ED Dermatology

Aims

Review terminology of skin conditions

Identify common non-serious ED presentations

Discuss serious but rare skin disorders

Definitions

Macule

Impalpable coloured lesion <1cm, circumscribed alteration of skin colour

Patch

Impalpable coloured lesion >1cm.

Papule

Palpable lump <1cm diameter.

Nodule

Palpable lump >1cm.

Vesicle

Palpable fluid filled lesion <1cm.

Bulla

Palpable fluid-filled lesion >1cm

Petechiae

red, non blanching spots <5mm

Purpura

red, non blanching spots >5mm

Plaque = Palpable disc shaped lesion

Wheal = Area of dermal oedema

Descriptive Terms

Annular : Ring shaped, hollow centre Arcuate : Curved Circinate : Circular Confluent : Lesions that run together Discoid : Circular without hollow centre Eczematous : Inflammed and crusted Keratotic: Thickened Lichenified: Thickened and roughed with accentuated

skin markings Zosteriform : Nerve distribution

History How long Had it before Is it worsening / anything improving it Distribution ie palms / plantar / face / mucosal membranes How did it start / evolve Itch Social changes eg diet / work / cleaning Meds & allergies Cutaneous manifestations of systemic disorders eg sore joints & past medical

history Family history Travel Contacts Viral symptoms or fevers

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Urticaria

Urticaria

Physical triggers / drugs / foods / stings / viral/ atopy / blood products / temperature...

Wheals, smooth with a red flare with some clearing leaving annular pattern & scratch marks. Dermatographism

Acute / Recurrent / Chronic Investigation

FBC / WCC / Eosinophils / Challenges

Complement levels with angiooedema Management

Remove cause / anti-histamines / steroids

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Eczema Flexural Distribution Itch ++ / Scratch marks, hyper or hypopigmented lesions Age related stages Atopic vs Contact Can be vesicular Treatment

Emollients ++ Treat infected skin Moist dressings Avoid triggers Antihistamines for itch Topical / systemic steroids Increase sunlight exposure / Phototherapy Immunomodulators / Immunosupressants : Cyclosporin / Azathioprine /

Tacrolimus /

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Psoriasis Itch / Pain / Decreased movement / FHx Extensor Distribution – well demarcated salmon pink silvery scales. Red surface on

removal / capillary bleeding (Auspitz sign)/ new lesions at site of trauma (Koebner’s Phenomenon)

Plaque / Guttate / Erythrodermic / Pustular variants / Inverse Triggers – Stress, Strep, HIV, Trauma, Drugs (Lithium + BetaBlockers Especially) Psoriatic Arthritis Treatment – topical v’s systemic : Systemic if failed topical / repeated admissions /

extensive plaques in elderly / severe arthropathy / generalised pustular or erythrodermic psoriasis Emollients ++ / Keratolytic agents Topical Steroids. Coal Tar. Dithranol. Vitamin D3 Retinoids – topical or oral. Phototherapy / Photochemotherapy (& methotrexate) Immunosuppressant's – Methotrexate, Cyclosporin, Mycophenalate Infliximab / CD4 monoclonal antibodies

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VZV Varicella / Chicken Pox – Respiratory droplets. Infectious for 2 days prior to

lesions. Ends when crusts Rash head / trunk / Simultaneous presence of rash at different stages. Macule / Papule / Vesicle /

Pustule / Crusts A/w headache / malaise / anorexia / cough / coryza and sore throat / low grade

fever Rx symptomatic. Antivirals in certain cases / Secondary infection risk

Shingles Dermatomal distribution & enlarged draining node Presents as pain, malaise, fever, rash in same distribution several days later Dx Clinical but can do smears or titres or isolation of virus in blisters Mx – antivirals / pain relief / IV antivirals if immunocompromised / IFN Complications : Corneal ulcers / Gangrene of affected area / Phrenic Nerve palsy

/ Meningoencephalitis / Ramsay Hunt syndrome / Neuralgia / Disseminated zoster

NB if AIDS – major CNS effects/

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HSV

Pain / Itch / Vesicles / Sore mouth / Gum swelling / Mouth ulcers

Small vesicles & lymph nodes Complications –

Erythema Multiforme / Encephalitis / Keratitis / Whitlow / Disseminated infection if immunocompromised / Visceral involvement / Neonatal / Meningitis

Rx topical / oral / IV antivirals

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Impetigo Group A beta haemolytic Strep or Staph aureus Contagious Vesicles to honey coloured crusted lesions. Painless. Face

or extremities Local adenopathy / Generally afebrile Rx topical / oral antiobiotics Generally resolves 7-10/7 Complications – Osteomyelitis / Septic Arthritis / Sepsis /

Pneumonia / Endocarditis Post strep glomerulonephritis / Scalded skin syndrome

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Erythema Multiforme Hypersensitivity reaction, polymorphous skin eruption Target Lesions

Symmetric eruption red round macules, oedematous papules, target lesions (x3 concentric areas of colour change) dorsum hands and forearms

Central dusky area due to keratinocyte necrosis. Can be vesicular and painful. Minor generally self limiting

Etiology HSV Immunologic disorders – IBD / SLE / graft v’s host Mycoplasma, TB, Histoplasmosis. Drugs: Sulphonamides. Barbiturates. Penicillin. Phenytoin. NSAIDS.

Allopurinol. Malignancy Idiopathic

Mx – Minor consider antivirals if HSV / symptomatic

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Erythema Nodosum

Painful nodules, poorly defined. +++ tender Hx – fever / painful nodules/ arthralgias / sore throat / drugs / Cough Aetiology:

Strep / TB / Yersinia / Leprosy / Coccidioidomycosis / Histoplasmosis Sarcoid SLE Behcets IBD Drugs – Sulphonamides / OCP

Management Definitive dx – wedge biopsy CXR ASOT / Throat Swabs. Symptomatic

• Self–limiting - 3-6 weeks• NSAIDS• Elevation• Compression Stockings.

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Koplik’s Spots / Measles

Primary infection respiratory epithelium - droplets Highly contagious Fever / Coryza / Koplik spots 2-3 days into prodrome

precedes rash (14 days). Maculopapular, lasts 5-7/7 may desquamate

Clinical diagnosis of Measles wrong in 50% of cases Probably requires serology for confirmation /

leucopaenia / lymphopaenia Complications: Superimposed bacterial infection.

Encephalitis. SSPE

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Slapped Cheek Syndrome

Fifth Disease “Erythema infectiosum” Parvovirus B19 Respiratory droplets Viral prodrome, slapped cheek, perioral pallor, later

extremities with palms and soles spared. Laced appearance

Antipyretics and antihistamines Generally benign. Rare aplastic crisis. In utero a/w

hydrops foetalis

Hand, Foot + Mouth

Usually Coxsackie A or Enterovirus Usually children, very infectious, incubation 3

days then fever malaise and rash / painful oral lesions

Treatment supportive

Kawasaki’s disease

Usually < 5 yo, early phase of prolonged fever, irritability, and involvement of mucous membranes (conjunctivitis and mouth). Hands and feet red and swollen early, later may have desquamating maculopapular rash

Association with cardiac abnormalities...

Treatment with IV Immunoglobulin

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Pityriasis Rosea

Presumed viral. ?HHV 7. Christmas tree distribution. Self limiting over 6-12 weeks. Herald patch often mistaken for

ringworm.

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Scabies Sarcoptes scabiei Intense itch Permethrin or Malathion

Applied at bedtime to whole body from chin to soles.

Treat all close contacts even if asymptomatic.

Wash all towels, clothes worn in last week and bedlinen

Vacuum house and furniture! Itch can persist for 6 weeks even after

successful treatment due to dead mites in skin.

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Melanoma

Asymmetrical Border irregular Colour Variegated Diameter >5mm Evolution / Elevation

So far...

Reviewed terminology

Common, but usually not serious/life threatening conditions

Serious conditions with blistering / skin loss

Erythema Multiforme major / SJS Pemphigus Pemphigoid TENS SSS ( Kawasaki’s )

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Erythema Multiforme Major

Stevens Johnson Syndrome Symmetric erythematous macules, head and neck and lower

body Progresses to bullae, skin necrosis and denudation, at least

x2 mucosal surfaces involved Widespread rash involving up to 10% BSA skin sloughing /

blistering. Treatment: Prompt drug withdrawal. Admission / supportive care / general burns care.

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Toxic Epidermal Necrolysis Widespread rash like sunburn initially >30% TBSA with later

necrosis and sloughing. +ve Nikolsky sign Large mucous membrane involvement. Remove causative agent & manage as severe burns (ICU /

Burns unit) Mostly thought to be drug related Debates re plasmapheresis / IG / Steroids etc, nil proven Complications: High mortality / NB Ophthalmology

involvement and regular eye irrigation

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Pemphigus Autoimmune Blisters in mouth followed by on skin. Diagnosis by biopsy – IgG in epidermis, disruption of connections

intercellular 3 Types:

Vulgaris – begins in mouth 50% cases Foliaceous – may be drug induced

• Least severe.• Often mistaken for eczema

Paraneoplastic.• NHL most common

Mx: Barrier nursing / antibx / IV fluids / systemic steroids +/- immunosuppressants (azathioprine / cyclophosphamide / methotrexate / gold / dapsone /ciclosporin)

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Pemphigoid

More common than pemphigus Generally benign Also Autoimmune Affects older age group Affects deeper layer in skin – tense flexural areas

Subepidermal / eosinophil rich with IgG and C3 deposited in basement membrane

Treatment same as Pemphigus – steroids +/- immunosupressants

Variants Gestational Mucous membrane (Cicatricial)

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Scalded Skin Syndrome Syndrome of acute exfoliation of the skin typically following an

erythematous cellulitis. Severity varies from a few blisters to a severe exfoliation affecting almost the entire body, but doesn’t involve mucous membranes as in TENS.

Staph aureus with epidermolytic exotoxins (A+B).

Nikolsky’s sign -separation of skin with gentle pressure.

Treatment. Antibiotics, supportive care.

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Purpuric Rash

Petechiae <5mm. Purpura >5mm. Causes:

Drugs: Steroids / Gold / Anticoagulants Senile Trauma

• Coughing / vomiting / direct. Infection

• Meningococcal, Cellulitis, Viral. Vasculitic

• E.g. HSP / Wegners / PAN Thrombocytopenia

• ITP / TTP / Leukaemia / DIC.

Red flags

Unwell patient Other serious comorbidity, eg immunodeficiency Large area of skin Mucosal or ocular involvement Specific conditions with serious complications

eg Kawasaki

If any doubts d/w senior colleague / dermatologist

Remember you can easily send them an image of

a rash ! (in hours)

A good reference website:

http://dermnetnz.org/doctors/