Emergency Dermatology: What You Don’t Know Can Kill - PowerPoint Presentation

Slide1

Emergency Dermatology: What You Don’t Know Can Kill

Nicholas Satterfield MD

Emergency Medicine PGY2

Henry Ford Hospital

Slide2

Slide3

Define dermatologic termsDiscuss the approach to dermatologic complaintsDiscuss dermatologic diseases with high morbidity and mortality

Objectives

Slide4

Skin Anatomy

Slide5

Flat lesionsMacule (< 0.5 cm)Patch (> 0.5 cm)

Derm Terms

Slide6

Elevated LesionsPapule (Up to 0.5 cm)Plaque (Greater than 0.5 cm)Nodule ( Papule but deeper, involves dermis and sometimes subcutaneous tissue)

Derm Terms

Slide7

Fluid FilledVesicles (Up to 0.5 cm)Bullae (Greater than 0.5 cm)Pustules (Vesicle but with pus)

Derm Terms

Slide8

Blood derived (From leakage of capillaries)Petechiae (Less than 0.5 cm)Purpura (Greater than 0.5 cm)

Derm Terms

Slide9

Erosion (loss of epidermis)Excoriation (itching leading to loss of epidermis)

Derm Terms: Secondary Changes

Slide10

Ulceration (Loss of epidermis and dermis)

Derm Terms:Secondary Changes

Slide11

Crusting (Collection of dried serum and cellular debris)

Derm Terms: Secondary Changes

Slide12

Lichenification (Thickened epidermis)

Derm Terms: Secondary Changes

Slide13

Atrophy (Thinning of epidermis or dermis)

Derm Terms: Secondary Changes

Slide14

Scaling (Shedding excess dead epidermal cells by keratinization and shedding)

Derm Terms: Secondary Changes

Slide15

Which would you rather have?

Slide16

Approach

Slide17

Slide18

Slide19

Slide20

Slide21

Slide22

Early Meningococcemia, RMSF, TSS, EM, SLE, viral

exanthemLyme

Meningococcemia, RMSF, HSP, Vasculitis, SLE, ITP, TTP, rubella, EBV, Endocarditis

Secondary Syphillis, Anthrax

Necrotizing fasciitis, TSS, STSS, SSSS, Kawasaki, EM, hypersensitivity reactions, cellulitis, viral exanthem

EM, Stevens-Johnson, TEN, Pemphigus vulgaris, varicella zoster, HSV, necrotizing fasciitis (late)

Bacterial

folliculitis

, gonorrhea,

cellulitis

Slide23

Which would you rather have?

Slide24

Timing and progressionLocationChanges over timeTravelPMHOccupationMedications

History

Slide25

Fevers (Rocky mountain spotted fever, toxic shock syndrome, Stevens-Johnson syndrome, toxic epidermal necrolysis, Kawasaki Disease)Very Young (Meningococcemia, Kawasaki disease)Elderly (Meningococcemia, pemphigus vulgaris, meningococcemia, toxic epidermal necrolysis, Stevens-Johnson syndrome)Toxic Appearing (Necrotizing fascitis, meningococcemia, toxic epidermal necrolysis, Stevens-Johnson syndrome, toxic shock syndrome, rocky mountain spotted fever)Immunocompromised (Meningococcemia, herpes zoster, necrotizing fascitis)

Red Flags

Slide26

Diffuse Erythroderma (Staphyloccocal scalded skin syndrome, toxic shock syndrome, streptococcal toxic shock syndromePetechiae/Purpura (Meningococcemia, necrotizing fascitis, vasculitis, DOC, rocky mountain spotted fever)Mucosa/Oral Lesions (Erythema multiforme major, toxic epidermal necrolysis, Stevens-Johnson syndrome, pemphigus vulagaris)Severe pain or tenderness (Necrotizing fascitis)Recent new drug use (Erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson SyndromeArthralgias (Rocky mountain spotted fever, viral illness)

Red Flags Continued

Slide27

Putting it together

Slide28

Slide29

PathologyAcute inflammatory condition leading to maculopapular rashBelieved to be due to immune complex depositionHas multiple etiologiesInfectious (HSV or mycoplasm most common)Drugs (Penicillins, sulfonamides, dilantin, barbituates)

Erthema

Multiforme

Slide30

Prodrome of malaise, fever, arthralgiaDusky red papules with sudden appearance that as they enlarge the central area pecomes cyanotic and dustyTend to develop on palm, soles, extensor surfaces (knees and elbows)If due to drug reaction it tends to appearLesions may develop for 2-4 weeks then resolve in 1-2 weeksRarely can have a recurrent form or persistent form that is usually from HSV infection

Slide31

Major includes one area of mucosal involvementMost common is oral (up to 70%) erythema, erosions or bullaeCan also have ocular bullae, pseudomembranes and purulent discharge (10-20%) which can lead to keratitis conjunctival scarring and visual impairment

Minor vs Major

Slide32

If you suspect drug reaction stop the drugSupportive (NSAIDS, antihistamines)Kenalog (triamcinolone) 0.1% cream for non face and genitalsHydrocortisone 1% cream for face and genitalsLidex (fluocinonide) 0.05% gel for oral lesionsMagic mouth wash (2% viscous lidocaine, benadryl and maalox)Steroids?Rosens suggests to use if on trunk, EM Major and immunosuppressed If so start at 40-60 mg/daily with 2-3 week taperDermatology referralOptho referral: topical steroids and antibiotics

Treatment

Slide33

SJS

TEN

Slide34

PathologyAltered drug metabolism and immune complex mediated reactionEtiologyMedicationsInfection (Mycoplasma pneumonia, CMV)

Stevens-Johnson Syndrome and Toxic Epidermal

Necrolysis

Slide35

Slide36

Slide37

Risk Factors

HIV

Genetics

Malignancy?

SLE

Presentation

Prodrome

of

myalgias

, fevers, cough, sore throat

Lesions begin around face and trunk with some extremity involvement

Erythematous

macules

and papules that start to have skin sloughing

Nikolsky

sign

Stomatitis

(erosive)

Conjunctivitis

Esophagitis

Respiratory Failure

Slide38

Slide39

Primarily due to electrolyte abnormalities and infectionVision lossVaginal stenosis Organ failure secondary to septic shockSCORTEN

Morbidity and Mortality

180 mg/dl

2

50 mg/dl

Slide40

IDENTIFICATIONPROPER DISPOSITION: SCORTEN greater or equal to 2 should go to burn unitStop the suspected drugSteroidsNo consensusIVIG, plasmapheresis, Anti-TNF, cyclosporineSmall studies, not recommended

Management

Slide41

EM MinorEM MajorSJSTENEpidermal detachmentNoNoYesYesMucosal InvolvementNoYesYesYesMost Common etiologyInfectiousInfectiousDrugDrugDegree of epidermal detachment %BSA00<10%>30%

Comparing Drug Reactions

Slide42

IgG against keratinocytesPresentationElderly with oral erosions, vesicles and bullae for weeks to monthsThen get skin vesicles and bullaeSlow progressive disease

Pemphigus Vulgaris

Slide43

Treat with steroids (1 mg/kg/day)Admit if signs of infection or toxicityOutpatient Dermatology follow up

Management

Slide44

Slide45

Neisseria meningitidis infection that includes bacteremia with CNSRisk factorsCrowded environmentsComplement deficienciesAsplenic patientsProtein C and S deficienciesUsually occur in ages 6 months to 1 year and young adults (usually less than 20)

Meningococcemia

Slide46

Often first appears to be viral URIGet petechiae starting at wrist and ankles that spread and become papulesMeningitis symptomsQuickly become septic: multiorgan failure and DICCan get hemorrhagic destruction of adrenal glands (Waterhouse-Friderichsen syndrome)

Slide47

Get blood cultures and punch biopsy (significantly more sensitive than CSF gram stain)

Treat with

ceftriaxone

2 g q12

If still concerned for Rocky mountain spotted fever add

doxycycline

For severe penicillin allergies use IV

chloramphenicol

4g per day

Close contacts (day care personnel, people sharing housing, ED who are in contact with oral secretions or someone who has been in contact for 4 hours over the past week get prophylaxis

Cipro

500 mg once

Rifampin

600 mg BID for two days

Single dose IM

ceftriaxone

250 mg (pregnancy)

Slide48

Immune mediated destruction of plateletsUsually idiopathicSecondary causesHIV, HCVSLECLLPetechia and purpura usually in dependent areasSignificant bleed in approximately 10%: Usually GI rarely ICHCBC and coags show isolated thrombocytopenia

Immune Thrombocytopenic Purpura

Slide49

ICH or GI bleed and plt<30,000PlateletsIVIG (1g/kg)Steroids(methylprednisone 1 g/d for 3 days)Bleeding or new diagnosis and plt <30,000Steroids (methylprednisone 1g/d for 3 days)IVIG (1g/kg) only if bleedingPlt 20,000 to 30,000 with no bleeding: observationPediatricsOnly treat if significant bleedingMost cases self resolve in less than 3 months

Slide50

Microangiopathic hemolytic anemia

Thrombotic Thrombocytopenic Purpura

Slide51

Microangiopathic Hemolytic Anemia (SOB, fatigue, chest pain)Thrombocytopenia (bleeding)FeverRenal insufficiencyNeurologic finding (headache, confusion, dizziness, stroke, coma)

TTP Pentad

Slide52

AnemiaThrombocytopeniaEvidence of hemolyticSchistocytesElevated LDH and billirubinADAMTS13 assay

Labs

Slide53

AdmitPlasma exchangeNeeds to be started earlyIf high clinical suspicion get started before all labs are backGet hematology involved earlySteroids: 125 mg methylprednisone IV Q6-12

Management

Slide54

Slide55

Staph aureusLocal infection causing shock due to toxinsEnterotoxin and toxic shock syndrome toxinToxins are super antigens that directly activate T cells at MHC without the need for antigen presenting cellsGroup A StrepLocal infection post surgical or after traumaVery painful and tender area of infectionBacteremia leads to sepsis

Staphylococcal and

Streptoccocal

Toxic Shock Syndrome

Slide56

Slide57

Like any other infectionFind your sourceSource controlAntibiotics (clindamycin and vancomycin/zosyn/carbapenem)Fluid resuscitationIonotropic support if needed

Management

Slide58

Questions