Quick viewing(Text Mode)

Dermatology EM SPR Handout

Dermatology EM SPR Handout

9/20/19

Objectives East of England – Emergency Medicine • Understand common terminology

• Common

Dr D Vijayasankar HST Training Day • Tips 20th Sept 2019

For Exam Preparation Know the difference

• Common terminologies in Dermatology • Multiforme, Marginatum, • Criteria's in diagnosing skin/systemic conditions presenting with dermatological Nodosum problem • Differential diagnosis of common and life • SSS/TEN/Necrotising Fascitis threatening conditions • Pemphigoid and • Aetiology • Causative organism • Common viral exanthems

1 9/20/19

Why is it Important? Anatomy

Epidermis • Sebaceous Extra ordinary structure gland • Skin diseases are very common Capillary • Everyone will have suffered Erector pilae • 10-15% of GP work

• Second commonest cause of loss of work. Subcutaneous Hair follicle tissue Nerve Sweat gland

Question History and Why it is necessary

• Primary skin disease or manifestation of systemic disease • Enlist four things you would elicit in Dermatology • Onset, duration, spread,phasic history? • Pruritis • Wet or dry • Why history is important in dermatology? • Exacerbating factors • Medication • PMH, FH, SH (occupation)

2 9/20/19

Examination Question • Distribution

– Spread • List six categories in distribution examination? – Unilateral or bilateral – Symmetrical or asymmetrical – Flexor or extensor

– Exposed or protected

– Centripetal or centrifugal – , hair, scalp, mucosae

Examination Question

• Morphology – Monomorphic or pleomorphic • What are the generic treatments in – Bizarre shapes, ring, linear dermatology? – Palpate – Common terms

• Other exam as required, e.g hepatosplenomegaly, LN

3 9/20/19

Treatments Dermatology Atlas

• Dressings • Emollients • Antibiotics http://dermatlas.med.jhmi.edu/derm/ • Antihistamines • Analgesia • Steroids • Other, PUVA, counselling

Lesion Types

• Macule • Purpura • • Pustule • Plaque • Cyst • Wheal • Scale • • Erosion • Vesicle • Crust • Excoriations Zebra Principle

4 9/20/19

Erythematous Exanthems History Clue’s – Erythematous Exanthems

• Starts on Face • – , , Infectiosum • Usually viral in origin • Starts on Trunk • Could be secondary to toxin produced by – , Scarlet organism • Papulo vesicular • Systemic symptoms – Chicken pox • Extremities – Headache, and fever – Hand, foot and mouth

Measles Measles (Rubeola) • RNA paramyxovirus • Lasts 4 – 7 days • From prodrome till 4 days • 7 – 18 days incubation period after rash onset (Infectivity) • Preceded by fever, cough and red eyes (look unwell) • Rash lasts 4 - 7 days

• Koplik’s Spots • Typically begins at the hairline and spreads caudally

5 9/20/19

Rubella Rubella (German Measles)

• RNA • Rash from face to whole • Young children though body in 24hrs adolescents and adults • generalized, tender can get infected lymphadenopathy that • Seven days before and involves all nodes four days after (Infectivity) • Prodrome may not be present

Fifth Disease (Erythema Infectiosum)

• Classic slapped-cheek • Human • A benign self-limited appearance. • Primarily is a disease of disease • bright red erythema appears children aged 3-15 years • oral analgesics and abruptly over the cheeks • Not infectious once rash antihistamines or topical • erythematous macular-to- appears antipruritic lotions morbilliform eruption occurs • prognosis is excellent for primarily on the extremities typical childhood cases • lacy pattern

6 9/20/19

Roseola infantum ( 6th Disease)

• Exanthum Subitum • Children less than 2 years of age • History of high fever followed by rapid fall in tempt and a characteristic maculopapular rash • HHV-6 • Has a complete recovery in few days

ChickenPox • Pyogens • Flushed face with circumoral • 1 – 7 days pallor.

• Scarlatiniform rash • Petechiae on the soft palate. • Sandpaper rash • Strawberry tongue • Rash fades, peeling affects • The body rash appears 12-24 the fingertips, toes and groin hours after onset of illness area • Infectivity 5 – 7 days • 2-8 years age group

7 9/20/19

Varicella -zoster A 17 year old male presents to the ED with a rash which appeared suddenly over his trunk & tops of his arms & legs • Typical vesicular rash • Most infectious period 3 days ago. He has developed more • <10 years of age more 1-2 days lesions and they are slightly itchy. He completed a brief course of V common • Until the lesions have for tonsillitis 2 weeks ago. He feels • Trunk and then crusted otherwise well. spreading to the face and scalp 1) What is the likely diagnosis? (1) 2) What organism is most likely to have • oval teardrop on an precipitated this rash? (1) erythematous base 3) What information will you provide him regarding the prognosis? (1)

SJS

Stevens-Johnson Syndrome • Less than 10% TBSA • 10-30% TBSA mixed TEN/SJS • >30% TEN

8 9/20/19

Erythema Multiforme Management: A 32 year old male with • Majority if cases – no Rx required; resolves over 2-3 presents with a weeks rash. His temperature is 37.8 but other observations are normal. • Rx cause à HSV – PO; Mycoplasma – antibiotics (e.g. erythromycin) 1) What is the likely diagnosis? • Stop offending drug (1) 2) Except for inflammatory • Supportive Rx à PO antihistamines; topical ; bowel disease give 2 other mouthwashes causes of this skin disorder? • Eye involvement requires specialist ophthalmologist (1) 3) Name one other symptom assessment that may be associated with • major – may require admission for this skin disorder (1) supportive Rx

Erythema Nodosum SAQ 3:

• Hot, tender, ill-defined nodular erythematous eruption – A 17 year old male presents to the ED with a rash. He describes having a cold sore 1 week typically pretibial area of lower legs, can also affect forearms/ ago followed by the abrupt onset of the rash. trunk The rash started peripherally & spread centrally. He is unwell, febrile, tachycardic and • of subcutaneous fat () with complaining of a headache. He also has a sore mouth, gritty eyes & haematuria on involvement of adjacent vasculature dipstick testing. • Immunological reaction affecting all age groups 1) Describe the key features of this rash? • Can be associated with arthralgia & fever (1) 2) What is the likely diagnosis? (1) • Clinical diagnosis 3) What is the most likely infective agent • Lasts 3-8 weeks à tends to leave bruised appearance that has precipitated the rash? (1) • Management according to cause

9 9/20/19

A 14 year old boy attends the ED with a sore left nostril. He has recently had a coryzal illness & his nose became cracked & sore after wiping it so much. He presents to the ED with his mother, 6 year old sister & 2 month old brother. They are attending as the affected area seems to be spreading.

1) What is the likely diagnosis? (1) 2) Name the causative microbe? (1) 3) What important advice will you provide prior to discharge home? (1)

Impetigo

• Superficial infection of skin caused by Group A A 52 year old woman presents with a swollen & exquisitely tender left lower limb. She recalls Streptococci or . scratching her ankle a few days ago with her fingernail whilst putting her trousers on. She is a • Initially ulcerative erythematous area à exudes serous diet controlled type 2 diabetic. The leg is fluid à golden brown crust. erythematous, hot to touch & very tender. She is nauseous, lost her appetite and has a • Highly contagious, spreads rapidly – temperature of 38.4 degrees. advice re: prevention of spread

• Bullous – caused by S.aureus 1) What is the likely diagnosis? (1) • Local infection à topical fusidic acid. 2) Name the causative microbe? (1) • Extensive à oral or IV antibiotics 3) Detail 2 components of your management plan? (1)

10 9/20/19

Erysipelas

• Superficial form of cellulitis • Bacterial (usually streptococcal, occasionally • Area of intense redness, heat & clearly defined margins staph). • Very tender • Can occur in association with or in the absence of • Typically caused by group A Strep (streptococcal infection) skin breach. • Usually associated with systemic upset • Area warm, erythematous, tender, poorly defined margins ± lymphadenopathy. • Treated with antibiotics – e.g. phenoxymethylpenicillin • Treatment depends on severity • Analgesia • Local infection – oral antibiotics (Pen V/ fluclox/ co-amox or erythro) • Systemically unwell – Admit + IV antibiotics. • Cellulitis of the face – risk of IC complication (CST)

Cellulitis Necrotising Fasciitis

• Rare but severe bacterial infection of soft tissues • Can occur with/ without trauma • May follow illicit IM heroin injection (“muscle popping”) • Typically Strep pyogenes, sometimes with Staph aureus or other bacteria • Often both aerobic & anaerobic organisms. • Infection involves fascia & subcutaneous tissues with gas formation & development of gangrene. • Infection may spread to adjacent muscles causing myonecrosis or pyogenic myositis.

11 9/20/19

Necrotising Fasciitis Necrotising Fasciitis

• Rare but severe bacterial infection of soft tissues • Fournier’s gangrene – affects abdomen & groin. • Can occur with/ without trauma • Initial symptoms vague: severe pain but little to find on • May follow illicit IM heroin injection (“muscle popping”) examination. • Typically Strep pyogenes, sometimes with Staph aureus • Tenderness, swelling, erythema, crepitus, pyrexia. or other bacteria • Rapid spread of infection – marked swelling, • Often both aerobic & anaerobic organisms. discolouration, haemorrhagic , skin necrosis. • Infection involves fascia & subcutaneous tissues with • Toxic shock may occur – very high mortality. gas formation & development of gangrene. • X-ray – may show gas in soft tissues, but may be • Infection may spread to adjacent muscles causing normal. myonecrosis or pyogenic myositis. • Treatment: Resuscitation, IV antibiotics (pen + clinda), urgent debridement, ITU.

Shingles • à reactivation of VZV that has remained dormant in dorsal root ganglion following primary infection A 45 year old female re-presents to the ED. She was in the ED 2 days ago with pain over the left • Usually in elderly side of her forehead. She has now developed a rash over the same area. • Erythema à vesicular rash in a dermatomal distribution à crusting • Can affect any dermatome 1) What is the name of this specific condition & what is the causative microbe? (1) • Initially presents as pain (diagnostic difficulty), rash develops 2) What potential complication would you 1-4 days later specifically check for? (1) 3) Give 2 steps you would take in your management plan? (1)

12 9/20/19

Shingles Shingles • Unilateral distribution over 1-2 dermatomes • • Ophthalmic shingles à via long ciliary nerves; risk of Antiviral treatment: If given early can reduce corneal ulceration risk of post-herpetic pain (within 72 hours of • Oral lesions à maxillary & mandibular shingles start of rash) • Ramsay-Hunt syndrome – Infection of geniculate • Aciclovir 800mg 5 times daily for 7 days ganglion causes facial palsy with lesions in pinna of ear, side of tongue & hard palate • Analgesia • Specialist referral & antiviral treatment for ophthalmic shingles & immunodeficient patients with shingles • Antibiotics for secondary bacterial infection.

Bullous pemphigoid vs

A 75 year old female is sent to ED Pemphigoid Pemphigus by her carer. She has developed Generalised mucocutaneous blistering disease Generalised mucocutaneous blistering eruption large, itchy tense blisters on her Rare Rare ankles and feet. The skin in that Autoimmune Autoimmune Affects elderly most commonly Affects 50-60 years of age most commonly area was previously normal but she IgG + activated T-lymphocytes attack basement membrane, IgG binds to desmoglein protein à separation of hemidesmosomal proteins à separation of keratinocytes from each other had complained of itching + burning from dermis sensation. Below epidermal basement membrane - sub-epidermal Intraepidermal (superficial) (deep) Tense blisters (up to 10cm diameter) – associated with Clear vesicles or bullae (varying in size) à turbid + flaccid 1) Apart from those detailed in question 2 give two pruritus + burning blisters (2-3 days) differential diagnoses for this type of skin change? (1) Ulceration with tissue loss (less painful) Rupture à painful denuded areas (slow to heal) Originate from normal skin or atop erythematous/ urticarial Originate from normal skin or atop erythematous/ urticarial 2) Give 2 features that differentiate pemphigus vulgaris plaque plaque from ? (1) Nikolsy’s sign negative Nikolsky’s sign positive Intertriginous & flexural areas Head, trunk & mucous membranes 3) Give 2 possible complications of this disorder (1) Mucosal ulceration 10-25% of cases (less severe) Mucous ulceration 95% of cases (more severe) Oral steroids Oral steroids & immunosupression Good prognosis Poor prognosis without treatment

13 9/20/19

Bullous pemphigoid vs Pemphigus vulgaris

Diagnosis: Skin from edge of & direct immunofluorescence A 1 year old boy is brought to ED by his Complications: Protein, fluid & electrolyte losses through involved skin à mum with a rash. Mum noted that his skin felt rough when she was bathing him 2 days hypoalbuminaemia, hypovolaemia & electrolyte disturbances ago & then today she noted an area of skin Treatment: in the axilla which was wrinkled & starting to - PV: Admission usually required; high dose corticosteroid, peel. bisphosphonate (long term steroids), Antibiotics for secondary infection, Analgesia, IV fluids/ electrolyte replacement, immunosuppressant 1) Give the likely diagnosis & 1 other differential therapy, IV immunoglobulin diagnoses for these skin changes? (1) - BP: Admission if severe/ widespread, High dose steroids initially à maintenance dose, topical steroids if localised disease, bisphosphonate 2) What is the responsible organism for this condition? (1) (long term steroid), antibiotics for secondary infection, Analgesia, IV 3) Give 2 points of your management plan for this patient? fluids/ electrolyte replacement, immunosuppressive agents, IV (1) immunoglobulin

Staphylococcal Scalded Skin Syndrome (SSSS) Staphylococcal Scalded Skin Syndrome (SSSS) - Develops in patients with clinically inapparent staphylococcal infections (nasopharynx, conjunctiva, - Differential diagnoses: TEN; TSS; exfoliative drug umbilicus) eruptions; ; , pemphigus vulgaris - Exotoxin produced by staph aureus causes acantholysis - Management: fluid resuscitation, correction of & intraepidermal cleavage of the skin electrolyte disturbances, identification + treatment of - Occurs primarily in infants & young children & source of toxigenic staphylococcal infection with immunosuppressed adults antibiotics - 3 phases: Initial (tender diffuse ) à - NOT recommended exfoliative (2nd day skin wrinkles & peels – Nikolsky sign +) à desquamation (3-5 days large flaccid vesicles & bullae rupture & shed in large sheets) - Underlying tissue resembles scalded skin & rapidly desiccates • No mucous membrane involvement

14 9/20/19

Toxic Epidermal Necrolysis (TEN) A 24 year old female with cerebral palsy has - Explosive dermatosis characterised by: Tender warm erythema (initially presented to the ED with a 2 week history of lethargy, loss of appetite, generalised arthralgia eyes, nose, mouth, genitalia + becoming generalised) à bullae & itchy skin. She subsequently developed tender formation (flaccid, ill-defined between + dermis) à exfoliation red areas around her eyes & mouth which (Nikolsky sign +, epidermis sheds in sheets leaving raw denuded areas spread. She now has blistering around her lips & of exposed dermis) mouth ulcers are making it difficult for her to drink. She has recently been diagnosed with - Associated with systemic illness à 1-2 week prodrome of malaise, epilepsy. anorexia, arthralgia, fever, URTI - Concomitant skin tenderness, pruritus, tingling or burning may occur 1) What is the likely diagnosis? (1) during this prodrome 2) What is the likely cause for this condition in this - Affects all age groups, no predilection to sex patients case? Name 1 other potential cause of this - Poorly understood pathogenesis – thought to be partly immunologic + condition (1) genetic predisposition 3) Give 2 points of your management plan for this patient? (1)

Toxic Epidermal Necrolysis (TEN) Toxic Epidermal Necrolysis (TEN) Mortality 25-30% - Multiple causes – medications most common cause Causes: Management: - Average onset after inciting agent ~2 weeks - Sulfa + penicillin - Cutaneous extension follows an unpredictable time course (1-15 antibiotics, rifampicin/ - Admission – critical care/ unit days) anti-TB agents

- Mucous membrane involvement à oral, ocular, anogenital, GI, - Anticonvulsants - Airway assessment + control if urinary, respiratory tracts (carbamazepine/phenyto required à sloughing of airway/ - Peri-labial blistering + erosive lesions à disfigurement; poor oral in) respiratory epithelium can occur intake with hypovolaemia - - Ocular complications à purulent conjunctivitis, painful erosions, - Hypovolaemia + electrolyte blindness - NSAID’s/ abnormality correction - 2 major complications + leading causes of death in TEN: 1) - Malignancy hypovolaemia with electrolyte disturbance; 2) infection (Staph + Pseudomonas) - HIV - Prompt+ aggressive antibiotic - Idiopathic therapy if infection

15 9/20/19

Differential diagnoses:

Lesion Morphology Differential considerations

Macule Viral / erythema multiforme/ meningococcaemia/ Drug erution/ naevus/ lice infestation/ trauma/ / celllulitis (early)/ Papule / BCC/ / naevus/ / / skin tags/ / urticaria/ eczema/ / insect bites/ / / / erythema multiforme/ varicella (early)

Plaque Eczema/ / / tinea versicolor/ psoriasis/ / urticaria/ erythema multiforme Nodule BCC/ SCC/ Metastatic carcinoma/ melanoma/ / furuncle/ / warts

Wheal Urticaria/ / insect bites/ erythema multiforme

Pustule Acne/ folliculitis/ hydradenitis suppurative/ HSV/ HZV/ VZV/ impetigo/ psoriasis/ / Vesicle HSV/HZV/VZV/ impetigo/ thermal burm/ friction blister/ TEN/ bullous pemphigoid/ pemphigus vulgaris/ toxicodendron dermatitis Bulla Bullous impetigo/ toxicodendron dermatitis/ thermal burn/ friction blister/ TEN/ bullous pemphigoid/ pemphigus vulgaris Scales Psoriasis/ pityriasis rosacea/ dermatophytic infections/ thermal burn

Crusts Eczema/ dermatophytic infection (tinea)/ impetigo/ / insect bite

Erosions / dermatophytic infections/ eczema/ TEN/ erythema multiforme/ bullous pemphigoid/ pemphigus vulgaris Ulcers Apthous lesions/ chancroid/ thermal/ pressure / friction / ischaemic ulcer/ malignancy/ / bullous pemphigoid/ pemphigus vulgaris/ pyoderma gangrenosum

Benign Pustular Melanosis of the Newborn

• Present from birth

• Sterile, neutrophils only

• Pustules last 24 hrs, hyperpigmented lesions for weeks

16 9/20/19

Erythema Toxicum Neonatorum Sebaceous Hyperplasia

• Term neonates aged 3 • white spots on the days to 2 weeks. forehead, nose and • small, erythematous , vesicles, and, cheeks. occasionally, pustules. • overgrowth of the • The lesions typically sebaceous glands resolve within 2 weeks • Due to carry over of maternal hormones.

Cradle Cap (Seborrhea)

• Greasy and yellow, scaly patches. • Unknown cause • Usually appears during the first couple of weeks. • Wet Compresses (Saline) to affected area. • Soft brush to remove scales from scalp • Anti- seborrheic shampoo

17 9/20/19

Cutis marmorata Hand foot and Mouth Disease

• exposure to cold but also sepsis and dehydration

• immature vascular tone

• improves with age

• Peripheral cyanosis

Hand Foot and Mouth Disease Impetigo

• Coxsackie A16 • The spots are often found on • Staphylococci or group A • common childhood illness the palms and soles beta-hemolytic • Mouth sores, fever, and a • Rash does not itch rash • 1 week streptococci. • Fever and a sore throat • Pain relief and plenty of • erythematous macule • small red spots on the fluids • multiple small pustules tongue, gums, or mucous membranes. They may • honey-colored crust blister or form ulcers.

18 9/20/19

Cat-Scratch Disease

Cat Scratch Disease Molluscum Contagiosum

• Bartonella henselae • disease classically • children and adults younger characterized by painful than 21 years regional lymphadenopathy • Papule initially and • Antipyretics and analgesics progresses to a vesicle • Local heat may be applied • proximal lymphadenopathy • Aspiration of tender, in about two weeks fluctuant nodes • ?Antibiotics

19 9/20/19

Molluscum Contagiosum

• cutaneous infection • Become confluent to caused by DNA poxvirus form a plaque that affects both • Trunk and extremities children and adults • Self-limited and heals • Asymptomatic after several months or • Pain / Pruritis years • Firm, smooth and • Topical applications umbilicated papules • Surgical Care

Orf

◆Occupational viral infection ◆Red papules, vesicles, pustules ◆Umbilication ◆Self-limiting

20 9/20/19

Erythroderma •Hyper or hypothermia Anthrax •Fluid loss •Protein loss

■Bacillus anthracis •High output cardiac failure ■Usually occupational •Malabsorption, hypocalcaemia, folate deficiency ■Biological warfare

■Papule at site of with deep erythema

■Haemorrhagic bullae

■Central eschar

Sarcoptes scabiei

• Direct and prolonged • small papules, vesicles, contact with an infected and burrows individual • topical antiscabietic • Mites can survive up to agents, with repeat 3 days away from application in 7 days human skin • Ivermectin • recent onset of intense Scabies itching that is accentuated at night.

21 9/20/19

Kawasaki Disease

• Fever, lasting more than 5 • Acute febrile vasculitic days syndrome of early childhood. • Polymorphous erythematous • 90-95% of cases occur in rash children younger than 10 • Nonpurulent bilateral years conjunctival injection • Classical 5 criterions for • Oropharyngeal changes diagnosis • Peripheral extremity changes • Nonpurulent cervical lymphadenopathy

Contact Dermatitis

Eczema ◆Type IV hypersensitivity ◆Similar appearance to eczema ◆Bizarre shapes ◆Localised ◆Precipitants –Nickel –Nail varnish –Rubber ◆Itching ◆Erythema –Plants ◆Weeping ◆Oedema ◆Crusting ◆Papules

◆Scaling ◆Vesicles ◆Flexor surfaces ◆Lichenification

◆Fissuring

22 9/20/19

Pompholyx

◆Sago-grain pattern of deep Pityriasis Rosea vesicles

◆Palms and soles of feet ◆Possibly viral ◆Herald patch ◆May coalesce to bullae and ◆Medallions of erythema with central scale cause de-gloving ◆Follows cleavage lines of skin ◆Christmas tree pattern

Psoriasis

◆Well-demarcated plaques ◆Silvery easily removed scales ◆Extensor surfaces ◆Pustulosis ◆Nails – pitting, onycholysis ◆Other types – guttate, napkin, flexural ◆Arthropathy

23 9/20/19

Lyme Disease

◆Tick bite ◆Erythema chronicum migrans ◆Annular erythematous plaque ◆Central clearing ◆Late cardiac, arthritic, neurological complications

Common

Herpes Simplex

24 9/20/19

Miliaria Rubra Erythema Multiforme

• Generalized red pinpoint ◆Hypersensitivity reaction rash frequently seen on ◆Bilateral peripheral symmetrical the neck, armpit and ◆Target lesions ◆Precipitants chest. –Streptococci • Prevented by keeping –Herpes the room at a reasonable –Mycoplasma temperature –Penicillin –Sulphonamides

HSP

Erythema Nodosum

◆Painful tender papules on shins ◆Precipitants –Sulphonamides –Sarcoid –Streptococci –TB

25 9/20/19

Reading Thank you!

• Common terminologies in Dermatology • Differential diagnosis of common and life threatening conditions • Aetiology • Causative organism • http://www.pcds.org.uk/

26

Top View