dermatology pearls part i: spotlight on rashes · •protection from radiation: melanin provides...
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Dermatology Pearls Part I: Spotlight on Rashes
Janet Tcheung, MD, FAAD
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Objectives
• Provide a framework to describe cutaneous findings
• Recognize and diagnose common cutaneous conditions and diseases for inpatient/outpatient settings
• Provide first line treatments of common skin diseases
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Roadmap
• Skin structure and function
• Dermatologic Descriptors
• Rashes
– Drug (DRESS, AGEP, SJS, Morbilliform)
– Infection (Bacteria, HSV, VZV, Fungal)
– Infestations (Scabies, Bed bugs)
• Topical Steroid Primer
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Function of Skin
• Physical barrier: protects against physical, chemical, and microbial insults
• Immunologic barrier: senses and responds to pathogens
• Temperature regulation
• Protection from radiation: melanin provides shield against UV radiation
• Nerve sensation
Aad.org
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Skin Structure
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Epidermis
• Stratum corneum– Major physical barrier – Takes 4 weeks for cells to migrate from basal cell layer
to top of stratum corneum where they are shed
• Granulosum– Helps form “cement” that holds together stratum
corneum cells
• Spinosum• Basal Cell Layer
– “Stem cells” of the epidermis– Undifferentiated proliferating cells
Aad.org
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Epidermis
Aad.org
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Other Cellular Components
• Melanocytes
– Pigment producing cells
– Located in basal cell layer
• Langerhans Cells
– Tissue macrophage
– Serves as immunologic barrier of skin
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Dermatologic descriptors
• Primary Lesions
• Secondary Lesions
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PRIMARY LESIONS
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Primary Lesions: Flat
• Macule:– < 5mm
– Flat area / Nonpalpable
– Color altered
• Patch– > 5mm
– “Large macule”
– Color altered
Image: medicinenet.com
Dermatology Handbook, British
Academy of Dermatologists, 2014
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Primary Lesions: Raised
• Papule
– < 5mm
– Solid raised lesion
• Plaque
– > 5mm
– Palpable, elevated
Dermatology Handbook, British
Academy of Dermatologists, 2014
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Primary Lesions: Nodule
• Firm
• Thicker
• DeeperRapini, Dermatology, 2008
Foo, Aus Journ of Derm, 2014
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Primary Lesions: Fluid filled
• Vesicle
– < 5mm
– Raised, clear, fluid-filled
• Bulla
– > 5mm
– Raised, clear fluid-filled
Dermatology Handbook, British
Academy of Dermatologists, 2014
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Primary Lesions: Nonblanching
Purpura
– Extravasation of blood into tissue
– 4-10mm
Pethechiae-Bleeding from capillaries-Pinpoint red, brown, purple macules<4mm
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SECONDARY LESIONS
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Secondary Lesions: Excoriations
Excavations dug into skin by scratching
Dermatology Handbook, British
Academy of Dermatologists, 2014
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Secondary Lesions: Lichinification
Roughening of skin with accentuation of skin markings
Dermatology Handbook, British
Academy of Dermatologists, 2014
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Secondary Lesions: Scale
Flakes of stratum corneum
Dermnetz.org
Jain, Dermatology 2012
Dermatology Handbook, British
Academy of Dermatologists, 2014
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Secondary Lesions: Crust
• Rough surface c/w dried serum, blood, bacteria, and cellular debris
Aad.org
Dermatology Handbook, British Academy of Dermatologists, 2014
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Secondary Lesions: Ulcer
Loss of epidermis and dermis
Aad.org
Jain, Dermatology 2012
Dermatology Handbook, British Academy of Dermatologists, 2014
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APPROACH TO RASHES
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Rash Differential
• Drug (DRESS, AGEP, SJS, Morbilliform)
• Infection (viral, fungal, bacterial)
• Infestations (Scabies, Bed bugs)
• Inflammatory (Contact, Eczema)
• Cancer (CTCL)
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Helpful Questions to Ask
• Symptoms: itchy vs tender/painful• New drugs• Contacts with rash (Scabies, Bed bugs)• Where did it start before progressing
– Drug: trunk and spread centrifugally– Arthropod assault/bed bugs: exposed skin
• ROS: fever, joint pain, dysphagia, sore throat, cough, dysuria, stinging eyes– Drug rash– Infection (viral exanthem, HSV/VZV)
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DRUG RASH
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Epidemiology
• Incidence: 0.1% to 1%
• WHO: 2% of of all drug rashes ‘serious’
– Results in death
– Requires hospitalization
– Prolongs hospitalization
– Persistent disability / incapacity
– Life-threatening
Bolognia, Dermatology 2008
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Drug Rashes
Dangerous Benign
DRESS Morbilliform
AGEP
SJS / TEN
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Case
• 47 yo, otherwise healthy, male admitted for osteomyelitis
• Patient had traumatic injury of right femur leading to compound fracture s/p MVA
• Multiple surgeries complicated by infection
• + Staph aureus
• TMP-SMX x 22 days
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Pcds.org
TBSA: 80%
+LAD
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What is your next step in management?
A. Obtain a shave biopsy
B. Topical triamcinolone 0.1% cream
C. Obtain labs to further work-up (CBC, CMP)
D. Essential oils to help soothe the rash
E. Stop the offending medication
F. Both A and E
G. Both C and E
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DRESS
• Drug Reaction with Eosinophilia and Systemic Symptoms
• Severe drug-induced reaction
• Delayed onset: 2-6 weeks after initiation
• Mortality Rate: 10-20% (liver failure)
Cacoub, American Journal of Medicine 2011
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• Carbamazepine
• Phenobarbital
• Lamotrigine
• Allopurinol
• Sulfasalazine
• Nevirapine
Cacoub, American Journal of Medicine 2011
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DRESS: Diagnostic Criteria
• Rash, nonspecific
And 3 / 4 criteria
• Liver involvement(AST/ALT elevated 9-10x)
• Hypereosinophilia
• Lymphadenopathy
• Fever > 38
Walsh, Clin Exp in Derm, 2010
Kardaun, Br J Derm, 2007Shiohara, Allergol Int, 2006Moriceau, Case Reports in Clrit Care 2016
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DRESS: Treatment
• Discontinuation of causative drug
• Corticosteroids
Garcia-Doval, Archives of Dermatology 2000
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Acute Generalized ExanthematousPustulosis (AGEP)
• Pustular drug rash with high fever
• Rash:
– Pustules, numerous
– Distribution: face, skin foldsdissiminate in hours
– Symptoms: burning, pruritus
– 50% also with facial and hand edema, purpura, vesicles, bullae, EM-like lesions, mucous membrane involvement
Sidoroff J Cutan Pathol. 2001
Paradisi Clinical Thera. 2008
Roujeau Archives. 1991Guevara-Gutierrez IJD 2009
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Case
• 42 yo F with recent diagnosis of unclear autoimmune disease• Presented with rash that started 5-6 days prior to presentation• Areas involved:
– Neck folds– Chest– Abdomen– Upper arms– Scalp– Thighs
• Symptoms: itching and burning• 2 weeks prior to presentation: started hydroxychloroquine• ROS:
– Fever at rash onset but now resolved– Myalgia– Arthritis
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What is your diagnosis?
A. Follicultis
B. Erythema Multiforme
C. Stevens-Johnson Syndrome
D. Acute Generalized Exanthematous Pustulosis
E. Drug Reaction with Eosiniophilia and Systemic Symptoms
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AGEP• Acute Generalized Exanthematous Pustulosis• Pustular drug rash with high fever• Acute extensive formation of sterile pustules• Locations: folds or face• Systemic signs/symptoms:
– Fever– Burning or itching– Hand and facial edema – Lab abnormalities:
• Leukocytosis• Elevated neutrophil count• Elevated liver enzymes• Mild eosinophilia• Transient renal failure
• Typically resolves in <15 days
Sidoroff J Cutan Pathol. 2001
Paradisi Clinical Thera. 2008Roujeau Archives. 1991Guevara-Gutierrez IJD 2009
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Median time between initiation of drug and
AGEP:
Antibiotics: 1 day
Other: 11 days
Sidoroff Br J Derm 2007
Roujeau Archives 1991
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Choi Annal Dermatol 2010
Guevara-Gutierrez IJD 2009
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AGEPMost common drugs: antibiotics, calcium channel blockers, antimalarials
Gupta, Indian J Dermatol 2016
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Treatment
• Stop offending drug
• Corticosteroids
• Antipyretics
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Case
• 52 yo female admitted for CNS toxoplasmosis
• Dermatology consulted due to spreading rash
• 1 day duration
• Started on pyrimethamine and sulfadiazine x 3 days
• ROS: + sore throat, fatigue, myalgia
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Pcds.org
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Pcds.org
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What is your diagnosis?
A. SJS/TEN
B. Morbilliform Drug Rash
C. Psoriasiform Drug Rash
D. Sun burn
E. Eczema
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SJS / TEN
• Stevens-Johnson and Toxic Epidermal Necrolysis
• Rare, acute and life-threatening
• Involves mucosa and skin
• Extensive keratinocyte cell death leading to separation of dermal-epidermal junction
• Time course: 7-21 days
• May begin as benign appearing dermatosis and rapidly progress
Bolognia, Dermatology 2008
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SJS/TEN
• Mortality rate:
– TEN: 25-50% (16% in children)
– SJS: ~ 5% (0% in children)
• Most of casesdrugs
• Most common drugs:
– Antibiotics
– NSAIDs
– Anticonvulsants
Emedicine.medscape.comHsu, . J Am Acad Dermatol. 2017
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SJS/TEN: Symptoms
• Initial: fever, stinging eyes, dysphagia– May precede rash
• Mucosal involvment:– Erythema and erosions
– Buccal, ocular, genital mucosae
– Repiratory tract epithelium: 24% with TEN
– GI
Bolognia, Dermatology 2008
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SJS/TEN
• Tender rash appears on trunk then spread
• Morphology of skin rash– First lesions are erythematous, dusky red, or purpuric
macules that coalesce• +Nikolsky sign: detachment of epidermis from dermis when
exerting tangential lateral pressure
– Red macular lesions take on a characteristic gray hue
– Necrotic epidermis then detaches from dermis and fluid fills the space between epidermis and dermis giving rise to flaccid blisters
– “Wet cigarette” paper appearance of skinwhen pulled awaylarge areas of raw bleeding dermis ‘scalding’
Bolognia, Dermatology 2008
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SJS/TEN
• Tender rash appears on trunkthen spread
• Erythematous macules
• Dusky/gray
• Epidermal and dermal detachment
• Flaccid Blisters
• Sloughing of skin
• Raw “scalded” bleeding dermisBolognia, Dermatology 2008
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Sjssupport.orgEmedicine.medscape.org
Pcds.org
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Nikolsky Sign
• Detachment of epidermis from dermis when exerting tangential lateral pressure
http://www.pcds.org.uk/p/Quinn, JAMA Derm 2005
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TEN: Factors a/w Poor Outcome
• Increasing age
• Extent of epidermal detachment
• Number of medications
• Elevated: serum urea, creatinine, glucose
• Depression of Blood Count: neutropenia, lymphopenia, thrombocytopenia
Bolognia, Dermatology 2008Aad.org
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SJS/TEN: Complications
• Fluid and Electrolyte Imbalance
• Secondary infection (sepsis)
• Skin: dyspigmentation, scarring, genitalia w/adhesions, loss of nails without regrowth
• Eye: blindness, corneal scarring, symplepharon, synechiae, ectropian, entropian
• Lung: brochiolitis, bronchiectasis, obstructive d/o
• GI: oral pain, esophageal strictures
• Renal Insufficiency
• Urethral adhesions, erosions, strictures
Bolognia, Dermatology 2008
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SJS/TEN: Treatment
• Early identification and withdrawal of offending drug– Prompt withdrawal reduces risk of death by 30% per day
• Skin: Dermatology consult, daily wound care
• Eyes: Ophthalmology consult, ointments/drops
• GI: Nutrition support/NG tube, magic mouth wash, petroleum jelly for lips
• GU: Urine catheter to prevent urethral strictures
• Treatment controversial: corticosteroids (1-2mg/kg/day), IVIG, cyclosporine, thalidamide, plasmapheresis
Garcia-Doval, Arch Dermatol, 2000
Zimmerman n, JAMA Dermatolol 2017
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Magic Mouth Wash
• Compound of 3 different ingredients
• Ingredients may vary
– 1 part Viscous lidocaine 2%
– 1 part Maalox
– 1 part Diphenhydramine 12.5mg/5ml elixir
• Swish and spit / swallow 1-2 teaspoons q6h
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Time to Rash Onset after Drug Ingestion
Rash Time
DRESS 2-6 WEEKS
AGEP HOURS-2DAYS
SJS / TEN 7-21 DAYS
MORBILLIFORM 7-21 DAYS
Dress
7 days 14 days 21 days
Start Drug
SJS / TEN
Morbilliform
AGEP
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Take Home Points: serious drug rash
• Early dermatology consult
• Facial edemaAGEP
• Marked peripheral blood eosinophiliaDRESS
• Mucous membrane lesionsSJS/TEN
• Painful lesionsSJS/TEN
• Dusky lesionsSJS/TEN
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Take Home Points: serious drug rash
• Early dermatology consult• Facial edema
– AGEP
• Eosinophilia + organ involvement– DRESS
• Mucous membrane lesions– SJS/TEN
• Painful lesions– SJS/TEN
• Dusky lesions– SJS/TEN
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Drug Rashes
Dangerous Benign
DRESS Morbilliform
AGEP
SJS / TEN
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Morbilliform Drug Rashes
• Most common drug rash (>90%)
• Described as morbilliform / exanthematous: “maculopapular”
• Lesions begin as:
– Erythematous maculespapules
– Start on trunk extremities
– Symmetric distribution
• Symptoms: pruritus, low grade fever
Revuz and Valeyrie-Allanore, Dermatology, 2008
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Treatment
• Discontinue offending agent (if possible)
• ‘Treating through’
– Close monitoring
– Desensitization
• Topical cortisteroids
• Antihistamines
Revuz and Valeyrie-Allanore, Dermatology, 2008
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INFECTIONS AND INFESTATIONS
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MIRM
• Mycoplasma pneumoniae-induced Rash and Mucositis
• Other names:– Atypical Stevens-Johnson– Fuch’s syndrome– Mycoplasma pneumonaie-associated mucositis
• Proposed reclassification of these cases• 25% extrapulmonary complications• Mean age: 11.9 +/- 8.8years• Male predominance
Canavan, JAAD 2015
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Cutaneous Involvement
• Sparse 61 (47%)
• Absent 42 (34%)
• Moderate 24 (19%)
Canavan, JAAD 2015
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MIRM: Mucosal Involvement
• Ocular lesions
• Oral lesions, esophageal involvment
• Genital, anal
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MIRM : Rash
• Cutaneous lesions: pleomorphic
• Majority with full recovery (~80%)
• 8% of patients with recurrence
Canavan, JAAD 2015
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MIRM: Treatment
• Antibiotics
• Pain management
• Oral care
• Ophthalmology consult
• Hydration / nutrition support
• Corticosteroid
• IVIG
• Plasmaphoresis
Canavan, JAAD 2015
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Magic Mouth Wash
• Compound of 3 different ingredients
• Ingredients may vary
– 1 part Viscous lidocaine 2%
– 1 part Maalox
– 1 part Diphenhydramine 12.5mg/5ml elixir
• Swish and spit / swallow 1-2 teaspoons q6h
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Case
• 37 yo woman in the ER for rash on lips and extremities
• Reports itching on arms, tenderness to lips
• Has had difficulty eating due to lip involvement
• Rash preceded by cold sores
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Pcds.org
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Pcds.org
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Which virus is most commonly associated with this rash?
A. HSV
B. Coxsackie A16
C. EBV
D. CMV
E. Influenza
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Erythema Multiforme
• Acute, self limited, but potentially recurrent dz
• Rash: abrupt onset of papular “target” lesions, majority appearing within 24 hours
• Target lesions favor acrofacial sites
• Minor: little/no mucosal lesions, no systemic sx
• Major: severe mucosal involvement + systemic features
• Most common precipitating factor: HSV
• Does not progress to TEN
Yacoub, Clin Mol Allergy. 2016
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Erythema Multiforme Continued
• Mucosal Lesions
– Vesiculobullous and rapidly develop into painful erosions
– Buccal mucosa, lips, ocular, genital mucosae
• Systemic Symptoms (EM Major)
– Fever
– Fatigue
– Arthralgias with joint swelling
Yacoub, Clin Mol Allergy. 2016
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Treatment
• Supportive care– Petroleum jelly to erosions– Oral antihistamines to relieve burning/stinging of skin
• Severe EM– Systemic corticorsteroids 0.5-1mg/kg/day – Pulse methylprednisolone 1mg/kg/day x 3days
• HSV-associated EM, recurrent– Prophylaxis for 6+months– Oral acyclovir 10mg/kg/day– Valacyclovir 500-1000mg/day– Famciclovir 250mg BID
Yacoub, Clin Mol Allergy. 2016
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Varicella Zoster Virus
• HSV3
• Chickenpox (varicella)
• >90% of infections seen in <10 yo
• Transmitted via inhalation of infected air droplets (airborne isolation) or direct contact
• Rash: lesions in different stages of development – Erythematous maculesvesicles with rim of red “dew
drops on a rose petal”papules that rupturecrust
– Pruritic
Bolognia, Dermatology 2008
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Jain, Dermatology 2012Pcds.org/uk
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Diagnosis and Treatment
• Diagnosis: clinical exam, PCR, viral cx, direct fluorescent antibody
• Immunocompetent kids/adolescents: no txneeded, supportive care
– No aspirinReye’s Syndrome
• Immunocompetent/compromised adults: antiviral, supportive care
Bolognia, Dermatology 2008
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Breakthrough varicella
• Varicella among those vaccinated
• Most are mild
• Severe cases involved disseminated VZV with other organs involved
– Literature review yielded <60cases
– >31million doses distributed annually worldwide
– Bottom line: RARE!
• Oka strain vs wild-type
Leung, Expert Rev Vaccines, 2017
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Herpes Zoster (Shingles)
• Reactivation of varicella virus
• Latent in sensory dorsal ganglion nerves
• Triggers: trauma, irradiation, immunosuppression
• Prodrome: pain, tenderness, paresthesia, pruritus, tingling
Gnann, N Engl J Med 2002Jain, Dermatology, 2012
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Zoster: Rash
• Grouped vesicles on an erytheamtous base within dermatomecrusts
• Typically involves 1 dermatome, unilaterally
Gnann, N Engl J Med 2002
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Complications• Increase with increasing age
• Postherpetic neuralgia
• Secondary bacterial infections
• Scarring
• Ophthalmic zoster
• Ramsey-Hunt syndrome: reactivation of VZV in geniculate ganglionvesicles of ear canal, tongue, hard palate, acute facial nerve paralysis, loss of taste In anterior 2/3 of tongue
• Meningoencephalitis
• Motor paralysis
• Pneumonitis
• HepatitisGnann, N Engl J Med 2002
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Immunocompromised
• Unusual clinical presentations
• Persistent crusted verrucous lesions
• Postherpetic hyperhidrosis
• Disseminated disease (>20 vesicles outside primary or adjacent dermatome)
• Visceral involvment
Gnann, N Engl J Med 2002
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Shingles Diagnosis
• Clinical exam• Viral Culture• Direct
immunofluorescenceassay
• PCR
• To obtain adequate sample: rub the base of the vesicle
Gnann, N Engl J Med 2002
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Treatment
• Goal: accelerate healing, limit severity and duration of acute and chronic pain, reduce complications, reduce risk of dissemination (immunocompromised)
• Best to treat <72, but some benefit even after
• Acyclovir 800mg q4h (5xdaily) 7-10days
• Valacyclovir 1g TID x 7 days
• Famciclovir 500mg TID x 7days
Gnann, N Engl J Med 2002
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Postherpetic Neuralgia
• Pain that persists more than 30 days after the onset of the rash or after cutaneous healing
• Incidence and duration directly correlated with patient’s age
• Symptoms within affected dermatome:– Sensory abnormalities
– Neuropathic pain
– Allodynia: any stimuli (light touch) perceived as pain
• Lasts months to years
Gnann, N Engl J Med 2002
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Treatments: Postherpetic Neuralgia
• May need a combination of medications
• Gabapentin 300mg PO daily and titrate slowly to daily dose of 3600mg (divided in3 doses) over 4 weeks
• Topical steroids
• Capsaicin 0.025-0.074% cream TID
• Lidocaine 5% patch applied to painful sites, up to 3 patches at a time for max 12 hours
Gnann, N Engl J Med 2002
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Herpes Zoster: Take Home Points
• More common in advancing age and immunocompromised
• Ophthalmology referral for involvement around eyes or nose
• To diagnose: swab base of lesions (vigorously)
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Case
• 82 yo female with severely itchy rash affecting most of her body
• Rash involves trunk, extremities, and groin
• Itching is ratted at 10/10, leading to insomnia
• Social: lives in nursing home, roommate itchy
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What treatment would you recommend?
A. Oral prednisone
B. Topical diphenhydramine and calamine lotion
C. Topical permethrin
D. Moisturize skin with petroleum jelly
E. Hydroxyzine orally
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Scabies
• Mite: Sarcoptes scabiei var. hominis
• Entire life cycle: human epidermis
• Can survive for a week in the environment
• Transmission: close personal contact, fomites
• Incubation before sx develop: 2-6 weeks
Emedicine.medscape.com
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Scabies : Rash
• Rash:
– Papules
– Nodules
– Vesicles
– Excoriations
– Eczematous dermatitis
• Pathognomonic Sign: Burrow
• Severely itchy!
Emedicine.medscape.comMeinking, Dermatology 2008Pcds.org/uk
Burrow: Tunnel that female mite excavates
while laying eggs
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Flinders, Am Fam Physician. 2004
Finger web spaces
Axillae
Waistline
Genitalia
Wrist
Emedicine.medscape.com
Meinking, Dermatology 2008
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Crusted Scabies
• Immunocompromised – Elderly
– Mental impairment
– HIV
– Transplant
• 1000’s of mites on skin surface
• Minimal pruritus
• Highly contagious
Emedicine.medscape.com
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Pcds.org/uk
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Diagnosis and Treatment
• Diagnosis– Clinical exam– Scabies prep– Dermatoscopic exam– Biopsy
• Treatment:– Permethrin 5% cream
• Leave on overnight, wash off in AM, repeat in one week (for nymphs)• 2mo-5yo : treat head to toe
– PO Ivermectin (Crusted Scabies)– Vacuum, wash all clothing in hot water, bag unwashables for 14 days– Treat close contacts
Emedicine.medscape.com
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Take Home Points: Scabies
• Use distribution of rash to help with diagnosis
– Finger webspaces, wrists, axillae, waist, genitalia
• Adults: neck down involvement
• Children and Crusted Scabies: all over
• Treat if high pretest probability
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Case
• 28 yo female with itchy rash
• Started 6 weeks ago
• New sites continue to crop up
• Denies going outside and uses insect repellant when she does
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Dermnetnz.org
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What would you recommend?
A. Pest control with careful examination of mattress seams.
B. Oral ivermectin
C. Insect repellant with greater % DEET.
D. Oral prednisone
E. Both A and B
F. Both B and E
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Bedbugs
• Cimex lectularius
• Blood-sucking human parasites
• Oval-shaped, flat, reddish brown, ~5mm
• Feed at night
• Hide in seams of mattresses, furniture, luggage, holes in wall, pipes, gutters
Emedicine.medscape.com
Dermnetz.orgElston, Dermatology 2008
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Pcds.org/uk
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Bedbugs
• Rash: papular urticaria, urticaria, bullae, papules
• Exposed skin
• “Breakfast, lunch, and dinner”
Emedicine.medscape.comDermnetz.orgElston, Dermatology 2008Aad.org
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Treatment
• Mattress covers
• Professional Exterminator: Pesticides / heat treatment
• Permethrin treated clothing
• Cover up
• Topical steroid and antihistamines for itching rash
Emedicine.medscape.org
pcds.org.uk
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Topical Corticosteroid Primer
• Effectiveness depends on diffusion through stratum corneum
• Percutaneous absorption depends on:
– Active ingredient
– Concentration
– Vehicle
– Skin location
Lookingbill, Principles of Dermatology 2008
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Vehicle
• More occlusive, better penetration
• Solutions/sprays/aerosols: ingredients dissolved in alcoholic vehicles
• Lotions: suspensions of powder in water
• Creams: semisolid emulsions of oil in water
• Ointments: emulsions of water droplets suspended in oil
Lookingbill, Principles of Dermatology 2008
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Topical Corticosteroid Primer: Location
• Thicker stratum corneumlower absorption
• Mucosal skin
• Eyelids
• Face/Skin folds
• Trunk/extremities
• Palm/soles Lowest Absorption
Highest Absorption
Lookingbill, Principles of Dermatology 2008
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Volume to be Dispensed
• Common prescribing error• Take into consideration:
– Size of area to be treated– Frequency of application– Time between appointments or before predicted clearing of
rash– $$
• 1 grams covers ~10x10cm• 1 application:
– Face 2g– Arm 3g– Leg 4g– Whole body: 30g
Lookingbill, Principles of Dermatology 2008
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General Guidelines
• Become familiar w/1 per potency class
• Remember potency also depends on vehicle!
– Sprays, solutions, gels: hairy areas
– Creams: thinner plaques, rubs in well
– Ointments: lichenified, thicker plaques
Lookingbill, Principles of Dermatology 2008
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Strength Topical Steroid
Lowest Hydrocortisone 1%
Low Hydrocortisone 2.5%
Medium Triamcinolone 0.1%
High Fluocinonide 0.05%
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Side Effects
• Atrophy (thinning of skin)• Striae (stretch marks)• Hypopigmentation• Acne• Enhanced fungal infections• Retarded wound healing• Contact dermatitis• Glaucoma, cataracts• Sytemic Side Effects: adrenal
suppression, cushing’s syndrome, growth retardation
Lookingbill, Principles of Dermatology 2008
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Take Home Points
• Take vehicle/location into account
• Prescribe enough
• Become familiar with 1 per potency class
• Use least potent that is still effective
• “Stop when when smooth and flat”
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References• Cacoub P, Musette P, Descamps V, Meyer O, Speirs C, Finzi L, Roujeau JC. The DRESS syndrome: a literature review. Am J Med. 2011 Jul;124(7):588-97.• Walsh SA, Creamer D. Drug reaction with eosinophila and systemic symptoms (DRESS): a clinical update and review of current thinking. Clin Exper Dermatol 2010;36:6–11.
• Kardaun SH, Sidoroff A, Valeyrie-Allanore L, et al. Response to Variability in the clinical pattern of cutaneous side -effects of drugs with systemic symptoms: does a DRESS syndrome really exist? [letter to the editor]. Br J Dermatol 2007;156:575–612.
• Shiohara T, Inaoka M, Kano Y. Drug-induced hypersensitivity syndrome (DIHS): a reaction induced by a complex interplay among herpesviruses and antiviral and antidrug immune responses. Allergol Int 2006;55:1–8.
• Garcia-Doval I, LeCleach L, Bocquet H, Otero XL, Roujeau JC. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of death? Arch Dermatol. 2000 Mar;136(3):323-7.
• Moriceau, Florent et al. “DRESS Syndrome in the ICU: When a Patient Is Treated with Multiple Drugs.” Case Reports in Critical Care 2016 (2016): 9453286. PMC. Web. 19 Mar. 2017.• Foo, Seow, et al, “Spontaneous Regression of Atypical Primary Cutaneous Diffuse Large B-Cell Lymphoma.” Austin J of Dermatology, 2014; 1 (2):1007.• medskin.co.uk
• dermnetnz.org/• Gupta T, Garg VK, Sarkar R, Madan A. Acute Generalized Exanthematous Pustulosis Induced by Fexofenadine. Indian J Dermatol. 2016 Mar-Apr;61(2):235.• Garcia-Doval I, LeCleach L, Bocquet H, Otero XL, Roujeau JC. Toxic epidermal necrolysis and Stevens-Johnson syndrome: does early withdrawal of causative drugs decrease the risk of
death? Arch Dermatol. 2000 Mar;136(3):323-7.• Zimmermann S, Sekula P, Venhoff M, Motschall E, Knaus J, Schumacher M, Mockenhaupt M. Systemic Immunomodulating Therapies for Stevens-Johnson Syndrome and Toxic Epidermal
Necrolysis: A Systematic Review and Meta-analysis. JAMA Dermatol. 2017 Mar 22• Hsu DY, Brieva J, Silverberg NB, Paller AS, Silverberg JI. Pediatric Stevens-Johnson syndrome and toxic epidermal necrolysis in the United States. J Am Acad Dermatol. 2017 Mar 9
• Yacoub MR, Berti A, Campochiaro C, Tombetti E, Ramirez GA, Nico A, Di Leo E, Fantini P, Sabbadini MG, Nettis E, Colombo G. Drug induced exfoliative dermatitis: state of the art. Clin MolAllergy. 2016 Aug 22;14:9
• Aad.org• Emedicine.medscape.com• Bolognia, JL, Jorizzo, JL, Rapini, RP, Dermatology, 2nd edition, 2008
• Canavan TN, Mathes EF, Frieden I, Shinkai K. Mycoplasma pneumoniae-induced rash and mucositis as a syndrome distinct from Stevens-Johnson syndrome and erythema multiforme: a systematic review. J Am Acad Dermatol. 2015 Feb;72(2):239-45.
• Leung J, Broder KR, Marin M. Severe varicella in persons vaccinated with varicella vaccine (breakthrough varicella): a systematic literature review. Expert Rev Vaccines. 2017 Apr;16(4):391-400.
• Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med. 2002 Aug 1;347(5):340-6.• Pcds.org/uk• Quinn AM, Brown K, Bonish BK, Curry J, Gordon KB, Sinacore J, Gamelli R, Nickoloff BJ. Uncovering histologic criteria with prognostic significance in toxic epidermal necrolysis. Arch
Dermatol. 2005 Jun;141(6):683-7. PubMed PMID: 15967913.• Pcds.org/uk
• Lookingbill, “Principles off Dermatology” Saunders; 3 edition (June 15, 2000).
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