Nicholas Satterfield MD Emergency Medicine PGY2 Henry Ford Hospital Define dermatologic terms Discuss the approach to dermatologic complaints Discuss dermatologic diseases with high morbidity and mortality Flat lesions Macule (< 0.5 cm) Patch (> 0.5 cm) Elevated Lesions Papule (Up to 0.5 cm) Plaque (Greater than 0.5 cm) Nodule ( Papule but deeper, involves dermis and sometimes subcutaneous tissue) Fluid Filled Vesicles (Up to 0.5 cm) Bullae (Greater than 0.5 cm) Pustules (Vesicle but with pus) Blood derived (From leakage of capillaries) Petechiae (Less than 0.5 cm) Purpura (Greater than 0.5 cm) Erosion (loss of epidermis) Excoriation (itching leading to loss of epidermis) Ulceration (Loss of epidermis and dermis) Crusting (Collection of dried serum and cellular debris) Lichenification (Thickened epidermis) Atrophy (Thinning of epidermis or dermis) Scaling (Shedding excess dead epidermal cells by keratinization and shedding) Early Meningoc occemia, RMSF, TSS, EM, SLE, viral exanthem Lyme Meningococc emia, RMSF, HSP, Vasculitis, SLE, ITP, TTP, rubella, EBV, Endocarditis Secondary Syphillis, Anthrax Necrotizing fasciitis, TSS, STSS, SSSS, Kawasaki, EM, hypersensitivi ty reactions, cellulitis, viral exanthem EM, Stevens- Johnson, TEN, Pemphigus vulgaris, varicella zoster, HSV, necrotizing fasciitis (late) Bacterial folliculitis, gonorrhea, cellulitis Timing and progression Location Changes over time Travel PMH Occupation Medications 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) Diffuse Erythroderma (Staphyloccocal scalded skin syndrome, toxic shock syndrome, streptococcal toxic shock syndrome Petechiae/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 Syndrome Arthralgias (Rocky mountain spotted fever, viral illness) Pathology Acute inflammatory condition leading to maculopapular rash Believed to be due to immune complex deposition Has multiple etiologies Infectious (HSV or mycoplasm most common) Drugs (Penicillins, sulfonamides, dilantin, barbituates) Prodrome of malaise, fever, arthralgia Dusky red papules with sudden appearance that as they enlarge the central area pecomes cyanotic and dusty Tend to develop on palm, soles, extensor surfaces (knees and elbows) If due to drug reaction it tends to appear Lesions may develop for 2-4 weeks then resolve in 1-2 weeks Rarely can have a recurrent form or persistent form that is usually from HSV infection Major includes one area of mucosal involvement Most common is oral (up to 70%) erythema, erosions or bullae Can also have ocular bullae, pseudomembranes and purulent discharge (10-20%) which can lead to keratitis conjunctival scarring and visual impairment If you suspect drug reaction stop the drug Supportive (NSAIDS, antihistamines) Kenalog (triamcinolone) 0.1% cream for non face and genitals Hydrocortisone 1% cream for face and genitals Lidex (fluocinonide) 0.05% gel for oral lesions Magic mouth wash (2% viscous lidocaine, benadryl and maalox) Steroids? Rosens suggests to use if on trunk, EM Major and immunosuppressed If so start at mg/daily with 2-3 week taper Dermatology referral Optho referral: topical steroids and antibiotics SJS TEN Pathology Altered drug metabolism and immune complex mediated reaction Etiology Medications Infection (Mycoplasma pneumonia, CMV) 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 Primarily due to electrolyte abnormalities and infection Vision loss Vaginal stenosis Organ failure secondary to septic shock SCORTEN 180 mg/dl 250 mg/dl IDENTIFICATION PROPER DISPOSITION: SCORTEN greater or equal to 2 should go to burn unit Stop the suspected drug Steroids No consensus IVIG, plasmapheresis, Anti-TNF, cyclosporine Small studies, not recommended EM MinorEM MajorSJSTEN Epidermal detachment No Yes Mucosal Involvement NoYes Most Common etiology Infectious Drug Degree of epidermal detachment %BSA 0030% IgG against keratinocytes Presentation Elderly with oral erosions, vesicles and bullae for weeks to months Then get skin vesicles and bullae Slow progressive disease Treat with steroids (1 mg/kg/day) Admit if signs of infection or toxicity Outpatient Dermatology follow up Neisseria meningitidis infection that includes bacteremia with CNS Risk factors Crowded environments Complement deficiencies Asplenic patients Protein C and S deficiencies Usually occur in ages 6 months to 1 year and young adults (usually less than 20) Often first appears to be viral URI Get petechiae starting at wrist and ankles that spread and become papules Meningitis symptoms Quickly become septic: multiorgan failure and DIC Can get hemorrhagic destruction of adrenal glands (Waterhouse-Friderichsen syndrome) 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) Immune mediated destruction of platelets Usually idiopathic Secondary causes HIV, HCV SLE CLL Petechia and purpura usually in dependent areas Significant bleed in approximately 10%: Usually GI rarely ICH CBC and coags show isolated thrombocytopenia ICH or GI bleed and plt