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DERMATOLOGY
DESQUAMATION
OF THE SKIN
ERYTHEMA MULTIFORME
Iris and target-like patterns
with concentric macules and
papules on the palm
Multiple, confluent target-like papules
and vesicles on the central facies. Bullae
on the lips and the buccal mucosa.
ERYTHEMA MULTIFORME
ERYTHEMA MULTIFORME
MAJOR
•Erythematous iris and targetlike papules, plaques, bullae,
and erosions on the trunk, arms,
neck, and face.
•Mucosal involvement is
manifested by erosive lip
lesions and conjunctivitis.
ERYTHEMA MULTIFORME
MAJOR
Child with
erythema
multiforme,
following
smallpox
vaccination
STEVENS-JOHNSON
SYNDROME
Generalized eruption of
lesions that initially
had a target-like
appearance but then
became confluent,
brightly erythematous,
and bullous. The
patient had extensive
mucous membrane
involvement and
tracheobronchitis.
STEVENS-JOHNSON
SYNDROME
STEVENS-JOHNSON
SYNDROME
STEVENS-JOHNSON
SYNDROME
TOXIC EPIDERMAL
NECROLYSIS
Generalized, macular
eruption with some
target-like lesions
which rapidly
developed epidermal
necrosis, positive
Nikolsky's sign,
bulla formation, and
denuded erosive areas.
This eruption was due
to sulfonamide drugs.
TOXIC EPIDERMAL
NECROLYSIS
STAPHYLOCOCCAL
SCALDED-SKIN SYNDROME
In this infant, painful,
tender, diffuse erythema
was followed by
generalized epidermal
desquamation.
Staph. aureus had
colonized the nares with
perioral impetigo, the site
of exotoxin production.
STAPHYLOCOCCAL
SCALDED-SKIN SYNDROME
TOXIC SHOCK SYNDROME
DRUG REACTIONS
Cutaneous necrosis:
warfarin
Bilateral areas of
cutaneous infarction
with purple-to-black
coloration of the
breast surrounded by
area of erythema,
occurred on 5th day of
warfarin therapy
DRUG REACTIONS
Ampicillin
Symmetrically
arranged, brightly
erythematous
macules and papules,
discrete in some areas
and confluent in
others on the back
and extremities.
DRUG REACTIONS
Penicillin
Large, urticarial
wheals on face, neck,
& trunk with
angioedema in
periorbital region
DRUG REACTIONS
Amiodarone
Drug-induced pigmentation:
Striking slate-gray pigmentation in
facial distribution.
Blue color (ceruloderma) is due to
deposition of melanin contained in
macrophages and endothelial cells
in the dermis.
Pigmentation is reversible, but it
may take > 1 year!
In this patient it took 33 months for
the ceruloderma to disappear.
CASE STUDY
A 14-year-old boy presented to the ER
complaining of 4 days of increasing dysphagia,
dysuria, photophobia, and a macular rash extending
from trunk toward the extremities – some lesions are
forming bullae.
He has been using tetracycline for 2 weeks for
acne. Vital signs are normal, except for a temperature
of 103.1oF. He appears ill and had copious amounts of
ocular drainage and small vesicles on the nasal and
oral mucosa. Vesicles are also present on the penis
and scrotum.
CASE STUDY
 Labs revealed slight leukocytosis of 11.7
 Blood cultures and herpes tests were negative
Most likely diagnosis:
Steven-Johnson syndrome
Presumptive cause: Tetracycline
Treatment: Stop the drug. IV steroids.
CASE STUDY
The oral lesions became so painful, the patient
could not swallow his own saliva. TPN started. The
patient was given a patient-controlled anesthesia
pump for self-administration of morphine.
As the vesicles spread, they coalesced into
larger bullae and sloughed off. Because of the need
for increasing wound care, the patient was
transferred to the ICU.
Ophthalmologic and urology consultation was
obtained to address symptoms.
CASE STUDY
CASE STUDY
The area of denuded skin increased, and this
development required even more labor-intensive
treatment – patient was transferred to the county
burn unit for wound management.
His condition improved during the next two
weeks, and he eventually recovered with minimal
scarring. Follow-up continued on an outpatient basis
in the Eye, Skin and Urology clinics.