillin
Immune Modulators such as Sulfasalazine
NSAIDs such as Aspirin, Oxicam
Paracetamol

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22
Q

What surfaces does TEN/Steven-Johnsons Syndrome affect?

A

Skin and mucosal linings

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23
Q

What are the symptoms of TEN/Steven-Johnsons Syndrome?

A 
Early on Flu-like Sx:
Fever >39
Sore throat and painful swallowing
Cough and runny nose
Sore red eyes
General aches and pains

Rash Development:
Tender, painful red skin rash
Often starts on trunk and extends rapidly over hours to days onto the face and limbs
Macules, diffuse erythema, blisters
Target lesions
Mucosal ulceration
Progresses to sloughing off of dead skin/mucosal surfaces. Nikolsky Positive (exfoliation on gentle touching of skin)

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24
Q

If suspecting TEN/Steven-Johnsons Syndrome what should you ask about in the history?

A

Have you started any new medications recently?

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25
Q

What features does mucosal involvement cause in TEN/Steven-Johnsons Syndrome?

A

Conjunctivitis- red, sore, sticky
Oral ulceration
Red/Crusting lifts
Painful swallowing (pharyngitis/oesophagitis)
Cough due to upper respiratory tract involvement
Diarrhoea- due to GI involvement

26
Q

What are some complications of TEN/Steven-Johnsons Syndrome?

A 
Dehydration
Infections of the damaged surfaces
Septicaemia
ARDS
Hypoperfusion and shock
DIC
27
Q

How is TEN/Steven-Johnsons Syndrome diagnosed?

A

History and examination
Skin biopsy- can do Tzanck Smear, Microscopy (exclude other causes of blistering), immunofluorescence (indicates immunobullous disorders)
Bloods- Show low WCC, low Neutrophils. Raised CRP/ESR

28
Q

What scoring system is used to estimate the risk of mortality in TEN/Steven-Johnsons Syndrome?

A

SCORTEN is a scoring system used to predict mortality

29
Q

What is the treatment for TEN/Steven-Johnsons Syndrome?

A

Stop the causative drug
Admit and urgent dermatology referral
Supportive Treatment- ICU, HDU
Fluids- risk of dehydration and high output cardiac failure
Analgesia as very painful
Sterile handling and isolate to reduce risk of secondary infections
Protect the skin inc topical antiseptics, dressings, emollients
Temperature care- keep warm as can lose a lot of heat
IV Ig/ Plasmapheresis/ Cyclosporine /Cyclophosphamide / Anti-TNF
If eye involvement involve ophthalmology

Note- Steroids are not used as they increase the risk of infection. Psychological support is important too. Include dermatology nurses for advice on dressings.

IVIg is the most widely used and has been found to be effective

30
Q

If a patient has been successfully treated for TEN/Steven-Johnsons Syndrome what is it important to do?

A

Advice not to take the drug again

Educate of similar drug classes and not to avoid these incase of cross reaction

31
Q

What are some features that would make you consider an insect bite as a cause of blistering?

A

Localised
Grouped together
Seasonal
Puncture site

32
Q

What is angioedema?

A

An acute swelling of the skin and mucous membranes. All parts of the body can be affected but it most commonly occurs around the eyes and lips

33
Q

Why is angioedema life threatening?

A

If it involves the URT it can cause airway obstruction = death

34
Q

What is the difference between angioedema and urticaria?

Group answer by Area affected, Appearance, Associated Features

A

Urticaria is more common and less severe than angioedema.

Area Affected-
Urticaria only affects the skin (epidermis and dermis) whereas angioedema affects the subcutaneous and sub-mucosal surfaces.

Appearance-
Urticaria appears as red, itchy patches
Angioedema causes soft tissue swelling so leads to swelling around the lips and eyes.

Associated features-
Urticaria is often itchy
Angioedema is often accompanied by pain and tenderness, itch is much less common.

35
Q

What are some causes of angioedema?

A

Allergy (Angioedema within 1-2 hours of exposure)- Food allergy, drugs (e.g. penicillin, NSAIDs, Vaccines) insect bites, bee stings.
Non-Allergic Drug Reactions- ACEi can cause this, onset days or months after stating medication
Idiopathic
Hereditary- Rare autosomal dominant disease
Acquired C1 Inhibitor deficiencies can occur with B cell lymphoma or antibodies generated against C1 inhibitor

36
Q

What are the features of angioedema?

A 
Swelling around the lips and eyes
Associated pain and tenderness
Known causative agent if allergic
May or may not be itchy
GI cramps and pains if swelling there
Difficulty breathing, tight chested
37
Q

What does allergic angioedema usually occur with?

A

Urticaria- so there is often associated itching and redness of the skin.

38
Q

What drug has been known to cause a non-allergic angioedema?

A

ACE inhibitors- this occurs without accompanying urticaria

39
Q

Does hereditary angioedema occur with urticaria?

A

It does not

40
Q

What is the treatment for acute angioedema?

A

Medical emergency as there is a risk of airway compromise so ABCDE approach- secure the airway.

Could his be anaphylaxis- treat according to anaphylaxis protocols

Adrenaline, Steroids, Anti-histamines

41
Q

What are the doses of adrenaline, hydrocortisone and chlorphenamine if anaphylaxis/angioedema in a child less than 6 months old?

A

Adrenaline IM- 150 micrograms (0.15ml 1 in 1,000)
Hydrocortisone IV- 25mg
Chlorphenamine IM/IV- 250 micrograms/kg

Adrenaline can be repeated every 5 minutes if necessary. Inject at anterolateral aspect of middle third of thigh.

42
Q

What are the doses of adrenaline, hydrocortisone and chlorphenamine if anaphylaxis/angioedema is a child aged 6 months to 6 years?

A

Adrenaline IM 150 micrograms (0.15ml 1 in 1000)
Hydrocortisone IV- 50mg
Chlorphenamine IM/IV- 2.5mg

Adrenaline can be repeated every 5 minutes if necessary. Inject at anterolateral aspect of middle third of thigh.

43
Q

What are the doses of adrenaline, hydrocortisone and chlorphenamine if anaphylaxis/angioedema in a child aged 6-12?

A

Adrenaline IM 300 micrograms (0.3 1 in 1000)
Hydrocortisone IV- 100mg
Chlorphenamine IM/IV- 5mg

Adrenaline can be repeated every 5 minutes if necessary. Inject at anterolateral aspect of middle third of thigh.

44
Q

What are the doses of adrenaline, hydrocortisone and chlorphenamine if anaphylaxis is expected in a child aged 12 or older or an adult?

A

Adrenaline IM- 500 micrograms (0.5 1 in 1000)
Hydrocortisone IV- 200mg
Chlorphenamine IM/IV- 10mg

Adrenaline can be repeated every 5 minutes if necessary. Inject at anterolateral aspect of middle third of thigh.

45
Q

What investigation can be done to see if a patient had true anaphylaxis?

A

Serum tryptase- remains elevated for upto 12 hours afterwards

46
Q

What causes hereditary angioedema?

A

C1 inhibitor deficiency

47
Q

What is the management for angioedema is anaphylaxis has been ruled out?

A

Protect the airway
Regular antihistamines e.g. Chlorphenamine, Certrizine
Steroids e.g. Prednisolone

If drug induced (ACEi) use an alternative

48
Q

What are the features of urticaria?

A

Weals- transient oedematous dermal papules and plaques. Individual lesions persist for less than 24 hours
Itching
Red, pink or white weals
Raised

49
Q

What is the cause of acute urticaria?

A

Most often the cause is unknown
Often allergy and type I (IgE mediated) hypersensitivity
E.g. Drugs, Foods, Latex, Bee sting, Plants
Infection- URTI, Bacterial infections, Viral hepatitis, infectious mononucleosis (glandular fever), mycoplasma

50
Q

What is physical urticaria?

A 
This accounts for 50% of urticaria cases and can be due to:
Light touch
Pressure
Heat
Sweat
cold
Water
Sunlight
Direct contact with irritants

(It’s triggered by physical causes)

51
Q

What is the most common form of urticaria?

A

Spontaneous urticaria

No cause is usually identified and often patients have urticaria co-exist with angioedema

52
Q

What causes urticaria?

A

Mast cell degranulation which releases histamine. Histamine is vasodilator leading to redness and oedema, it also causes itching.

53
Q

What test might be done to identify the cause urticaria in cases thought to be due to allergy?

A

Skin prick testing as it is a type I hypersensitivity reaction

Note- allergic contact dermatitis is type IV and patch testing is done for this

54
Q

What monoclonal antibody is helpful in patients with type I hypersensitivity reactions?

A

Omalizumab- it is an anti IgE antibody

May be used for the treatment of chronic urticaria

55
Q

What is the treatment for urticaria?

A

Antihistamines- cetirizine, loratadine
Avoid known trigger factors
Cool affected areas with cold compresses, ice packs, cooling creams

NOTE- IF SUSPECTING ANAPHYLAXIS MANAGEMENT IS WITH ADRENALINE, HYDROCORTISONE AND ANTIHISTAMINE. REPEAT ADRENALINE EVERY 5 MINUTES IF NEEDED.

56
Q

What should you think about if someone has a rash like uriciaria but there is no wheeling?

A

Scombroid fish poisoning- due to scombrotoxin being produced in fish that has not been stored properly. Can occur with mackerel and tuna.

Features include- racing heart, nausea and vomiting, abdominal pain, difficulty breathing, collapse due to low blood pressure.

57
Q

What is eczema herpeticum?

A

This is an disseminated infection of the skin by HSV

It is characterised by fever, multiple blisters and punched out erosions. Blisters produce a clear fluid which can be sent for PCR.

58
Q

Which patients are more prone to developing eczema herpeticum?

A

Patients with atopic dermatitis/eczema. This is because there are breaks in the skin which reduce the barrier immunity.

It is most commonly seen in infants and small children

59
Q

What are the features of eczema herpeticum?

A

Blistering lesions
Multiple and appear similar to each other
May be filled with a clear yellow fluid or thick purulent material
Punched out appearance of blisters
Weeping and bleeding of blisters
Lesions heal over 2-6 weeks and this can be with or without scaring

60
Q

How is eczema herpeticum diagnosed?

A

History and Examination
Escalate to a dermatologist as can be severe
If there is any eye involvement or Hutchinson’s Sign involve and opthamologist

Swabs from the lesions- PCR and MC + S due to secondary bacterial infections which can occur. Vital culture and Tzanck smear

61
Q

What is the treatment for eczema herpeticum?

A

Admit for anti-viral therapy
Oral Aciclovir 400-800mg 5 times daily
Or Valaciclovir 1 g BD
Both for 10 -14 days and longer if lesions haven’t healed.

IV Aciclovir if PO not suitable or deteriorating patient.

SPM- Dermatology (10 decks)

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