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Dermatologic Emergencies
Joshua Radke, MDUC Davis Emergency Medicine
None
Disclosures
Neonatal Rashes Vasculitides Vesicular Lesions Infectious Lesions Immune-mediated Lesions
Outline
Erythema toxicum neonatorum Cutis marmorata Seborrheic dermatitis
Neonatal Rashes
Benign eruption
First 5 days of life
Crops of papules/pustuleson erythematousbase
Erythema Toxicum Neonatorum
Etiology unclear
Treatment:◦ Reassurance
Usually resolves in 2-7 days
Erythema Toxicum Neonatorum
First 2-4 weeks of life
Secondary to cold exposure
Reticulated mottled appearance
Cutis Marmorata
Cutis Marmorata
Cutis marmorataMottling
Erythematous, scaling plaques
Consider with involvement of ears and eyebrows
Usually mild, but can have significant inflammatory component
Seborrheic Dermatitis
Treatment:
◦ Removal of scale
◦ Medicated shampoos
◦ Topical steroids
Seborrheic Dermatitis
Henoch-Schonlein Purpura Kawasaki’s Disease
Vasculitides
Most common vasculitis in 3-15 yo
IgA deposition in small vessels
Diagnosis generally clinical
Henoch-Schonlein Purpura (HSP)
Classic Tetrad◦ Palpable Purpura◦ Abdominal pain◦ Renal disease◦ Arthritis/arthralgias
Renal disease typically transient
HSP
Supportive
NSAIDs for pain
Steroids for severe disease
HSP - Treatment
Kawasaki’s Disease Usually <5 yo
Unknown etiology
Vasculitis of small and medium vessels
Self-limited
CRASH and burn◦ C - Conjunctivitis◦ R - Rash◦ A – Adenopathy, cervical◦ S – Strawberry tongue◦ H – Hand/foot changes or edema
Need 4/5 plus fever > 38.5 C for 5 days
Atypical/incomplete Kawasaki’s◦ ESR/CRP if fewer than 4 criteria
Kawasaki’s - Diagnosis
IVIG◦ 2 mg/kg over 8-12 hours
High Dose Aspirin◦ 80-100 mg/kg/day
divided q 6hr◦ Treat until fever resolves◦ Then low dose until
normalization of inflammatory markers
Kawasaki’s - Treatment
Pemphigous vulgaris Bullous pemphigoid
Vesicular Lesions
Most common in 40-60 yo
Small, flaccid bullae
Form superficial erosions and crusted ulcerations
Oral lesions may be present months before cutaneous lesions
Pemphigous Vulgaris
Unknown cause
Possibly autoimmune
Drugs◦ Penicillamine and captopril
Pemphigous Vulgaris
Local wound care
Pain management
Steroids◦ PO prednisone◦ Immunosuppresants (dermatology)
Mortality 10-15%◦ Secondary infection, dehydration, thromboembolic
disease, side effects of high-dose steroids
PV - Treatment
Chronic autoimmune condition
Blisters occur deeper than pemphigous
Better prognosis than pemphigous
Treat with topical or oral steroids, methotrexate
Bullous Pemphigoid
Staphylococcal scalded skin syndrome Toxic shock syndrome
Infectious Lesions
Children ≤ 6 yo
Exotoxin-producing Staphylococci
Usually begins with erythema and crusting around mouth
Staphylococcal Scalded Skin Syndrome (SSSS)
Quickly spreads down body
Followed by bulla formation and desquamation
SSSS
Clinical resolution in 3-7 days
Most patients will recover without antibiotic coverage
IV nafcillin or PO dicloxacillin/cloxacillin
SSSS - Management
Diffuse desquamating erythroderma
Exotoxin mediated
Group A beta-hemolytic Strep as well as Staphylococcal species
Toxic Shock Syndrome
Fever of at least 38.9 C
SBP < 90 mm Hg
Skin rash
Involvement of at least 3 organ systmes
TSS - Diagnosis
Elevated WBC Anemia Thrombocytopenia Elevated coags Elevated transaminases Elevated BUN, Creatinine Elevated creatinine kinase
TSS - Labs
IV fluids
Pressors
Ventilator support
Antibiotics◦ Clindamycin◦ Nafcillin or Vancomycin for deep infections
TSS - Treatment
Contact Dermatitis Exfoliative dermatitis Erythema multiforme Stevens-Johnson Syndrome Toxic Epidermal Necrolysis
Immune-mediated Lesions
Inflammatory reaction of the skin
Delayed hypersensitivity reaction◦ Lymphocyte mediated
Brief contact with potent caustic or from repeated or prolonged contact with milder irritant
Contact Dermatitis
Contact Dermatitis
•Rhus genus•Rubber compounds•Nickel•Paraphenyldenediamine•Ethylenediamine
Avoidance of irritant/allergen
Treat secondary bacterial infections
Antihistamines◦ Diphenhydramine or hydroxyzine
Systemic steroids
Contact Dermatitis - Management
Erythema and scaling >90% of skin surface
Cause by drugs, chemical agents, underlying systemic disease (malignancy)
Exfoliative Dermatitis
Treatment:
Correct hypothermia and hypovolemia
Systemic corticosteroids
Exfoliative Dermatitis
Acute, usually self-limited
Distribution symmetrical◦ Palms and Soles◦ Backs of hands and
feet◦ Extensor surfaces
Target lesion is the hallmark
Erythema Multiforme
Drugs HSV infection Viral infections
◦ Hepatitis, influenza A Fungal diseases
◦ Dermatophytosis, histoplasmosis, coccidioidomycosis Bacterial infections
◦ Streptococcus, tuberculosis Collagen vascular disorders
◦ Rheumatoid arthritis, lupus, dermatomyositis Pregnancy Malignancy
Erythema Multiforme - Causes
Severe form of erythema multiforme
Bullae and mucous membrane involvement
Multisystem involvement
Death from infection and dehydration
Stevens-Johnson Syndrome
Search for underlying cause
Mild cases resolved in 2-3 weeks
Severe cases last up to 6 weeks
IV hydration, local skin care
Analgesia and systemic corticosteroids
EM/SJS - Treatment
Separation of large sheets of epidermis
from underlying dermis
Begins with viral prodrome
Macular rash develops◦ +/- target lesions◦ + mucous membrane
involvement
Toxic Epidermal Necrolysis
Macular exanthem starts centrally
Dermal-epidermal dissociation◦ + Nikolsky sign
Denudation with shear stress◦ Skin commonly painful
Toxic Epidermal Necrolysis
Drugs◦ Sulfa, penicillin, aspirin, barbiturates, phenytoin,
NSAIDS, carbamazepine, allopurinol
Vaccination◦ Polio, measles, smallpox, diphtheria, tetanus
Lymphoma
TEN - causes
15-20% mortality
Involvement of conjunctivae and cornea may lead to permanent scarring and blindness
TEN - Prognosis
Discontinue offending agent
Fluid replacement
Infection control
Steroids◦ Controversial
Plasmapheresis◦ Experimental
TEN - Treatment
Blok, Barbara K., Dickson S. Cheung, and Timothy Fortescue. Platts-Mills. "Chapter 17: Dermatology." First Aid for the Emergency Medicine Boards. New York: McGraw-Hill Medical, 2011.
Maconochie, Ian. “Best Practice: Kawasaki Disease.” Arch Dis Child Educ Pract Ed2004;89 Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K.
Aaron. "Chapter 118: Dermatologic Presentations." Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.
References
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