Dermatologic Emergencies

Joshua Radke, MDUC Davis Emergency Medicine

None

Disclosures

Neonatal Rashes Vasculitides Vesicular Lesions Infectious Lesions Immune-mediated Lesions

Outline

Erythema toxicum neonatorum Cutis marmorata Seborrheic dermatitis

Neonatal Rashes

Benign eruption

First 5 days of life

Crops of papules/pustuleson erythematousbase

Erythema Toxicum Neonatorum

Etiology unclear

Treatment:◦ Reassurance

Usually resolves in 2-7 days

Erythema Toxicum Neonatorum

First 2-4 weeks of life

Secondary to cold exposure

Reticulated mottled appearance

Cutis Marmorata

Cutis Marmorata

Cutis marmorataMottling

Erythematous, scaling plaques

Consider with involvement of ears and eyebrows

Usually mild, but can have significant inflammatory component

Seborrheic Dermatitis

Treatment:

◦ Removal of scale

◦ Medicated shampoos

◦ Topical steroids

Seborrheic Dermatitis

Henoch-Schonlein Purpura Kawasaki’s Disease

Vasculitides

Most common vasculitis in 3-15 yo

IgA deposition in small vessels

Diagnosis generally clinical

Henoch-Schonlein Purpura (HSP)

Classic Tetrad◦ Palpable Purpura◦ Abdominal pain◦ Renal disease◦ Arthritis/arthralgias

Renal disease typically transient

HSP

Supportive

NSAIDs for pain

Steroids for severe disease

HSP - Treatment

Kawasaki’s Disease Usually <5 yo

Unknown etiology

Vasculitis of small and medium vessels

Self-limited

CRASH and burn◦ C - Conjunctivitis◦ R - Rash◦ A – Adenopathy, cervical◦ S – Strawberry tongue◦ H – Hand/foot changes or edema

Need 4/5 plus fever > 38.5 C for 5 days

Atypical/incomplete Kawasaki’s◦ ESR/CRP if fewer than 4 criteria

Kawasaki’s - Diagnosis

IVIG◦ 2 mg/kg over 8-12 hours

High Dose Aspirin◦ 80-100 mg/kg/day

divided q 6hr◦ Treat until fever resolves◦ Then low dose until

normalization of inflammatory markers

Kawasaki’s - Treatment

Pemphigous vulgaris Bullous pemphigoid

Vesicular Lesions

Most common in 40-60 yo

Small, flaccid bullae

Form superficial erosions and crusted ulcerations

Oral lesions may be present months before cutaneous lesions

Pemphigous Vulgaris

Unknown cause

Possibly autoimmune

Drugs◦ Penicillamine and captopril

Pemphigous Vulgaris

Local wound care

Pain management

Steroids◦ PO prednisone◦ Immunosuppresants (dermatology)

Mortality 10-15%◦ Secondary infection, dehydration, thromboembolic

disease, side effects of high-dose steroids

PV - Treatment

Chronic autoimmune condition

Blisters occur deeper than pemphigous

Better prognosis than pemphigous

Treat with topical or oral steroids, methotrexate

Bullous Pemphigoid

Staphylococcal scalded skin syndrome Toxic shock syndrome

Infectious Lesions

Children ≤ 6 yo

Exotoxin-producing Staphylococci

Usually begins with erythema and crusting around mouth

Staphylococcal Scalded Skin Syndrome (SSSS)

Quickly spreads down body

Followed by bulla formation and desquamation

SSSS

Clinical resolution in 3-7 days

Most patients will recover without antibiotic coverage

IV nafcillin or PO dicloxacillin/cloxacillin

SSSS - Management

Diffuse desquamating erythroderma

Exotoxin mediated

Group A beta-hemolytic Strep as well as Staphylococcal species

Toxic Shock Syndrome

Fever of at least 38.9 C

SBP < 90 mm Hg

Skin rash

Involvement of at least 3 organ systmes

TSS - Diagnosis

Elevated WBC Anemia Thrombocytopenia Elevated coags Elevated transaminases Elevated BUN, Creatinine Elevated creatinine kinase

TSS - Labs

IV fluids

Pressors

Ventilator support

Antibiotics◦ Clindamycin◦ Nafcillin or Vancomycin for deep infections

TSS - Treatment

Contact Dermatitis Exfoliative dermatitis Erythema multiforme Stevens-Johnson Syndrome Toxic Epidermal Necrolysis

Immune-mediated Lesions

Inflammatory reaction of the skin

Delayed hypersensitivity reaction◦ Lymphocyte mediated

Brief contact with potent caustic or from repeated or prolonged contact with milder irritant

Contact Dermatitis

Contact Dermatitis

•Rhus genus•Rubber compounds•Nickel•Paraphenyldenediamine•Ethylenediamine

Avoidance of irritant/allergen

Treat secondary bacterial infections

Antihistamines◦ Diphenhydramine or hydroxyzine

Systemic steroids

Contact Dermatitis - Management

Erythema and scaling >90% of skin surface

Cause by drugs, chemical agents, underlying systemic disease (malignancy)

Exfoliative Dermatitis

Treatment:

Correct hypothermia and hypovolemia

Systemic corticosteroids

Exfoliative Dermatitis

Acute, usually self-limited

Distribution symmetrical◦ Palms and Soles◦ Backs of hands and

feet◦ Extensor surfaces

Target lesion is the hallmark

Erythema Multiforme

Drugs HSV infection Viral infections

◦ Hepatitis, influenza A Fungal diseases

◦ Dermatophytosis, histoplasmosis, coccidioidomycosis Bacterial infections

◦ Streptococcus, tuberculosis Collagen vascular disorders

◦ Rheumatoid arthritis, lupus, dermatomyositis Pregnancy Malignancy

Erythema Multiforme - Causes

Severe form of erythema multiforme

Bullae and mucous membrane involvement

Multisystem involvement

Death from infection and dehydration

Stevens-Johnson Syndrome

Search for underlying cause

Mild cases resolved in 2-3 weeks

Severe cases last up to 6 weeks

IV hydration, local skin care

Analgesia and systemic corticosteroids

EM/SJS - Treatment

Separation of large sheets of epidermis

from underlying dermis

Begins with viral prodrome

Macular rash develops◦ +/- target lesions◦ + mucous membrane

involvement

Toxic Epidermal Necrolysis

Macular exanthem starts centrally

Dermal-epidermal dissociation◦ + Nikolsky sign

Denudation with shear stress◦ Skin commonly painful

Toxic Epidermal Necrolysis

Drugs◦ Sulfa, penicillin, aspirin, barbiturates, phenytoin,

NSAIDS, carbamazepine, allopurinol

Vaccination◦ Polio, measles, smallpox, diphtheria, tetanus

Lymphoma

TEN - causes

15-20% mortality

Involvement of conjunctivae and cornea may lead to permanent scarring and blindness

TEN - Prognosis

Discontinue offending agent

Fluid replacement

Infection control

Steroids◦ Controversial

Plasmapheresis◦ Experimental

TEN - Treatment

Blok, Barbara K., Dickson S. Cheung, and Timothy Fortescue. Platts-Mills. "Chapter 17: Dermatology." First Aid for the Emergency Medicine Boards. New York: McGraw-Hill Medical, 2011.

Maconochie, Ian. “Best Practice: Kawasaki Disease.” Arch Dis Child Educ Pract Ed2004;89 Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K.

Aaron. "Chapter 118: Dermatologic Presentations." Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.

References

Questions?