Dermatology Pearls for Inpatient Medicine · • Patient admitted to hospital for 4 plus weeks. •...
Transcript of Dermatology Pearls for Inpatient Medicine · • Patient admitted to hospital for 4 plus weeks. •...
Dermatology Pearls for Inpatient Medicine
Dr Peter J Green MD FRCPC Professor, Division of Dermatology
Dalhousie University
Objectives
1. Review spectrum of cutaneous manifestations seen with inpatient population
2. Differentiate urgent and emergent presentations
3. Review therapeutic management of cutaneous diseases
Before we go on….
• If you say maculopapular…….
• Dermatologist thinks two things:
• You mean a viral or drug eruption
• You frontin'
The drug rash
The set up
• Patient admitted to hospital for 4 plus weeks.
• Develops red, itchy “rash” all over
• “No new soaps, ?laundry detergent on sheets”
• “ No new meds” ( better be sure……)
Key points: drug eruption• Common , delayed hypersensitivity
• Symmetric, blanching erythema that progresses over days, sparing mucous membranes
• Common triggers in hospital will be antibiotics , cardiac meds, seizure meds
• Will not be : warfarin, tylenol, constipation meds, sleeping pills, opiates, iron
• Danger signs: mucous membranes, painful, sick patient, blistering AND/OR specific LABS
Key points• Skin findings: new widespread, symmetric
eruption with recent drug exposure
• Always go back at least 3 weeks to look for new med exposure
• Make a time line to clarify drugs vs skin findings
Don’t….
X. Start benadryl just because someone has a drug eruption
X. Assume new skin findings in patient who started meds is a drug eruption
X. Re-challenge patients to meds they report as true allergy
Do….✓ Stop the suspected drug when possible
✓ Educate the patient about duration ( it gets more extensive before it gets better)
✓ Ask about previous exposures to same med
✓ Educate about re-exposure
✓ Know signs this is a serious drug eruption
Serious Drug Eruptions
• SJS/TEN
• Drug Hypersensitivity syndrome
• Acute generalized exanthematous pustulosis
SJS/TEN▪ SJS and TEN probably a spectrum of severe
blistering disease from drug exposure ▪ SJS/TEN - Widespread blisters predominant
on the trunk and face, with underlying erythema and one or more mucous membrane erosions
▪ SJS/TEN overlap BUT may be separated based on • 1. Clinical features/blistering pattern eg target vs
sheet like • 2. Percent of skin that is detached ie 10% vs 30%
When to suspect SJS/TEN▪ Patient looks and feels sick
▪ Widespread rash with dusky areas plus fever
▪ Skin is painful rather than pruritic
▪ Separation of skin/blistering
▪ Mucous membrane involvement
▪ Recent DANGER drug exposure
“Danger Drugs”▪ Allopurinol
▪ Anticonvulsants• Phenytoin, lamotrigine, carbamezapine,
phenobarbital
▪ Sulfa
▪ NSAIDs ( Oxicams)
▪ Antiretrovirals
Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University
Admission – After Clinical Diagnosis of SJS/TEN ♦ Admit to ICU or IMCU (under medicine)
♦ Discontinue offending drug ♦ Monitor respiratory status for possible airway
intervention ♦ Establish IV access (through non-lesional skin if
possible) and begin fluid resuscitation with crystalloids (burn protocol)
• Goals – MAP > 65mmHg, CVP 8-12mmHg, urine output 0.5-1ml/kg/h
♦ Skin biopsy to confirm diagnosis (lesional skin) ♦ Reverse isolation in a heated environment with
strict contact precautions ♦ Monitor CBC, electrolytes and extended
electrolytes, liver function, creatinine, serum albumin, CRP/ESR, coagulation factors (transfuse as needed)
♦ Optimize pain management ♦ Calculate SCORTEN
Medical Therapy First Line (order both therapies together) ♦ Cyclosporine 3 mg/kg/day PO/NG divided twice daily for 7-14 days
(decrease to 1mg/kg/day divided BID if IV dosing) ☐ Monitor serum creatinine and blood pressure. Do baseline
creatinine and repeat before the end of treatment. ♦ And Etanercept 50mg subcut x 1
Second Line ♦ IVIG 1-2g/kg/day for 3 days (For NS dosing: http://novascotia.ca/dhw/
NSPBCP/IVIG-calculator.asp)
Additional Therapy ♦ Corticosteroids 1mg/kg/day x 4 weeks, tapered over 3-6 months
Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University
Wound Care ♦ Burn care dressings by RN trained for burn care (if possible)
♦ Careful patient handling to reduce shear forces on skin ♦ Chlorhexidine/saline (1:5000 dilution) compresses x 20
mins to skin daily ♦ Non-adherent dressings (petrolatum coated such as
Jelonet) to denuded skin ♦ Avoid use of adhesive tapes ♦ Hydrous emollient application PRN once re-
epitheliaztion occurs ♦ Mucosal membrane care
♦ Chlorhexidine mouthwash QID ♦ Topical anesthetic or spray for buccal pain ♦ Petrolatum regularly to lips ♦ Foley catheter PRN
Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University
Consultations to Consider ♦ Ophthalmology
o For consideration of amniotic membrane transplantation in those with moderate to severe ocular involvement and topical therapies such as lubricants
♦ Gynecology/Urology o If significant mucosal membrane
involvement
Other Supportive Measures ♦ DVT prophylaxis ♦ Consider pan-culturing and broad spectrum
antibiotics if indicated ♦ Nutrition supplementation through NG tube if
necessary (hypercaloric, high protein diet) ♦ Physical therapy and mobilization when able
Protocol for the Management of Drug Induced SJS/TEN in Adults Authors: Dr. A. Sutherland and Dr. L. Finlayson Division of Clinical Dermatology and Cutaneous Science Dalhousie University
Drug Hypersensitivity Syndrome
• When to suspect
• Looks like a widespread drug eruption with erythema WITH FACIAL EDEMA
• Fever, lymphadenopathy , unwell patient
• Delayed onset after DANGER drug exposure ( 2-8 weeks)
• Atypical lymphocytosis, marked eosinophilia and/or other visceral involvement ( LIVER, KIDNEY, LUNG, HEART, THYROIDITIS)
DHS : Danger Drugs• Anticonvulsants
• Minocycline
• Allopurinoal
• Azothioprine
• Dapsone
• Sulpha
Drug Hypersensitivity Syndrome
• STOP offending drug
• Supportive therapies
• Investigate/monitor visceral involvement
• Consider prednisone 1mg/kg
• Lung/heart …. renal/liver less responsive
A case for you: Drug eruption or not…
The set up• 64 year old with DM admitted to hospital with
toe pain and suspected left limb cellulitis,
• Xray of toe shows non specific changes, no osteomyelitis
• IV antibiotics ( vanco )started with improvement of cellulitis
• 5 days after admission, nurses ask about cream to use for worsening and painful yeast infection
What is the hallmark clinical finding ?
Pustules
Acute Generalized Exanthematous Pustulosis
• Rapid appearance of fever, minute sterile pustules after antibiotic exposure (B-lactam , others)
• Often starts in intertriginous folds i.e. armpits, groin with more rapid spread
• Lasts for 1-2 weeks with progression towards desquamation ( peeling)
• Identify and D/C offending agent
AGEP: DIFF DX
• SJS/TEN
• DRESS
• Pustular psoriasis
• Staph scalded skin syndrome
And speaking of groins….
What about…
Inverse Psoriasis
One offs…test yourself
Case 1
New onset skin findings in someone admitted with
asthma flare..
I would describe as…
A. Oslers nodes and Janeway lesions
B. Target lesions
C. Hemorrhagic vesicles and bullae
D. Palpable purpura
I would diagnose…
A. Endocarditis
B. Erythema multiforme from mycoplasma pneumonia
C. Autoimmune bullous disease
D. Vasculitis
I would describe as…
A. Oslers nodes and Janeway lesions
B. Target lesions
C. Hemorrhagic vesicles and bullae
D. Palpable purpura
I would describe as…
A. Oslers nodes and Janeway lesions
B. Target lesions
C. Hemorrhagic vesicles and bullae
D. Palpable purpura
I would diagnose…
A. Endocarditis
B. Erythema multiforme from mycoplasma pneumonia
C. Autoimmune bullous disease
D. Vasculitis
I would diagnose…
A. Endocarditis
B. Erythema multiforme from mycoplasma pneumonia
C. Autoimmune bullous disease
D. Vasculitis
Vasculitis and skin• Small vessel
• Hypersensitivity ( drug, infection, CTD, meds)
• ANCA positive vasculitis
• Churg-Strauss, Granulomatous with polyangiitis, MPA
• Medium vessel
• Polyarteritis nodosa
Vasculitis• Clinical finding of palpable purpura confirms
vasculitis
• Laboratory investigations
• I start with : CBC, ANA, ANCA, cryoglobulins, hep B, hep C, BUN, Cr, urinalysis, IgG’s, C3, C4, ESR
Case 2
Chest rash 6 weeks duration in patient with
previous breast Ca
I would order…
A. Oral antiviral
B. Topical steroid
C. Cephalexin
D. Skin punch biopsy
Metastatic inflammatory breast carcinoma
Take home point: consider metastatic disease of breast with persistent, localized skin findings
24 year old with Downs syndrome admitted with pneumonia- care
giver mentions one year history of itch and rash
I would describe as…
A. Maculopapular
B. Dry and scaly
C. Generalized
D. Crusted
I would describe as…
A. Maculopapular
B. Dry and scaly
C. Generalized
D. Crusted
What is the hallmark clinical finding ?
Crusting
What does this finding confirm?
Crusted ( Norweigan scabies)
Crusted scabies• Severe infestation with 100’s of
mites
• Highly contagious
• Usual scabies treatment with Topical 5% permethrin is insufficient
• 6% salicylic acid and multiple treatments with 5% permethrin
• Oral Ivermectin is best but hard to get
• CONTACTS AND CONTAINMENT!!
Case 3
56 year old female admitted for 6 days for investigations of TIA
New skin changes, unresponsive to
Cephalexin over 48 hours
I would ask about…
A. Itch vs pain
B. Culture and sensitivities for fluid swab
C. Raynauds, photosensitivity , pleuritis/pericarditis, arthritis
D. Recent tick bite
I would ask about…
A. Itch vs pain
B. Culture and sensitivities for fluid swab
C. Raynauds, photosensitivity , pleuritis/pericarditis, arthritis
D. Recent tick bite
I would…
A. Switch to IV Cefazolin
B. Switch to Doxycycline 100mg BID 21 days
C. Treat with oral steroids
D. D/C antibiotics, supportive therapy
I would…
A. Switch to IV Cefazolin
B. Switch to Doxycycline 100mg BID 21 days
C. Treat with oral steroids
D. D/C antibiotics, supportive therapy
Allergic Contact Dermatitis
Allergic contact dermatitis• Numerous sources in topical preparations,
cosmetics, occupation etc
• eg Tea tree oil, vitamin E, Polysporin, adhesive, lidocaine, formaldehydes etc
• Range from eczematous to vesiculobullous
• Severe presentations resemble infections process
• Consider with well localized, ITCHY eruptions in a well patient who has failed to respond to antibiotics
Therapeutic hotline
Topical steroid• Potency determined by vasoconstriction assay
( NOT percentage of molecule)
• Absorption greatest on thinnest skin, least on thickest : eyelid/genitals>palms and soles
• Ointments ( vaseline) more potent than creams ( white)
• Dry and scaly vs oozing, exudative
What to use• PEDS:
• 1 % hydrocortisone cream or ointment
• ADULTS: FACE or FOLDS
• 1 % hydrocortisone cream or ointment
• ADULTS: BODY, EXTREMITIES
• Betamethasone valerate 0.1% OR triamcinolone acetonide 0.1% cream or ointment
Potency of steroids• Mild potency
• 1%HC
• Medium ( 100X)
• BMV/TRIAMCINOLONE/MOMETASONE
• High
• BETAMETHASONE DIPROPRIONATE/FLUOCINOLIDE
• Ultrahigh ( 600X)
• CLOBETASOL
How much to apply?
• More than the pharmacist will tell them….
• Fingertip unit = 0.5 gms
• Two palm surfaces
Steroids: tips• Fear of atrophy
• 1% HC will likely never cause atrophy , unless used under occlusion for prolonged period
• Choose base for AREA being treated e.g. ointments for hands/feet, lotions for scalp
• AVOID ‘shotgun’ mixes of steroids/antibiotics/antifungals
• eg: kenacomb/viaderm
Other complications of steroids
Perioral dermatitis• Acneiform facial eruption, perioral with sparing of
vermilion border
• Most common in children and adult females
• In adults, daily topical moisturizers implicated
• Topical steroids used to treat will create dependance, tolerance and escalation
• Treat with topical metronidazole/oral tetracyclines if moderate to severe
others
Questions