Skin emergencies Flashcards
List the main emergency skin conditions
- Anaphylaxis - covered in other cards in resp.
- Erythroderma
- Toxic epidermal necrolysis (TEN)
- Steven-johnson syndrome
- Acute meningococcaemia
- Necrotising faciitis - covered in skin infections deck.
- Pustular psoriasis - covered in psoriasis deck.
- Eczema herpeticum - covered in skin infections deck.
What is erythroderma ?
- This is a descriptive term rather than a diagnosis, and is defined as erythema affecting at least 90% of the body surface area.
- It often precedes or is associated with exfoliation (skin peeling off in scales or layers),
List some of the common causes of erythroderma
- Drug eruptions e.g. Alopurinol, Antibiotics, Carbamazapine, PPI’s, gold, sulphonureas, catopril + many more
- Dermatitis esp atopic
- Psoriasis
- Lymphomas & leukaemias
- Idiopathic (in approx
What are the clinical features of erythroderma ?
- Skin appears inflamed, oedematous & scaly (affecting more than 90% of the body)
- Systemically unwell with lymphadenopathy & malaise
- Skin warm to touch & may have associated pruritis
What complications can develop as a result of erythroderma?
- Patients may develop tachycardia & then enter high output cardiac failure
- Disturbed thermoregulation - may develop hyperthermia
- Compensatory hypermetabolism due to heat loss which can lead to cachexia
- Lymphadenopathy - biopsy should be considered incase of lymphoma
- Secondary infection
- Fluid loss & electrolye imbalances
What is the management of erythroderma ?
- Initial management is supportive & symptomatic - thermoregulation, corection of fluid/electrolyte imbalances & treat any infection
- Emollients & wet wraps needs to maintain skin moisture
- TCS to help relieve inflammation
- Treat the underlying cause when known
What is toxic epidermal necrolysis (TEN) ?
- It is a rare life-threatening skin disorder characterised by keratinocyte necrosis resulting in epidermal & mucosal detachment affecting > 30% of the body
- Some authors consider TEN to be the severe end of a spectrum of skin disorders which includes erythema multiforme and Stevens-Johnson syndrome
What is TEN almost always caused by ?
Almost always secondary to a drug reaction
List some of the common drugs known to induce TEN
- Phenytoin
- Sulphonamides
- Allopurinol
- Penicillins
- Carbamazepine
- NSAIDs
What are the clinical features of TEN?
- May have a non-specific or target-like lesion prodromal rash
- Systemically are unwell - fever > 38, tachycardia
- Widespread tender erythema affecting > 30% of body surface
- Epidermis separates off (skin peeling/desquamation) with mild lateral pressure (pos Nikolsky’s sign), this affects > 30% of the body.
- Fluid-filled blisters - pos nikolsky’s sign
- When skin & blisters peel to reveal bright red oozing dermis
- Associated mucosal involvement (crusting oral mucosa)
- Conjuncitvitis
How is TEN or SJS diagnosis confirmed ?
Skin biopsy
What complications can TEN or SJS result in ?
Has significant morbidity for TEN (>30%), SJS mortality is less (5-12%) most often due to bacterial sepsis also due to :
- Dehydration, electrolyte imbalances & Protein loss
- Thermoregulatory difficulties
- Multi-organ failure
What is the management of TEN?
- Withdrawl of causative agent
- Managed in burns/ICU
- Minimise handling of patient
- Supportive Mx - correcting fluid/electrolyte imbalances, infecitons & loss of thermoregulation
1st line = IV immunoglobulin +/- immunosuppressive agents (ciclosporin & cyclophosphamide)
What is steven-johnson syndrome (SJS)?
- Stevens–Johnson syndrome (SJS) and TEN are believed to be variants of the same condition.
- SJS/TEN is a rare, acute, serious, and potentially fatal skin reaction in which there are sheet-like skin and mucosal loss.
- SJS is characterised by erosions of at least 2 mucosal surfaces + a variable degree of cutaneous involvement (<10% of body surface)
Note - if 10-30% of body surface affected its known as SJS/TEN overlap syndrome
What is SJS usually caused by ?
Drugs:
- NSAID’s
- Sulphonamides
- Anti-convulsants e.g. carbamazepine
- Antibiotics
May also be caused by infections
What are the clinical features of SJS?
Those of TEN but:
- Characteristically a prodrome of respiratory symptoms, followed 14 days later by erosions of ≥ 2 mucosal surfaces + variable cutaneous involvement (same cutaneous features as TEN but < 10% surface area)
- Haemorrhagic crusting of oral mucosa + other mucosal sites involved
What may have caused the oral erosions shown here ?
SJS
