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Dermatologic Emergencies
Boston University School of Medicine
Internal Medicine Noon Conference
July 26th 2013
Amy Y-Y Chen, MD, FAAD
[email protected]
Conflicts of Interests
• No Conflicts of Interests
Objectives
• Identify clinical clues to the diagnosis of
potentially life-threatening dermatologic
conditions
• Describe the clinical presentation of
important dermatologic emergencies
• Discuss infectious and pharmacologic
causes of life-threatening dermatoses
Outline
• Introduction
• Infections
– Bacterial
– Viral
• Life threatening drug eruptions
• Others
Introduction
• ~15-20 % of visits to primary care
physicians and emergency departments are
due to dermatologic complaints
• It is important to be differentiate simple
skin conditions from the more serious, life
threatening conditions that require
immediate intervention
Clues to the Presence of a Potential
Dermatologic Emergency
•
•
•
•
•
Fever and rash
Fever and blisters or denuding skin
Rash in immunocompromised
Palpable purpura
“Full body redness”
Inpatient Consults
CLEAR AND DEFINED
question
Inpatient Consults
• Have seen and examined the patient and able to
provide some pertinent hx
• Not acceptable:
– “Saw a derm note in EMR”
– “Something on the skin”
– “Patient being discharged today, needs stat consult”
• MD to MD contact
• If patient has pre-existing derm problem and was
doing well on therapy, consider keeping them on
therapy when they are admitted
Inpatient Consults
• Benefits and limitation of biopsy
– Not black and white
– Takes a few days to come back
– Tissue cultures can take a few weeks
– Suture removal
• Follow up on recommendation
– Topical therapy takes a few days to a week
to work
Infections
- Bacterial
- Viral
Staphylococcal Scalded Skin
Syndrome
• Etiology
– Toxin-mediated cleavage of the skin at granular
layer resulting in a split
– Risk factors: newborn, children or adults w/
renal failure
Staphylococcal Scalded Skin
Syndrome
• Dermatologic findings
– Erythema periorificially on the face, neck, axilla, groin.
Then generalized within 48 hrs as the color deepens
– Skin tenderness
– Flaccid bullae w positive Nikolsky sign
– Within 1-2 days, flexural areas begin to slough off
– Complete re-epithelialization in 2 weeks
Nikolsky Sign
• Positive when a blister occurs on normal
appearing skin after application of lateral
pressure w/ a finger
• Occurs in any superficial blistering process
Staphylococcal Scalded Skin
Syndrome
Staphylococcal Scalded Skin
Syndrome
• Clinical presentation
– Prodrome of fever, malaise, sore throat
• Complication
– Mortality rate is 3% in kids, > 50% in adults
and 100% in adults with underlying diseases
– If in newborn nursery, needs isolation
– Identify possible staph carrier
Necrotizing fasciitis
• Etiology
– Necrosis of subcutaneous tissue due to infection
• Type I : mixed anaerobes, gram negative aerobic bacilli and
enterococci
• Type II: group A streptococci
– Risk factors: diabetes, peripheral vascular disease,
immunosuppression
• Dermatologic findings
– Diffuse edema and erythema of the affected skin->
bullae-> burgundy color-> gangrene
– Severe pain, anesthesia. crepitus, exudates
Necrotizing fasciitis
Necrotizing fasciitis
• Clinical presentation
– Shock and organ failure
• Management
– Also need surgical debridement of the necrotic tissue
Meningococcemia
• Etiology
– Neisseria meningitides (gram neg diplococcus) spread
by respiratory route
– Often seen in young adults and children
– Risk factor: asplenia, immunoglobulin or terminal
complement deficiencies
• Dermatologic findings
– Abrupt onset of maculopapular or petechial eruption on
acral surface, trunk or lower extremities -> progression
to purpura in hours
– Angular edge with “gun metal gray” center
– +/- mucosal involvement
Meningococcemia
• Clinical presentation
– Flu like symptoms: fever, chills, malaise
– DIC, shock, death
Meningococcemia
Rocky Mountain Spotted Fever
• Etiology
– Rickettsia Rickettsii carried by ticks
– Only 60% aware of tick bites
– Geographic location
Rocky Mountain Spotted Fever
• Dermatologic findings
– Purpuric macules and papules
– Starts on the wrists and ankles within 2 weeks-> spread
to palms, soles-> to trunk and face
– Over 2-4 days, the skin will become hemorrhagic and
petechial
– May have eschar at site of bite
Rocky Mountain Spotted Fever
First starts on wrists and ankles
Rocky Mountain Spotted Fever
Rocky Mountain Spotted Fever
Rocky Mountain Spotted Fever
• Clinical presentation
– Triad: fever, headache and rash (only in 60%)
– Can have variety of organ involvement (cardiogenic
shock, hepatic failure, renal failure, meningismus and
DIC)
• Management
– Mortality is 30-70% if untreated vs 3-7% if treated
– Ideally should start within 5 days of infection
– DOXYCYCLINE ! Even in kids
Infections
-Bacterial
-Viral
Eczema Herpeticum
• Kaposi’s varicelliform eruption
• Etiology
– Herpes virus: HSV1 > HSV2
– Risk factor: any diseases w impaired skin barrier
• Dermatologic findings
– 2-3 mm umbilicated vesicles-> punched out erosions->
hemorrhagic crusts
– If severe, may have systemic involvement
Eczema Herpeticum
Varicella Infection
• Etiology
– Varicella Zoster Virus (VZV or HSV3)
– Causes of chicken pox (primary infection) and shingles
(reactivation)
• Dermatologic findings
– Primary
• Pruiritic erythematus macules and papules-> vesicles with clear
fluid surrounded by narrow red halos (dew drops on a rose
petal)
• Lesions in all stages of development
Varicella Infection
Varicella Infection
• Dermatologic findings
– Zoster
• Follows dermatome distribution
Varicella Infection
• Zoster
• Prodrome in 90%
• Disseminated lesions (> 20 vesicles outside of the area of
primary or adjacent dermatomes) and/or visceral involvement
seen in approximately 10% of immunocompromised patients
V1 Distribution
Management
• Treatment of underlying infections
– Antibiotics, broad spectrum until organism
identified
– Antiviral
• Supportive care with fluid and electrolyte
management
Life Threatening Drug Eruptions
Life Threatening Drug Eruptions
• Risk factors:
– HIV or immunosuppressed patients
– Elderly (polypharmacy)
– Genetic predisposition
• Management
– Stop the medication
– Supportive care
Stevens-Johnson Syndrome
(SJS)/Toxic Epidermal
Necrolysis (TEN)
• Pathophysiology:
– Drug induced mucocutaneous reaction
– Culprit medications: Sulfonamides, anticonvulsants,
allopurinol, NSAIDs. Usually given 1-3 weeks before
onset
– Genetic susceptibility
• SJS and TEN are continuum
– SJS: BSA < 10%
– SJS/TEN overlap: BSA 10-30%
– TEN: BSA > 30%
SJS/TEN
• +/- Clinical presentation
– Prodrome: fever, chills, malaise
– Stinging eyes, difficulty swallowing and urinating
• Dermatologic findings
–
–
–
–
Skin tenderness
Dusky erythema
Epidermal detachment and desquamation
Mucosal involvement
SJS/TEN
SJS/TEN
SJS/TEN
• Management
– Burn unit, ICU
– Ophthalmology, urology
– IVIG
– Systemic steroid is controversial
DRESS
• DRESS: Drug Reaction with Eosinophilia and
Systemic Symptoms
–
–
–
–
Anticonvulsant hypersensitivity syndrome
Drug-induced hypersensitivity syndrome
Hypersensitivity syndrome
Drug-induced delayed multi-organ hypersensitivity syndrome
• Pathophysiology:
– Idiosyncratic, problem with drug detoxification
– Drug exposure to onset of symptoms 2-6 wks
– Common culprit: aromatic anticonvulsant,
sulfonamides, minocycline, allopurinol, antiretroviral
drugs, NSAIDS, CCB
DRESS
• Dermatologic findings
– Maculopapular (morbilliform) and urticarial eruption most
common
– Vesicles, bullae, pustules, purpura, targetoid lesions, erythroderma
– Facial edema (mistaken for angioedema)
DRESS
• Clinical presentation
– Fever, eosinophilia, lymphadenopathy,
– Hepatic damage (can be fulminant),
endocrinopathy, myocarditis
• Management
– Systemic corticosteroid with slow taper
Others
Angioedema
• Pathophysiology
– Increased intravascular permeability
• Dermatologic findings
– Well circumscribed acute cutaneous edema due to
increased intravascular permeability
– Face, lips, extremities, genitalia
– Painful, usually not pruritic
• Clinical presentation
– Abdominal pain
– Respiratory distress
Angioedema
• Etiology:
– Often idiopathic
– Medications
• angiotensin-converting- enzyme inhibitor in 10-25% of cases
• Penicillin
• NSAID
– Allergens (foods, radiographic contrast media)
– Physical agents (cold, vibration, etc)
– C1 esterase inhibitor deficiency: hereditary vs associated with
autoimmune disorder or malignancy
Angioedema
• Management
–
–
–
–
–
–
Airway management
Antihistamines
Cool compresses
Avoid triggers
For pts with C1 esterase inhibitor deficiency:
Acute management vs short term vs long term prophylaxis:
androgens (danazol and stanozolol), C1 esterase inhibitor
concentrate, antifibrinolytics, icatibant (selective antagoist of
bradykinin B2 receptor)
Erythroderma
• Dermatologic findings
– Generalized erythema involving 90% of BSA
– Pruritus
• Clinical presentation
– Fever, malaise
– Excessive vasodilatation-> protein and fluid loss
• Hypotension, electrolyte imbalance, congestive heart failure
• Etiology:
– 50% due to preexisting dermatoses
• Seborrheic dermatitis, contact dermatitis, lymphoma (CTCL), leukemia, atopic
dermatitis, psoriasis, pityriasis rubra pilaris, idiopathic, drugs (esp in HIV pts)
– Search for clues on physical examination
Erythroderma
Erythroderma
• Management
– Supportive care with fluid and electrolyte
– Need to search for underlying causes-> treatment of
underlying dermatoses (topical corticosteroids,
emollients)
– Abx of signs of infection
– Mortality is 18%
Question 1:
This patient presents with few days history of
malaise and decrease oral intake. What is the most
appropriate therapy?
A)
B)
C)
D)
E)
Topical antibiotics
Oral antibiotics
IV antiviral
Topical antiviral
Topical steroids
Question 2:
This patient was given sulfonamides two weeks ago
for an UTI. She now presents to the ED with painful
skin, which one of the following is the most
important first step?
A)
B)
C)
D)
E)
Start IVIG
NSAID for pain control
Start high dose systemic steroids
Stop the sulfonamides
Call dermatology
Question 3:
The patient in Question 2 is now stabilized and in the
Burn unit. What organ system(s) can potentially be
involved in the disease process?
A) Eyes
B) Aerodiguestive track
C) Urinary tract
D) All of the above
E) None of the above
Question 1:
This patient presents with few days history of
malaise and decrease oral intake. What is the most
appropriate therapy?
A)
B)
C)
D)
E)
Topical antibiotics
Oral antibiotics
IV antiviral
Topical antiviral
Topical steroids
Question 2:
This patient was given sulfonamides two weeks ago
for an UTI. She now presents to the ED with painful
skin, which one of the following is the most
important first step?
A)
B)
C)
D)
E)
Start IVIG
NSAID for pain control
Start high dose systemic steroids
Stop the sulfonamides
Call dermatology
Question 3:
The patient in Question 2 is now stabilized and in the
Burn unit. What organ system(s) can potentially be
involved in the disease process?
A) Eyes
B) Aerodiguestive track
C) Urinary tract
D) All of the above
E) None of the above
Selected Future Reading
1.
2.
3.
4.
Usatine RP and Sandy N. Dermatologic Emergencies.
Am Fam Physician. 2010; 82: (7): 773-780
Kress DW. Pediatric dermatology emergencies. Current
Opinion in Pediatrics. 2011; 23:403-406.
Freiman A, Borsuk D and Sasseville D. Dermatologic
emergencies. CMAJ. 2005; 173 (11): 1317-1319.
OR you can rotate with us !!
References (including images)
1) Dermatology
2) Fitzpatrick’s Dermatology
3) Fitzpatrick’s color atlas and synopsis of clinical dermatology
4) DermNet.NZ
5) eMedicine
THANK YOU FOR YOUR
ATTENTION !
[email protected]