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Dermatology EM SPR Handout

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Dermatology EM SPR Handout 9/20/19 Objectives East of England – Emergency Medicine Dermatology • Understand common terminology • Common exanthems Dr D Vijayasankar HST Training Day • Tips 20th Sept 2019 For Exam Preparation Know the difference • Common terminologies in Dermatology • Erythema 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 Pemphigus • 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 Dermis 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 – Nail, 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 • Papule • Pustule • Plaque • Cyst • Wheal • Scale • Nodule • Erosion • Vesicle • Crust • Excoriations Zebra Principle 4 9/20/19 Erythematous Exanthems History Clue’s – Erythematous Exanthems • Starts on Face • Rash – Measles, Rubella, Infectiosum • Usually viral in origin • Starts on Trunk • Could be secondary to toxin produced by – Roseola, Scarlet organism • Papulo vesicular • Systemic symptoms – Chicken pox • Extremities – Headache, Malaise 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 virus • 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 parvovirus B19 • 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 Scarlet Fever rash • HHV-6 • Has a complete recovery in few days ChickenPox • Streptococcus 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 penicillin 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 ulcerative colitis presents with a weeks rash. His temperature is 37.8 but other observations are normal. • Rx cause à HSV – aciclovir 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 corticosteroid; 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 • Erythema multiforme 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 • Inflammation of subcutaneous fat (panniculitis) 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 Staphylococcus aureus. 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 impetigo – 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 Cellulitis • Superficial form of cellulitis • Bacterial skin infection (usually streptococcal, occasionally • Area of intense redness, heat & clearly defined margins staph). • Very tender • Can occur in association with wounds 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
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