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CONFLICT OF INTEREST • DR. HENNESSY-HARSTAD CONFIRMS THAT SHE HAS NO CONFLICT OF INTEREST IN THIS PRESENTATION. OBJECTIVES • PARTICIPANTS WILL IDENTIFY SEVEN SERIOUS RASHES AND TREATMENT • PARTICIPANTS WILL UTILIZE AN DIAGNOSTIC DECISION TREE TO IDENTIFY RASHES AND HOW TO TREAT • PARTICIPANTS WILL IDENTIFY MEDICATIONS MOST FREQUENTLY USED FOR TREATMENT OF RASHES • PARTICIPANTS WILL RECOGNIZE WHEN TO REFER PATIENTS TO SPECIALISTS BY THE NUMBERS • SKIN CONDITIONS AFFECT 20-30% OF THE POPULATION • COST EXCEEDS $96 BILLION DOLLARS A YEAR • 1 IN 3 PERSONS IN US ARE AFFECTED AT ANY GIVEN TIME MISDIAGNOSIS OF RASHES • CAN RESULT IN UNNECESSARY OFFICE VISITS • UNNECESSARY OR WRONG PRESCRIPTIONS • INCREASED COSTS • PATIENT SUFFERING, DISFIGUREMENT AND EVEN FATALITY • TIME CONSTRAINTS ARE REPORTED AS A LEADING REASON FOR MISDIAGNOSIS. • AWAWLLDA ET AL. (2008). WHY SO HARD TO DIAGNOSE? • NEARLY 2,200 DISEASES AND DISORDERS AFFECTING THE SKIN • DIFFERENT CONDITIONS BUT SIMILAR RASHES (I.E., BOTH PSORIASIS AND FUNGAL RASHES CAN APPEAR SCALED6-9) • SINGLE SKIN CONDITION CAN RESULT IN DIFFERENT PRESENTATIONS. FOR EXAMPLE, CONTACT DERMATITIS MAY PRESENT WITH A VESICULAR, SCALED, PAPULAR OR MACULAR RASH.10,11 DERM EMERGENCIES • HTTP://WWW.MIDLEVELU.COM/BLOG/DERMATOLOGIC-EMERGENCIES-7-RASHES-NPS-MUST-BE-ABLEIDENTIFY • ANGIOEDEMA • MENINGOCOCCEMIA • ROCKY MOUNTAIN SPOTTED FEVER • NECROTIZING FASCIITIS • STEVENS JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN) • TOXIC SHOCK SYNDROME • ERYTHRODERMA (GENERALIZED EXFOLIATIVE DERMATITIS) ANGIOEDEMA SUBSTANTIAL LOCALIZED FACIAL SWELLING, 50% OF PATIENTS WILL HAVE URTICARIA. ANGIOEDEMA CAN HAVE SYSTEMIC EFFECTS. ASSOCIATED WITH ANAPHYLACTIC REACTION SHORTNESS OF BREATH, CHANGES IN VOICE, TONGUE SWELLING OR THROAT TIGHTNESS AS THESE SYMPTOMS INDICATE AIRWAY INVOLVEMENT. HISTORY OF ACE INHIBITOAN ALLERGEN OR THE DISEASE MAY BE HEREDITARY. TREATMENT INVOLVES REMOVING THE OFFENDING MEDICATION OR ALLERGEN FROM THE PATIENT'S ENVIRONMENT, ANTIHISTAMINES AND STEROIDS. EPINEPHRINE AND SUPPORTIVE AIRWAY TREATMENT MAY BE NECESSARY IF THE AIRWAY IS INVOLVED. MENINGOCOCCEMIA • • PETECHIAL RASH • THE RASH: PETECHIAE, SMALL RED SPOTS THAT DO NOT BLANCHE WITH PRESSURE • RASH APPEARS ANYWHERE ON THE BODY INCLUDING THE PALMS AND SOLES OF THE FEET. • MENINGOCOCCEMIA CAN LEAD TO MENINGOCOCCAL MENINGITIS, DIC, SHOCK AND DEATH • • TREATMENT: AGGRESSIVE ANTIBIOTIC INTERVENTION INITIAL PRESSENTATION: FEVER AND RASH FOLLOWED BY FATIGUE, FEVER, HEADACHE AND BODY ACHES. FEBRILE PATIENTS PRESENTING WITH PETECHIAL RASH SHOULD BE SUSPECTED OF HAVING A MENGOCOCCEMIA DIAGNOSIS. BLOOD CULTURES MUST BE DRAWN AND THE PATIENT TREATED WITH IV ANTIBIOTICS UNTIL MENINGOCOCCEMIA IS RULED OUT WITH CULTURE RESULTS. ROCKY MOUNTAIN SPOTTED FEVER • • • CARRIED BY TICKS, • UNTREATED PATIENTS AND PATIENTS IN WHOM THE DISEASE IS NOT TREATED PROMPTLY HAVE A MORTALITY RATE OF 30 TO 70%. • • THE RASH : TYPICALLY APPEARS FIRST ON THE ANKLES AND WRISTS • BEGINS AS A MACULAR RASH MANIFESTING AS FLAT, PINK SPOTS PROGRESSING TO A RED, MORE PROMINENT PETECHIAL RASH. • COMPLICATIONS OF RSR INCLUDE ACUTE RENAL FAILURE, HEPATIC FAILURE, CARDIOGENIC SHOCK, DIC AND MENINGITIS • TREATMENT: ANTIBIOTICS, TYPICAL PRESENTATION: TRIAD OF FEVER, HEADACHE AND RASH. PATIENTS WHO ARE ADEQUATELY TREATED HAVE A MORTALITY RATE OF JUST 3 TO 7% THEN SPREADS TO THE PALMS, SOLES AND EVENTUALLY THE TRUNK AND FACE. NECROTIZING FASCIITIS • NECROTIZING FASCITIS IS CHARACTERIZED BY NECROSIS OF THE SUBCUTANEOUS TISSUE AND FASCIA BY GROUP A STREPTOCOCCUS • TYPICAL PRESENTATION: • • • INITIAL SWELLING AT THE SITE FOLLOWED BY INTENSE PAIN AND TENDERNESS. PAIN, TYPICALLY OUT OF PROPORTION TO THE EXTERNAL RASH, IS PRESENT SYSTEMIC SYMPTOMS: FEVER, MALAISE, MYALGIA • • • • LARGE BULLAE OFTEN DEVELOP IS ASSOCIATION WITH THE RASH. • EARLY IDENTIFICATION, AGGRESSIVE TREATMENT WITH ANTIBIOTICS AND SURGICAL DEBRIEDMENT OF THE AFFECTED AREA ARE NECESSARY TO IMPROVE SURVIVAL OUTCOME. RISK FACTORS: DIABETES, IMMUNOSUPPRESSION ION AND PERIPHERAL VASCULAR DISEASE. NECROTIZING FASCITIS CAN LEAD TO GANGRENE, SHOCK AND ORGAN FAILURE. MORTALITY IN NECROTIZING FASCITIS RANGES FROM 20 TO 80%. STEVENS JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN) • • SEVERE DRUG-INDUCED HYPERSENSITIVITY • TWO OR MORE MUCUS MEMBRANES ARE TYPICALLY INVOLVED INCLUDING THE ORAL OR BUCCAL MUCOSA AND THE GENITALIA. • SULFA DRUGS, ANTI-EPILEPTICS AND OTHER ANTIBIOTICS ARE THE MOST COMMON DRUGS CAUSING THESE RASHES • • OCCASIONALLY, SJS AND TEN ARE IDIOPATHIC. • RASH TYPICALLY BEGINS TO APPEAR 1 TO 3 WEEKS AFTER TAKING THE DRUG. • MORTALITY RATE OF 20 TO 25%. LOSS OF EPITHELIAL TISSUE LEADS TO SECONDARY INFECTION, FLUID LOSS AND ELECTROLYTE IMBALANCE. • TREATMENT IS SIMILAR TO THAT OF BURNS AND IS LARGELY SUPPORTIVE. RASH: MACULES THAT QUICKLY SPREAD AND COALESCE FORMING BLISTERING, NECROTIC, SLOUGHING LESIONS AND DESQUAMATION. THEORY: RESULT OF THE INABILITY OF THE BODY TO DETOXIFY DRUG METABOLITES. TOXIC SHOCK SYNDROME • LIFE-THREATENING CONDITION CAUSED BY GROUP A STREPTOCOCCUS OR STAPHYLOCOCCUS • • 50% OF CASES RESULT FROM SUPERABSORBANT TAMPON USE, • PRESENTATION: 2-3 DAY PRODROME OF MALAISE FOLLOWED BY FEVER, CHILLS, NAUSEA, RASH AND ABDOMINAL PAIN. • THE RASH APPEARS FIRST AS ERYTHEMATOUS MACULES OR PETECHIAE FOLLOWED BY DESQUAMATION. LOOKS LIKE A SUNBURN. • • BEGINS ON THE TRUNK AND SPREADS PERIPHERALLY TO THE EXTREMITIES, PALMS AND SOLES. • TREATMENT INCLUDING SUPPORTIVE THERAPY AS WELL AS ANTIBIOTIC THERAPY MUST BE INITIATED IMMEDIATELY AS TOXIC SHOCK SYNDROME HAS A MORTALITY RATE OF 30 TO 70%. AUREUS. OTHER CAUSES INCLUDE SURGICAL INFECTION, POSTPARTUM INFECTION, BURNS AND OSTEOMYELITIS. PATIENTS BECOME HYPOTENSIVE AND SUFFER FROM MULTI-ORGAN FAILURE, USUALLY IN 3 OR MORE BODY SYSTEMS. ERYTHRODERMA (GENERALIZED EXFOLIATIVE DERMATITIS) • ERYTHEMATOUS, SCALING RASH COVERING AT LEAST 90% OF THE BODY'S SURFACE. • • MOST CASES OF ERYTHRODERMA ARE IDIOPATHIC. • PRESENTATION: DIFFUSE PRURITUS FOLLOWED BY MALAISE, FEVER, CHILLS AND RASH. • SCALING OF THE SKIN APPEARS 2 TO 3 DAYS AFTER ONSET OF THE RASH. • CAUSE: EXCESSIVE VASODILATION AND THEREFORE HYPOTENSION, ELECTROLYTE IMBALANCE AND CONGESTIVE HEART FAILURE RESULT. • MANAGEMENT IS LARGELY BASED ON SUPPORTIVE THERAPY INCLUDING HYDRATION, ELECTROLYTE MONITORING AND CARDIAC SUPPORT. • 43% MORTALITY RATE. OTHER CAUSES INCLUDE PSORIASIS, ECZEMA, DRUG REACTION, LEUKEMIA AND LYMPHOMA. CATEGORIZATION OF RASHES • INFLAMMATORY: ALLERGIC OR CONTACT DERMATITIS, ATOPIC DERMATITIS, ECZEMA, ERYTHEMA MULTIFORME, GRANULOMA ANNULARE, LICHEN PLANUS, ROSACEA, SEBORRHEIC DERMATITIS, STASIS DERMATITIS AND URTICARIA. • VIRAL: HERPES, MOLLUSCUM CONTAGIOSUM, VIRAL EXANTHEMS AND WARTS • BACTERIAL: ACNE, CELLULITIS, FOLLICULITIS, HIDRADENITIS SUPPURATIVA AND IMPETIGO • FUNGAL: CANDIDIASIS AND TINEA • AUTOIMMUNE: LUPUS AND PSORIASIS • MISCELLANEOUS: ACNE NECROTICA, KERATOSIS PILARIS, MELASMA, PRURIGO NODULARIS AND SCABIES. VIRAL RASHES MACULAR PAPULAR RASH • MACULAR—FLAT AND CAN BE RED • PAPULAR—RAISED AND CAN BE RED • CONFLUENT—RUN TOGETHER • DISCRETE—INDIVIDUAL LESIONS MEASLES VESICULAR LESIONS • RAISED • MAY HAVE A RED BASE • FLUID FILLED • CHICKEN POX • BLISTERS SUCH AS IN SUNBURN • BULLAE IF GREATER THAN 1 CM • • • DRUG REACTIONS STEVEN-JOHNSON BURNS VARICELLA—CHICKEN POX RASH WITH SCALES • ECZEMA • DERMATITIS • PSORIASIS • TINEA Lyons, F. (2012). CASE STUDY • A 57-YEAR-OLD WHITE MAN PRESENTS TO A PRIMARY CARE CLINIC WITH A RASH THAT STARTED AS RED, ITCHY PATCHES 2 WEEKS AGO AND THEN PROGRESSED TO BLISTERS. • HE IS EXPERIENCING DISCOMFORT FROM THE ITCHING, BUT SAYS HE IS EXPERIENCING NO PAIN. • HE HAS TRIED MULTIPLE OVER-THE-COUNTER PREPARATIONS BUT ACHIEVED NO RELIEF. • MR.H. HAS ERYTHEMATOUS AND VESICULAR PAPULES AND PATCHES ON BOTH FOREARMS AND THE TOPS OF BOTH HANDS. • HE REPORTS NO HISTORY OF RASHES OR REACTION TO MEDICATIONS EXCEPT AN ALLERGY TO PENICILLIN, WHICH CAUSES HIVES. Using the differential diagnostic decision tree, the clinician notes that the rash is on both the arms and hands and is vesicular. The next step is to check tier 4 under "hands" and tier 4 under "arms" for vesicular rashes. • The differential diagnoses in tier 5 for common vesicular rashes on the arms include contact dermatitis chickenpox, • while the diagnoses for the hands include contact dermatitis, Lichen planus dyshidrotic eczema. Since the vesicular rash is not on the torso or legs, chickenpox most likely is not the cause of this rash. Although lichen planus and dyshidrotic eczema are listed as occurring on the hands, they do not affect the arms and should be eliminated as possible diagnoses. Contact dermatitis is the logical diagnosis. Contact dermatitis is an eczematous dermatitis caused by exposure to substances in the environment. The substances act as irritants or allergens and may cause acute or subacute or chronic eczematous inflammation. • Clinical presentation includes erythematous patches that may include papules, vesicles or scales (if chronic). • The intensity of inflammation depends on the degree of sensitivity and the concentration of the antigen. • Primary care providers can use information obtained from the history and physical to validate the selected diagnosis. In this case, further questioning revealed that Mr. H. had begun handling lubricated automotive parts at work shortly before he developed the rash. This fact reinforces the diagnosis of contact dermatitis. WHAT IS THE TREATMENT? • REMOVE THE OFFENDING AGENT • TOPICAL STEROID CREAM OR OINTMENT • ANTIHISTAMINE, SUCH AS BENEDRYL OR ATARAX FREQUENTLY USED MEDICATIONS • TOPICAL STEROIDS • ANTIFUNGALS • ANTIHISTAMINES • ANTIBIOTICS • EMOLLIENTS AND CALMING STEROIDS REMEMBER • LIGHT—THIN LAYER • LOW—POTENCY • SHORT—DURATION • IF USED ON A FUNGAL INFECTION—THE INFECTION WILL GROW ROUTES • TOPICAL • PO • IV ANTIFUNGALS REMEMBER • NEED A RING AROUND THE INFECTION • PO—FOR ONE MONTH • IDENTIFY TYPE OF FUNGUS • NEED FOLLOW-UP ROUTES • TOPICAL • CREAMS, SHAMPOOS, FOAMS, GELS • PO—NEEDED FOR TINEA CAPITAS • IV—SYSTEMIC INFECTION • SUPPOSITORIES DIRECT MICROSCOPY • POTASSIUM HYDROXIDE (KOH) PREPARATION, STAINED WITH BLUE OR BLACK INK • UNSTAINED WET-MOUNT • STAINED DRIED SMEAR • HISTOPATHOLOGY OF BIOPSY WITH SPECIAL STAINS, E.G., PERIODIC ACID-SCHIFF (PAS). SPECIMEN COLLECTION--FUNGAL • • • • • • • • • • SPECIMENS FOR FUNGAL MICROSCOPY AND CULTURE MAY BE: SCRAPINGS OF SCALE, BEST TAKEN FROM THE LEADING EDGE OF THE RASH AFTER THE SKIN HAS BEEN CLEANED WITH ALCOHOL. SKIN STRIPPED OFF WITH ADHESIVE TAPE, WHICH IS THEN STUCK ON A GLASS SLIDE. HAIR WHICH HAS BEEN PULLED OUT FROM THE ROOTS. BRUSHINGS FROM AN AREA OF SCALY SCALP. NAIL CLIPPINGS, OR SKIN SCRAPED FROM UNDER A NAIL. SKIN BIOPSY. MOIST SWAB FROM A MUCOSAL SURFACE (INSIDE THE MOUTH OR VAGINA) IN A SPECIAL TRANSPORT MEDIUM. A SWAB SHOULD BE TAKEN FROM PUSTULES IN CASE OF SECONDARY BACTERIAL INFECTION. THEY ARE TRANSPORTED IN A STERILE CONTAINER OR A BLACK PAPER ENVELOPE. Antifungal Agent Activity Usual dosage Adverse Reactions Drug interactions Patient Education Clotrimazole Candida spp. Oral: Dissolve 1 lozenge 5 X/day for 7-14 days Topical—daily Intravaginal-100 to 200mg dly for 3-7 days GI (oral); Skin irritation; elevated liver enzymes Tacrolimus Do not use with tampons and douches. Do not use with occlusive dressings. Ketoconazole Candida spp. Blastomyces, Coccidioides, Histoplasma Matassezia, Prototheca spp. Oral: 200-400 mg/day Topical 1-2X daily for 2-4 weeks GI upset; Site irritation; hepatotoxicity Alprazolam; cisapride, Antacids, anticholinergics, and H2 terfenadine, blockers should be taken triazolam, Candida supp. Cryptocuccus, Aspergillus spp. Blastomycaes dermatitidis, Histoplasma, Prototheca spp. Candidiasis: oral 50150 mg/day Invasive candidiasis: oral 6mg/kg/day (400-800 mg/day) Fluconazole (Owens, Skelley, & Kyle, 2010) 2 hours after oral administration, Do not wash topical application sites for at least 3 hours after application. GI disturbances, Cisapride, rifabutin Drug interactions are common, Take tablet headache, elevated , triazolam, with full glass of liver enzymes. warfarin water. Store suspension at room temperature or refrigerator. AZOLE ANTIFUNGALS GROUPS AND INDICATIONS • TRIAZOLES AND THE IMIDAZOLES. • TREAT SYSTEMIC INFECTIONS • TREAT TOPICAL INFECTIONS • . ATHLETES FOOT, RINGWORM, ETC WHAT THEY DO REMEMBER • AZOLES DO NOT GET ALONG WELL WITH OTHER DRUGS (727 DRUGS—204 W MAJOR INTERACTIONS) • HTTP://WWW.DRUGS.COM/DRUG-INTERACTIONS/KETOCONAZOLE-INDEX.HTML?FILTER=3&GENERIC_ONLY= • SIDE-EFFECTS • ITCHING, STINGING, BURNING, OR IRRITATION • SWELLING OF FACE, SORES IN MOUTH, EYE REDNESS • DISCOLORATION OF SKIN, BLISTERS—YELLOW CRUSTS; DRY OR CRACKED SKIN, PAIN OR REDNESS OF SKIN • DIZZINESS • BURNING, CRAWLING, ITCHNESS, NUMBNESS, PRICKLING/TINGLING FEELINGS • WATCH FOR MICRO DOSES (GRISEOFULVIN MICROSIZE ORAL SUSPENSION) SCALP INFECTION ANTIHISTAMINES • DIPHENHYDRAMINE • TOPICAL AND PO • ATARAX • LORATADINE • GOAL—COMFORT • DOSE AT STRONGEST ANTIBIOTICS THINGS TO CONSIDER • CULTURE BEFORE STARTING • THE PREVALENCE OF MRSA • SHOULD START TO SEE IMPROVEMENT WITHIN 72 HOURS ROUTES • TOPICAL • PO • IV ORAL CHOICES • 2ND AND 3RD GENERATION CEPHLOSPORINS • SULFAMETHOXAZOLE AND TRIMETHOPRIM (BACTRIM) • CLINDAMYCIN EMOLLIENTS • SOFTEN THE SKIN • MANY PRODUCTS ON MARKET • EUCERIN, VANICREAM, VASOLINE, • LARD • STEROID OINTMENT BID FOR 7DAYS • SEALING WATER INTO THE SKIN OTHER • MEDIHONEY • ANTIBACTERIAL • ANTIINFLAMMATORY • ELIMITE CREAM • TREATMENT OF SCABIES WHEN TO REFER TO SPECIALIST • WHEN YOU DO NOT KNOW • AFTER THE SECOND VISIT IF THERE IS NO RELIEF • IF THE RASH IS ONE OF THE SEVEN DERM EMERGENCIES • IF YOUR PATIENT ASKS FOR ONE REFERENCES • AMERICAN ACADEMY OF DERMATOLOGY. HTTPS://WWW.AAD.ORG/PRACTICE-TOOLS/QUALITYCARE/CLINICAL-GUIDELINES • AWADALLA F, ET AL. (2008). DERMATOLOGIC DISEASE IN FAMILY MEDICINE. FAM MED, 40(7), 507-511. • ELY JW, STONE MS. (2010). THE GENERALIZED RASH: PART II. DIAGNOSTIC APPROACH. AM FAM PHYSICIAN, 81(6), 735-739. • LYONS, F. (2012). SOLVING SKIN RASHES IN PRIMARY CARE. HTTP://NURSE-PRACTITIONERS-AND-PHYSICIANASSISTANTS.ADVANCEWEB.COM/FEATURES/ARTICLES/SOLVING-SKIN-RASH-IN-PRIMARY-CARE.ASPX • OWENS, J. N., SKELLEY, J. W., & KYLE, J. A. (2010). THE FUNGUS AMONG US: AN ANTIFUNGAL REVIEW. US PHARMACIST, 35 (8), 44-56. • SIMON, A., ET AL.(2009). MEDICAL HONEY FOR WOUND CARE—STILL THE ‘LATEST RESORT’?. EVIDENCE BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE, 6 (2), 165-173.