Things that make you go ughhh…. Adult DermatologyHeather Patterson PGY-2
Feb 22, 2007
Objectives • Learn key features of toxic rashes seen in
adults.
• Win the container of homemade chocolate chip cookies!
• Small solid elevation <1cm
Describe:
PAPULE
Describe:
• Palpable mass > 1cm NODULE
Describe:
• Elevated disc shaped lesion
PLAQUE
Describe:
• Flat area of discolouration
MACULE
Describe:
• Fluid filled area <0.5cmVESSICLE
Describe:
• Fluid filled area >0.5cmBULLAE
Describe:
• Area of dermal edema, raised, erythematousURTICARIA
Describe:
• Denuded area where epidermis is lost EROSION
Describe:
• Denuded area where dermis is lost
ULCER
Describe the rash.
Rocky Mountain Spotted Fever
Etiology?• Rickettsia rickettsee – found in Rocky Mountain wood tick saliva
How many hours does the tick need to feed for innoculation?
• 6 hours
Rocky Mountain Spotted Fever
• Clinical Presentation– Day 2-14 after bite– Sudden onset fever (>38.3) and rigors– Nausea/vomiting, anorexia– Headache, myalgias – Rash
Rocky Mountain Spotted Fever
How does the rash present on day 2-4 post onset fever?
• 2-6 mm blanchable pink macules starting on wrists and ankles
• Spreads cetripetally and includes palms and soles
Rocky Mountain Spotted Fever
How does the rash present on day 5-6 post onset fever?
• Non-blanchable petechial rash• Local edema surrounding petechie
Rocky Mountain Spotted Fever
• Labs:– Bands– Thrombocytopenia– ↑Na– ↑ Transaminases
Rocky Mountain Spotted Fever
• Doxycycline– 100mg po bid – 2.2 mg/kg for kids
• Chloramphenicol– In pregnancy
Treatment? Duration?
• Treat for 3 days after afebrile OR min of 5-7 days
Rocky Mountain Spotted Fever
• Mortality:– Untreated >30%– Treated 3-7%
Describe the rash.
Meningococcemia
• Clinical Presentation– Myalgias, malaise, sudden onset fever– +/- signs of meningitis– Rash
• Etiology– N. meningitidis– Droplet spread
Meningococcemia
How does the rash present early?
• Non specific erythematous lesions that look viral
Meningococcemia Classic appearance?
• Irregular borders, small• Pupura are painful and slightly raised• Usually on trunk and ext. but can be
anywhere
Meningococcemia
• Ceftriaxone and Vanco until isolated• Pen G 250 000U/kg/day divided q12h
Treatment?
Prophylaxis?• Rifampin 600mg q12h (5-10 mg/kg)
• Cipro 500mg IM x1• Ceftriaxone 250mg IM x1 (125mg for
kids)
Meningococcemia
• 40%
What is the mortality with this rash?
Describe the rash.
EM
Classic Rash?
• Target lesions• Progression: Macules Papules Central
Vessicles
EM - distribution
EMMucous membrane
involvement?
• EM – Minor: little to none• EM Major: always
Erythema Multiforme
• Drugs• Infection
– Herpes simplex– Mycoplasma
• Idiopathic (>50%)
Etiology?
Erythema Multiforme • Pathophysiology
– Perivascular mononuclear infiltrate– Dermal edema– Secondary epidermal changes
EM • EM Minor:
– Classic target lesions usually on face and extremities
– Vessicles but no bullae– Little to no MM involvement– Recurrent episodes associated with Herpes
simplex
EM • EM Major
– Target lesions more generalized– Bullae and + Nicholsky sign– Extensive MM involvement and systemic features:
• Conjunctivitis/corneal ulcers, uveitis• Cheilitis, stomatitis, GI erosions, resp tract erosions• Vulvitis, balanitis
– May progress to SJS/TEN – Most often a drug reaction
Describe the rash.
SJS/TEN Name 3 causes of
this rash.• Drugs, infection (mycoplasma, viral), vaccination, chemicals
Name 3 drug /classes that can cause this rash.• Sulfa
• Anticonvulsants• NSAIDs – oxicams• Allopurinol
SJS/TEN
• Pathophysiology– Cytotoxic immune reaction against
keratinocytes– Leads to vasculitis of superficial dermis and
epidermal necrosis
SJS/TEN
• Most consider this a spectrum of disease:– EM major SJS TEN
• May start with classic target lesions of EM BUT
about 50% of SJS/TEN do not have target lesions
SJS/TEN What %BSA is
involved in SJS?• <10%
What %BSA is involved in TEN
• >30%
SJS/TEN • Clinical Presentation
– Onset within 1-3 weeks of first exposure to antigen (repeat exposure has faster onset, ie days)– 2-3 day prodrome prior to rash:
• Cough, sore throat• Myalgias, malaise, headache• Anorexia• Fever• Skin burning, itching, tenderness• Conjunctival burning, itchiness
SJS/TEN
Prodromal Rash?
• PAINFUL, WARM• Mobilliform with diffuse erythema
SJS/TEN
How does the rash present early?
• Discrete dark red macules with crinkled surface
• Enlarge and eventually coalesce
SJS/TEN
How does the rash appear late?
• Raised FLACCID blisters• Confluent and necrotic with epidermis
sloughing in sheets leaving red dermis exposed
SJS/TEN
What is Nicholsky’s sign?
• Firm sliding pressure causes blistering/sloughing of normal appearing skin.
SJS/TEN
Mucous membrane involvement?
• Yes in 92-100% of cases• 85% have conjunctival lesions
SJS/TEN • Other findings/complications:
– Fever >38– Heme:
• Anemia• Neutropenia (coreltates with poor prognosis)
– GI, Resp• Epithelial erosions
– Renal• ATN, ARF
– Sepsis
SJS/TEN
• Supportive• Clean saline soaked gauze bandages• Avoid silver sulfadiazine• Fluids
– fluid replacement required for 3 degree thermal burn of similar BSA
Treatment in ED?
SJS/TEN
• High dose steroids• Cyclosporin/cyclophosphamide• Plasmaphoresis/IVIG• NAC• Erythromycin for eye involvement
Treatment outside ED?
SJS/TEN
• SJS – 5%• TEN – 30%
Mortality?
Describe the rash.
Staph Scalded Skin Syndrome
• Clinical Presentation– Seen in kids AND immunocompromised, alcholics,
CRF, malignancy– Often have primary infection– Fever, malaise– Skin tenderness in flexural areas prior to sloughing
• Pathophysiology– Staph exfoliative toxin targets zona granulosa– Causes intraepidermal splitting leading to
bullae formation
SSSS
How does the rash present early?
• Macular sandpaper rash with erythema• Deeper coloured erythema with skin
tenderness in flexural areas
SSSS
How does the rash present 24-48h post pain?
• FLACCID bullae in erythem regions
• Bullae coalesce and rupture leaving erythem base
• Looks like wet tissue paper
• Palms, soles, MM spared
SSSS Positive Nicholsky’s
sign?MM involvement?
• Yes BUT only on erythematous skin• No MM involvement or very mild
inflammation
SSSS
• Supportive• Clean saline soaked gauze bandages• May require ABx
– Clox– 1st gen cephalosporin– Vanco for MRSA– Macrolide
Treatment in ED?
SSSS
• Kids – 3%• Healthy adults – up to 50%• Adults with comorbidities – up to 100%
Mortality ?
Describe the rash.
Staph TSS Classic appearance?
• Fine erythematous macular sandpaper rash – looks like scarlet fever
• Extensive generalized non pitting edema• +MM involvement
Staph TSS What is the most common
underlying cause of this rash?• Tampons Name 2 other
causes.• Surgical wounds with abscess• Burns• Ulcers• Insect bites• Contraceptive devices
Staph TSS • Pathophysiology
– Production of endotoxin during bacterial replication
– Act as superantigen to T cells leading to massive cytokine release
Staph TSS – diagnostic criteria
1. Fever ≥ 38.92. Rash3. Hypotension or orthostatic hypotension4. Involvement of 3 of the following
1. GI – vomiting and diarrhea2. Muscular – severe myalgias or CK 2x normal3. MM involvement4. Renal – Cr or BUN 2x normal or pyuria5. Hepatic – bili, transaminases 2x normal6. CNS – confusion, headache, seizure, no focality7. Heme – thrombocytopenia plts < 100
Staph TSS – diagnostic criteria
5. Desquamation 1-2 weeks post onset illness6. Evidence against alternative diagnosis
Staph TSS
• ABCs• May require – pressors/ionotropes• ++ Fluid resuscitation• ABx
– Cloxacillin, naficillin – Clinda – Vanco if MRSA
• Find and treat source– Remove tampon, drain abscess etc
Treatment in ED?
Describe the rash.
Pemphigus Vulgaris • Pathophysiology
– Autoimmune disease– Loss of cell to cell adhesion in the epidermis
due to antibody binding to surface glycoproteins
Pemphigus Vulgaris
• Presentation:– Oral and MM involvement – painful bullae with
ulceration– May complain of epistaxis, hoarseness,
dysphagia, wt loss– Gums and vermillion boarders are common
locations
– Cutaneous lesions– General malaise
Pemphigus Vulgaris
Mucosal Lesions?
• Fragile bullous lesions • Become non healing painful ulcers
Pemphigus Vulgaris
Classic Appearance?
• FLACCID fragile bullae found on normal looking skin in a random pattern– But commonly seen on face,
scalp and upper trunk• Become non healing
painful ulcers
Pemphigus Vulgaris
Nicholsky sign?
• Positive
Pemphigus Vulgaris
• Supportive, analgesia, wound care• Prednisone 2-3mg/kg/day
– Treat until no new blisters are forming AND negative Nicholsky sign
• Consult Dermatology
Treatment in ED?
• Immune modulators– Derm
Describe the rash.
Bullous Pemphigoid
• Epidemiology– Most often seen in the elderly and men
• Pathophysiology– Most common autoimmune blistering disease– Antibody to basement membrane leads to
complement deposition and subepidermal blister formation
Bullous Pemphigoid
Classic Appearance?• TENSE bullae with
preference for:– Lower abdo, inner thighs,
groin, flexor surfaces of extrem.
• On normal or erythematous skin
• 66% with erythem or urticarial lesions prior to bullae
• Severe pruritis
Bullous Pemphigoid
Nicholsky sign?
• Negative
Pemphigoid • MM involvment?
– In 30% of patients
Pemphigoid
• Supportive• Wound care• Prednisone 0.5mg/kg/day
AND Clobetasone proprionate 40g/d divided bid
(or other high potency topical steriod)
• Consult Dermatology
Treatment in ED?
Bullous Pemphigoid
Mortality?
• 25-40% – Most common causes: secondary sepsis or
physiological stress leading to MI
Varicella Zoster What is Hutchison’s
sign?• Involvement of the nasociliary nerve – lesions on the tip of the nose.
What is the concern with this distribution?• Involvement of the eye
• Conjunctivitis, Corneal inflammation and scarring
• Uveitis, iritis
Varicella Zoster Ophthalmicus
• Acyclovir 800mg 5x daily x7-10daysOR
• Famciclovir 500mg tid x 7days• Consider IV if severe
• Referral to ophtho within 24h
Treatment in ED?
Conclusion • Hopefully you have learned key features
of several emergent rashes seen in adults!