Erythema Multiforme: Recognition and Management Kathryn P
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Skin Manifestation of SARS-Cov-2: the Italian Experience
Journal of Clinical Medicine Article Skin Manifestation of SARS-CoV-2: The Italian Experience Gerardo Cazzato 1 , Caterina Foti 2, Anna Colagrande 1, Antonietta Cimmino 1, Sara Scarcella 1, Gerolamo Cicco 1, Sara Sablone 3, Francesca Arezzo 4, Paolo Romita 2, Teresa Lettini 1 , Leonardo Resta 1 and Giuseppe Ingravallo 1,* 1 Section of Pathology, University of Bari ‘Aldo Moro’, 70121 Bari, Italy; [email protected] (G.C.); [email protected] (A.C.); [email protected] (A.C.); [email protected] (S.S.); [email protected] (G.C.); [email protected] (T.L.); [email protected] (L.R.) 2 Section of Dermatology and Venereology, University of Bari ‘Aldo Moro’, 70121 Bari, Italy; [email protected] (C.F.); [email protected] (P.R.) 3 Section of Forensic Medicine, University of Bari ‘Aldo Moro’, 70121 Bari, Italy; [email protected] 4 Section of Gynecologic and Obstetrics Clinic, University of Bari ‘Aldo Moro’, 70121 Bari, Italy; [email protected] * Correspondence: [email protected] Abstract: At the end of December 2019, a new coronavirus denominated Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was identified in Wuhan, Hubei province, China. Less than three months later, the World Health Organization (WHO) declared coronavirus disease-19 (COVID-19) to be a global pandemic. Growing numbers of clinical, histopathological, and molecular findings were subsequently reported, among which a particular interest in skin manifestations during the course of the disease was evinced. Today, about one year after the development of the first major infectious foci in Italy, various large case series of patients with COVID-19-related skin Citation: Cazzato, G.; Foti, C.; manifestations have focused on skin specimens. -
Lepromatous Leprosy with Erythema Nodosum Leprosum Presenting As
Lepromatous Leprosy with Erythema Nodosum Leprosum Presenting as Chronic Ulcers with Vasculitis: A Case Report and Discussion Anny Xiao, DO,* Erin Lowe, DO,** Richard Miller, DO, FAOCD*** *Traditional Rotating Intern, PGY-1, Largo Medical Center, Largo, FL **Dermatology Resident, PGY-2, Largo Medical Center, Largo, FL ***Program Director, Dermatology Residency, Largo Medical Center, Largo, FL Disclosures: None Correspondence: Anny Xiao, DO; Largo Medical Center, Graduate Medical Education, 201 14th St. SW, Largo, FL 33770; 510-684-4190; [email protected] Abstract Leprosy is a rare, chronic, granulomatous infectious disease with cutaneous and neurologic sequelae. It can be a challenging differential diagnosis in dermatology practice due to several overlapping features with rheumatologic disorders. Patients with leprosy can develop reactive states as a result of immune complex-mediated inflammatory processes, leading to the appearance of additional cutaneous lesions that may further complicate the clinical picture. We describe a case of a woman presenting with a long history of a recurrent bullous rash with chronic ulcers, with an evolution of vasculitic diagnoses, who was later determined to have lepromatous leprosy with reactive erythema nodosum leprosum (ENL). Introduction accompanied by an intense bullous purpuric rash on management of sepsis secondary to bacteremia, Leprosy is a slowly progressive disease caused by bilateral arms and face. For these complaints she was with lower-extremity cellulitis as the suspected infection with Mycobacterium leprae (M. leprae). seen in a Complex Medical Dermatology Clinic and source. A skin biopsy was taken from the left thigh, Spread continues at a steady rate in several endemic clinically diagnosed with cutaneous polyarteritis and histopathology showed epidermal ulceration countries, with more than 200,000 new cases nodosa. -
Erythema Marginatum
Figurative Erythemas Michelle Goedken, DO Affiliated Dermatology Scottsdale, AZ Figurative Erythemas • Erythema annulare centrifugum • Erythema marginatum • Erythema migrans • Erythema gyratum repens • Erythema multiforme Erythemas • Erythemas represent a change in the color of the skin that is due to the dilation of blood vessels, especially those in the papillary and reticular dermis • The color is blanchable and most last for days to months • Figurative erythemas have an annular, arciform or polycyclic appearance ERYTHEMA ANNULARE CENTRIFUGUM ERYTHEMA ANNULARE CENTRIFUGUM • Pathogenesis: EAC represents a reaction pattern or hypersensitivity to one of many antigens – IL-2 and TNF-alpha may have a role – Most patients do not have an underlying disease identified ERYTHEMA ANNULARE CENTRIFUGUM • Associated with: – Infection » Dermatophytes and other fungi (Candida and Penicillium in blue cheese) » Viruses: poxvirus, EBV, VZV, HIV » Parasites and ectoparasites – Drugs: diuretics, antimalarials, gold, NSAIDs, finasteride, amitriptyline, etizolam, Ustekinumab (2012) ERYTHEMA ANNULARE CENTRIFUGUM – Foods – Autoimmune endocrinopathies – Neoplasms (lymphomas and leukemias) – Pregnancy – Hypereosinophilic syndrome – Lupus (2014) ERYTHEMA ANNULARE CENTRIFUGUM http://www.dermaamin.com Rongioletti, F., Fausti, V., & Parodi, A ERYTHEMA ANNULARE CENTRIFUGUM • 2 major forms: – Superficial: classic trailing scale, may have associated pruritus – Deep: infiltrated borders, usually no scale, edges are elevated, usually not pruritic ERYTHEMA ANNULARE CENTRIFUGUM -
Diagnosis, Classification, and Management of Erythema
Arch Dis Child 2000;83:347–352 347 Diagnosis, classification, and management of Arch Dis Child: first published as 10.1136/adc.83.4.347 on 1 October 2000. Downloaded from erythema multiforme and Stevens–Johnson syndrome C Léauté-Labrèze, T Lamireau, D Chawki, J Maleville, A Taïeb Abstract become widely accepted that EM and SJS, as Background—In adults, erythema multi- well as toxic epidermal necrolysis, are all part of forme (EM) is thought to be mainly a single “EM spectrum”. In both EM and SJS, related to herpes infection and Stevens– pathological changes in the earliest skin lesion Johnson syndrome (SJS) to drug reac- consist of the accumulation of mononuclear tions. cells around the superficial dermal blood Aims—To investigate this hypothesis in vessels; epidermal damage is more characteris- children, and to review our experience in tic of EM with keratinocyte necrosis leading to the management of these patients. multilocular intraepidermal blisters.5 In fact, Methods—A retrospective analysis of 77 there is little clinical resemblance between paediatric cases of EM or SJS admitted to typical EM and SJS, and recently some authors the Children’s Hospital in Bordeaux be- have proposed a reconsideration of the “spec- tween 1974 and 1998. trum” concept and a return to the original Results—Thirty five cases, inadequately description.15–17 According to these authors, the documented or misdiagnosed mostly as term EM should be restricted to acrally urticarias or non-EM drug reactions were distributed typical targets or raised oedema- excluded. Among the remaining 42 pa- tous papules. Depending on the presence or tients (14 girls and 28 boys), 22 had EM (11 absence of mucous membrane erosions the EM minor and 11 EM major), 17 had SJS, cases may be classified as EM major or EM 16 and three had isolated mucous membrane minor. -
Fundamentals of Dermatology Describing Rashes and Lesions
Dermatology for the Non-Dermatologist May 30 – June 3, 2018 - 1 - Fundamentals of Dermatology Describing Rashes and Lesions History remains ESSENTIAL to establish diagnosis – duration, treatments, prior history of skin conditions, drug use, systemic illness, etc., etc. Historical characteristics of lesions and rashes are also key elements of the description. Painful vs. painless? Pruritic? Burning sensation? Key descriptive elements – 1- definition and morphology of the lesion, 2- location and the extent of the disease. DEFINITIONS: Atrophy: Thinning of the epidermis and/or dermis causing a shiny appearance or fine wrinkling and/or depression of the skin (common causes: steroids, sudden weight gain, “stretch marks”) Bulla: Circumscribed superficial collection of fluid below or within the epidermis > 5mm (if <5mm vesicle), may be formed by the coalescence of vesicles (blister) Burrow: A linear, “threadlike” elevation of the skin, typically a few millimeters long. (scabies) Comedo: A plugged sebaceous follicle, such as closed (whitehead) & open comedones (blackhead) in acne Crust: Dried residue of serum, blood or pus (scab) Cyst: A circumscribed, usually slightly compressible, round, walled lesion, below the epidermis, may be filled with fluid or semi-solid material (sebaceous cyst, cystic acne) Dermatitis: nonspecific term for inflammation of the skin (many possible causes); may be a specific condition, e.g. atopic dermatitis Eczema: a generic term for acute or chronic inflammatory conditions of the skin. Typically appears erythematous, -
Isotretinoin and the Risk of Erythema Multiforme Final SPC and PL
Isotretinoin and the risk of erythema multiforme Final SPC and PL wording agreed by the PhVWP in June 2010 Doc. Ref.: CMDh/PhVWP/021/2010 Rev 1 July 2010 SUMMARY OF PRODUCT CHARACTERISTICS Section 4.4 There have been post-marketing reports of severe skin reactions (e.g. erythema multiforme (EM), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN)) associated with isotretinoin use. As these events may be difficult to distinguish from other skin reactions that may occur (see section 4.8), patients should be advised of the signs and symptoms and monitored closely for severe skin reactions. If a severe skin reaction is suspected, isotretinoin treatment should be discontinued. Section 4.8 Skin and subcutaneous tissues Cheilitis, dermatitis, dry skin, localised exfoliation, pruritus, rash disorders: erythematous, skin fragility (risk of frictional trauma) Very common (≥ 1/10) Rare (≥ 1/10 000,< 1/1000) Alopecia Acne fulminans, acne aggravated (acne flare), erythema (facial), exanthema, hair disorders, hirsutism, nail dystrophy, paronychia, Very Rare (≤ 1/10 000) photosensitivity reaction, pyogenic granuloma, skin hyperpigmentation, sweating increased, ∗ Erythema multiforme, Stevens-Johnson Syndrome, toxic Unknown epidermal necrolysis. PACKAGE LEAFLET Possible side effects Skin and hair problems Unknown frequency Serious skin rashes (erythema multiforme, Stevens- Johnson syndrome, and toxic epidermal necrolysis), which are potentially life-threatening and require immediate medical attention. These appear initially as circular patches often with central blisters usually on arms and hands or legs and feet, more severe rashes may include blistering of the chest and back. Additional symptoms such as infection of the eye (conjunctivitis) or ulcers of the mouth, throat or nose may occur. -
04Amersoncommondermatoses
Conflicts of Interest None Common Dermatoses in Children & Adults Erin Amerson, MD Department of Dermatology UC San Francisco Outline Impetigo Infections & Infestations Organism 50-70% staphylococcus aureus Remainder group A beta- Skin cancer hemolytic streptococcus or both 2 Forms: Common dermatologic disorders Honey-colored crusts Less common but important diseases Bullous Impetigo- staphylococcus 1 Impetigo Treatment Systemic Abx + topical therapy is best Soak off thick crusts, may use mupirocin oint Beta-lactamase resistant antibiotics x 7 days Dicloxacillin Cephalexin To eradicate nasal Staph carriage Rifampin 600 mg qd X 5 days with your other Abx OR Mupirocin (Bactroban) to nares bid Methicillin Resistant Staph Aureus (MRSA) 40-59% MRSA at UCSF/SFGH Culture for organism and sensitivities Consider if recurrent infection Oral antibiotics that still work: Doxycycline or minocycline Trimethoprim-sulfamethoxazole Clindamycin Can combine any of the above with rifampin Save IV Vanco or Linezolid for MRSA resistant to EVERYTHING 2 Groin Fold Rash DDx Tinea cruris Seborrheic dermatitis Erythrasma Intertrigo Candida Inverse psoriasis Fungal/Yeast Infections of the Groin Tinea Cruris Dermatophyte and Scaly, crusted plaque with central clearing Nystatin not effective Yeast Infections Imidizole/Allylamines x 2-4 weeks as for tinea corporis Candida Moister, more red, satellite pustules Drying agents like Domeboro’s soaks, then Nystatin/Imidizoles 3 Treatment of Onychomycosis Trichophyton rubrum Why treat? Confirm fungal infection before treating DDx: psoriasis, trauma, lichen planus No longer use Griseofulvin: 12-18 months rx & poor efficacy Ketoconazole: risk ↑ LFT’s with long-term use Treatment of Onychomycosis Nail Psoriasis Terbinafine (Lamisil) 250 mg/day x 3-4 months Pulsing being studied Liver toxicity Itraconazole (Sporonox) Pulse at 400 mg/day x 7 days/ mo x 3 months Drug-drug interactions Liver toxicity/CHF/$$$$ 4 Tinea Capitis Tinea Capitis Treatment What to look for: p.o. -
Drug Eruptions
DRUG ERUPTIONS http://www.aocd.org A drug eruption is an adverse skin reaction to a drug. Many medications can cause reactions, especially antimicrobial agents, sulfa drugs, NSAIDs, chemotherapy agents, anticonvulsants, and psychotropic drugs. Drug eruptions can imitate a variety of other skin conditions and therefore should be considered in any patient taking medications or that has changed medications. The onset of drug eruptions is usually within 2 weeks of beginning a new drug or within days if it is due to re-exposure to a certain drug. Itching is the most common symptom. Drug eruptions occur in approximately 2-5% of hospitalized patients and in greater than 1% of the outpatient population. Adverse reactions to drugs are more prevalent in women, in the elderly, and in immunocompromised patients. Drug eruptions may be immunologically or non-immunologically mediated. There are 4 types of immunologically mediated reactions, with Type IV being the most common. Type I is immunoglobulin-E dependent and can result in anaphylaxis, angioedema, and urticaria. Type II is cytotoxic and can result in purpura. Type III reactions are immune complex reactions which can result in vasculitis and type IV is a delayed-type reaction which results in contact dermatitis and photoallergic reactions. This is important as different medications are associated with different types of reactions. For example, insulin is related with type I reactions whereas penicillin, cephalosporins, and sulfonamides cause type II reactions. Quinines and salicylates can cause type III reactions and topical medications such as neomycin can cause type IV reactions. The most common drugs that may potentially cause drug eruptions include amoxicillin, trimethoprim sulfamethoxazole, ampicillin, penicillin, cephalosporins, quinidine and gentamicin sulfate. -
Oral Diseases Associated with Human Herpes Viruses: Aetiology, Clinical Features, Diagnosis and Management
www.sada.co.za / SADJ Vol 71 No. 6 CLINICAL REVIEW < 253 Oral diseases associated with human herpes viruses: aetiology, clinical features, diagnosis and management SADJ July 2016, Vol 71 no 6 p253 - p259 R Ballyram1, NH Wood2, RAG Khammissa3, J Lemmer4, L Feller5 ABSTRACT Human herpesviruses (HHVs) are very prevalent DNA ACRONYMS viruses that can cause a variety of orofacial diseases. EM: erythema multiforme Typically they are highly infectious, are contracted early in HHV: human herpes virus life, and following primary infection, usually persist in a latent form. Primary oral infections are often subclinical, but may PCR: polymerase chain reaction be symptomatic as in the case of herpes simplex virus- HSV, HHV-1: herpes simplex virus induced primary herpetic gingivostomatitis. Reactivation VZV, HHV-3: varicella-zoster virus of the latent forms may result in various conditions: herpes EBV, HHV-4: Epstein-Barr virus simplex virus (HSV) can cause recurrent herpetic orolabial CMV, HHV-5: cytomegalovirus lesions; varicella zoster virus (VZV) can cause herpes zoster; Epstein-Barr virus (EBV) can cause oral hairy Key words: herpes simplex virus, human herpes virus-8, leukoplakia; and reactivation of HHV-8 can cause Kaposi varicella zoster virus, Epstein-Barr virus, recurrent herpes sarcoma. In immunocompromised subjects, infections labialis, recurrent intraoral herpetic ulcers, treatment, val- with human herpesviruses are more extensive and aciclovir, aciclovir, famcicylovir. severe than in immunocompetent subjects. HSV and VZV infections are treated with nucleoside analogues aciclovir, valaciclovir, famciclovir and penciclovir. These agents INTRODucTION have few side effects and are effective when started The human herpesvirus (HHV) family comprises a diverse early in the course of the disease. -
Drug Eruption
Drug eruption March 25,2015 Outline • Clinical features • Pathogenesis • How to approach? • Management? Need to know • Urticaria • Exanthematous rash • DRESS • Stevens-Johnson syndrome/TEN • Fix drug eruptions • Acute generalized exanthematous pustulosis • Photoallergic/Phototoxic. • Chemotherapy induced.. Generalized erythematous and slightly edematous maculopapular rashes Erythema and edema of face and periorbital area Investigations 28/8/47 30/8/47 2/9//47 Total 1110 1690 2024 Eosinophil SGOT 42 98 69 SGPT 130 108 88 Your Dx is D R E S S ? Drug Rash with Eosinophilia and Systemic Symptoms DRESS • Aromatic antiepileptic agents (phenytoin, carbamazepine, phenobarbital) • Sulfonamides, allopurinol, gold salts, dapsone, and minocycline. 5 days after prednisolone 30mg/d 5 days after prednisolone 30mg/d Gout after 2 weeks of allopurinol Toxic Epidermal Necrolysis from allopurinol Approach to the Acute Generalized Blistering Patient History : Onset ,underlying disease, New Drug ,other symptoms? ( fever,sore throat ) Physical examination : target lesion nikolsky sign, epidermal necrolysis, mucosal involvement Investigation : baseline lab,skin biopsy + Direct Immonofluorescence Differential diagnosis of TEN • SSSS (Staphylococcal scalded skin syndrome ) • Autoimmune blistering disease ( pemphigus,linear IgA dermatosis.. ) • Erythema multiforme Generalized exanthem Blistering ,denudation Generalized Cutaneous tenderness Nikolsky sign + desquamation Apoptosis desmoglein-1 TEN SSSS Pemphigus vulgaris Bullous pemphigoid Erythema multiforme Take -
Exanthems and Drug Reactions
Dermatology Exanthems and Morton Rawlin drug reactions ‘Well, Mr Jones, I think we should put you on this tablet to Background fix this problem. Now, the things you need to look out for Drug reactions are a common cause of rashes and can vary are any rashes…’ from brief, mildly annoying, self limiting rashes to severe conditions involving multiple organ systems. How often in general practice do you hear yourself Objective offering this advice? Why do almost all drugs list rash as This article outlines an approach to exanthems that a side effect? How do they occur and what can you do to may be related to drug reactions and details appropriate recognise and manage them? management. The skin is the largest organ of the body and, from a diagnostic Discussion viewpoint, we can see it change to various stimuli. Medications Rashes related to drug reactions are both nonallergic and allergic. Nonallergic rashes are usually predictable and are commonly used and are integral to the general practitioner’s may be avoidable. Allergic rashes include morbilliform armamentarium for treating most ills. However, it is also important erythema, urticaria and angioedema, erythema multiforme to note that increasing access to medications by consumers through and vasculitic rashes. The vast majority of cases are other health professionals (eg. naturopaths) and the self prescribed rapidly resolving and self limiting once the offending use of over-the-counter, complementary and alternative medicines agent is removed. Early recognition and supportive should be remembered in the history taking of a patient presenting measures are the keys to care in the majority of cases. -
Annular Rash on a Newborn Keith A
JFP_02.06_PhotoRnds.Final 1/23/06 1:31 PM Page 127 PHOTO ROUNDS Anne-Marie Warner, MD, Annular rash on a newborn Keith A. Frey, MD, and Suzanne Connolly, MD Departments of Family Medicine and Dermatology, Mayo Clinic Arizona, full-term, healthy female new- suggestive of left ventricular hypertro- Scottsdale born was delivered via cesarean phy. An echocardiogram was normal. A section because the labor did not Follow-up office visits for com- adequately progress. The mother, age 33 mon newborn feeding problems years and of Asian ancestry, had a signif- demonstrated consistent weight gain icant medical and obstetrical history: and normal vital signs, including chronic hepatitis B carrier without cir- heart rate and facial milia. However, rhosis, cutaneous lupus erythematosus by age 4 weeks an erythematous erup- (positive anti-Ro and anti-La antibodies), tion extending from the frontal scalp and a positive group B streptococcal and forehead to the cheek area had recto-vaginal culture at 35 weeks’ gesta- developed (FIGURES 1 AND 2). tion. The mother received 4 doses of intravenous ampicillin during labor. The infant’s initial hospital course ■ What is the differential was complicated by a transient and diagnosis? otherwise asymptomatic bradycardia. An electrocardiogram (ECG) confirmed a heart rate of 96 with normal interval ■ What tests should be done parameters, but there were changes to make the diagnosis? FIGURE 1 Rash on a newborn’s face ... FIGURE 2 ...and on the scalp FEATURE EDITOR Richard P. Usatine, MD University of Texas Health Sciences Center at San Antonio CORRESPONDENCE Keith A. Frey, MD, Department of Family Medicine, Mayo Clinic Arizona, 13737 North 92nd Discrete annular erythematous lesions with Similar lesions involving the light-exposed Street, Scottsdale, AZ 85260.