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Dermergencies & Acute Dermatologic Conditions

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Dermergencies & Acute Dermatologic Conditions DERMERGENCIES & ACUTE DERMATOLOGIC CONDITIONS April 10, 2019 Kerri Purdy, MD, FRCPC NOTE • This speaker has been asked to disClose to the audienCe any involvement with industry or other orGanizaons that may potenIally influenCe the presentaon of any eduCaonal material • ReCeivinG evaluaons is CriICal to the acCreditaon proCess. AMer the proGram, please provide feedback at hps://surveys.dal.Ca/opinio/s?s=46890 Presenter DisClosure • Presenter: Kerri Purdy, MD, FRCPC • Rela,onships with commercial interests: – Grants/Research Support: none – Speakers Bureau/Honoraria: None relevant to this presentaon but has reCeived honoraria for CME from various industry sponspors for CME events, ad board parICipaon (Abbvie, Janssen, Sanofi-Genzyme, Lilly, NovarIs, Galderma, BausChHealth, Pfizer – Consul,ng Fees: none – Other: none Objecves • ReCoGnize ConCerninG/life threateninG erupIons that may present first to the ED or to your offiCe • Common acute skin CondiIons that you will see in your office/clinic • Use a Case based approach to hiGhliGht key features of each CondiIon • Be able to reCoGnize these CondiIons and the reCommended iniIal management Case #1 • 24 yo female presents to ED with 2 day history of pharynGiIs and letharGy • PMHx: reCent diagnosis bipolar d/o • Consulted ENT for presumpIve tonsilliIs • Within 6 hours of admission RN notes a rash Case #1 What is the diagnosis? a) Maculopapular erupon b) ToxiC epidermal neCrolysis c) ParaneoplasIC pemphigus d) Staph sCalded skin syndrome e) PhototoxiC druG erupIon f) Who Cares, Call the dermatoloGist What is the diagnosis? a) Maculopapular erupon b) ToxiC epidermal neCrolysis (TEN) c) ParaneoplasIC pemphigus d) Staph sCalded skin syndrome e) PhototoxiC druG erupIon f) Who Cares, Call the dermatoloGist TEN hiGhliGhts • Life threateninG druG erupIon • HiGhest risk durinG the first 1-3 weeks of starInG a new mediCaon • Fever + skin pain + muCosal involvement • Full thiCkness epidermal neCrosis • Common Culprits: allopurinol, anIConvulsants, anIbioICs, sulfonamides • Mgmt: STOP THE CULPRIT DRUG!!!! – Call derm, ophthalmoloGy, admit to burn unit/ICU Case #2 • 55 yo female presents to the ED with painful erosions in her mouth and a new erupIon on her trunk • She is losinG weiGht as she is not able to eat or drink due to pain • PMHx: hypertension, dyslipidemia • Meds: HCTZ, ramipril, rosuvastan Case #2 Photo from www.dermnetns.org What are you thinkinG? a) Erythema mulforme b) Bullous pemphigoid c) PemphiGus vulGaris d) Kaposi variCelliform erupon e) Disseminated zoster f) Let me just Grab the derm reference book… What are you thinkinG? a) Erythema mulforme b) Bullous pemphigoid c) PemphiGus vulGaris d) Kaposi variCelliform erupon e) Disseminated zoster f) Let me just Grab the derm reference book… PemphiGus hiGhliGhts • Immunobullous disorder (pemphix = blister) • Painful erosions of oral muCosa (buCCal and palane most Commonly) • Can involve esophagus/anoGenital areas • >50% have flacCid bullae/erosions on skin • Without treatment hiGh mortality due to larGe areas of epidermal loss, fluid shiMs, seCondary infeCIon • Mgmt: Call derm, systemiC steroids 1mG/kG Case #3 • 17yo male presents to ED with history of facial swellinG and widespread erupIon • Generalized faGue and lymphadenopathy • PMHx: acne, asthma, seizure disorder • Meds: Carbamazepine, inhalers PRN Case #3 What is the diagnosis? a) Maculopapular erupon b) Stevens-Johnson Syndrome/TEN c) Serum siCkness-like reacIon d) DruG hypersensiIvity reacIon e) Drug-induced vasCuliIs f) Bed #2 is CodinG, I don’t have Ime for this What is the diagnosis? a) Maculopapular erupon b) Stevens-Johnson Syndrome/TEN c) Serum siCkness-like reacIon d) DruG hypersensiIvity reacIon (DRESS) e) Drug-induced vasCuliIs f) Bed #2 is CodinG, I don’t have Ime for this DRESS hiGhliGhts • DruG reacIon + eosinophilia + systemiC Sx • Onset usually 2-6 weeks aer druG started • Mortality up to 10% (visCeral involvement) • Fever + erupIon + lymphadenopathy* • Common Culprits: same as with TEN + minoCyCline and dapsone • Mgmt: Call derm, blood work, medicine (if systemiC involvement) +/- prednisone Case #4 • 37 yo female presents to ED mulIple Imes over a 2 weeks period ComplaininG of pain in the leGs and she develops a proGressive erupIon Case #4 • 65 yo male with acute leukemia (AML) – PMHx: atrial fibrillaon, GERD – Home meds: warfarin, atenolol, pantoprazole • Post induCIon Chemotherapy presents to ED with produCIve CouGh and fever – Diagnosis pneumonia; Rx CeMriaxone + azithromyCin • 2 days later presents with this erupIon Case #4 What is the diagnosis? a) Maculopapular erupon b) Stevens-Johnson Syndrome/TEN c) ACute exanthematous pustulosis d) DruG hypersensiIvity reacIon e) Pustular psoriasis (of von Zumbusch) f) I Can’t even tell what body part that is What is the diagnosis? a) Maculopapular erupon b) Stevens-Johnson Syndrome/TEN c) ACute exanthematous pustulosis (AGEP) d) DruG hypersensiIvity reacIon e) Pustular psoriasis (of von Zumbusch) f) I Can’t even tell what body part that is AGEP hiGhliGhts • Serious drug erupon • Latent period from druG exposure is short (typiCally 1-5 days) • Mortality ~ 5% (oMen older; ComorbidiIes) • Fever + nonfolliCular sterile pustules • Common Culprits: AnIbioICs, CCB, anImalarials, Carbamazepine • Mgmt: Call derm, stop druG, supporIve Case #5 • 17 yo male transferred from peripheral hospital with hypotension, tachyCardia and deCreased LOC • Exam reveals a new lesion on the riGht leG • Previously healthy, no meds, no allerGies Case #5 What should you do? a) Order stat blood Cultures x 2 b) ABC protoCol c) Call infeCIous diseases d) Call dermatoloGy e) Call ICU f) All of these sound reasonable… What should you do? a) Order stat blood Cultures x 2 b) ABC protoCol c) Call infeCIous diseases d) Call dermatoloGy e) Call ICU f) All of these sound reasonable… Ok but what is the diagnosis? a) Sepsis, obviously b) AtypiCal myCobacterial infeCIon c) Pyoderma GanGrenosum d) ACute febrile neutrophiliC dermatosis e) BlastomyCosis f) Hmmm… hopefully the derm or ID will help Ok but what is the diagnosis? a) Sepsis, obviously b) AtypiCal myCobacterial infeCIon c) Pyoderma GanGrenosum d) ACute febrile neutrophiliC dermatosis e) BlastomyCosis f) Hmmm… hopefully the derm or ID will help Pyoderma GanGrenosum hiGhliGhts • ReCurrent ulCeranG disease • AGe of onset 20-50 on average; Female > Males • AssoCiated with underlyinG disease in up to 70% – Inflammatory bowel, myeloproliferave, arthriIs • Can present with SIRS response • PathoGnomoniC features: – Undermined edges with Gunmetal border – Heals with cribiform sCarrinG (piGmented) • Mgmt: Call derm, supporIve Care, systemiC steroids iniIally 1-2mG/kG Case #6 • 32 yo otherwise healthy male presents with a new erupIon that is “freakinG him out” • No meds, no allerGies Case #6 What test should you order? a) CBC (esp platelets) b) Urinalysis (RBC Casts anyone?) c) ESR/CRP d) Urethral swab for G&C e) VDRL f) AerobiC blood Culture x 2 What test should you order? a) CBC (esp platelets) b) Urinalysis (RBC Casts anyone?) c) ESR/CRP d) Urethral swab for G&C e) VDRL f) AerobiC blood Culture x 2 Syphilis hiGhliGhts • MakinG a Comeback • Three stages: – Primary (ChanCre), seCondary (erupIon, palms/soles, alopeCia), terIary (Gummas/nodules) • SCreen with VDRL/RPR; Confirm FTA-ABS • If you think of it, treat it! – BENZATHINE PENICILLIN 2.4 MILLION UNITS sinGle IM dose (OK in preGnanCy) – Alternave: DoxyCyCline 200mG od x 14 days; AzithromyCin 2G po x 1; CeMriaxone 1G iv od x 10days Case #7 • 55 yo taxi driver presents to ED with a painful erupIon involvinG the lower extremiIes • PMHx: hypertension, hypothyroidism • Meds: HCTZ, eltroxin • He rolls up his pants to reveal… Case #7 What is your diagnosis? a) LeukoCytoClasIC vasCuliIs b) Erythema nodosum c) RoCky mountain spoNed fever d) Purpura fulminans e) Immune thromboCytopeniC purpura f) Why are we sIll doinG quizzes? What is your diagnosis? a) LeukoCytoClasIC vasCuliIs b) Erythema nodosum c) RoCky mountain spoNed fever d) Purpura fulminans e) Immune thromboCytopeniC purpura f) Why are we sIll doinG quizzes? VasCuliIs hiGhliGhts • LeukoCytoClasIC vasCuliIs = small vessels • Generally proGnosis Good but other orGan systems Can be involved (renal most Common) • Many Causes inCludinG autoimmune disorders, mediCaons, infeCIon (hep C), idiopathiC • Cardinal feature: palpable purpura • Mgmt: Call derm, baseline labs – CBC, Cr*, liver enzymes, ESR, urinalysis* Case #8 • 25 yo female presents with “boils” in the axillae that are draininG fluid • PMHx: nil • Meds: OCP • SoCial hx: student, smokes 1/2ppd, some EtOH • On exam, BMI 30 and you see this… Case #8 What is your diagnosis? a) Furunculosis b) Community acquired MRSA infeCIon c) HidradeniIs supprava d) InfeCted lymph nodes e) FolliCuliIs from shavinG f) Could be any of these?? What is your diagnosis? a) Furunculosis b) Community acquired MRSA infeCIon c) HidradeniIs supprava d) InfeCted lymph nodes e) FolliCuliIs from shavinG f) Could be any of these?? HidradeniIs supprava • Inflammatory skin CondiIon that affeCts skin with apoCrine Glands (axillae, inGuinal folds, inframammary) • Known as “acne inversa” • CliniCally see inflammatory nodules, absCesses, fistula, sCarrinG, double comedones • Hurley staginG is a CliniCal tool • More Common in females, smokers, obesity Hurley StaginG HidradeniIs Rx opIons • General measures (weiGht loss, smokinG Cessaon, loose ClothinG, anIsepIC wash) • AnIbioICs (topiCal & systemiC) • Intralesional steroid injeCIons • IsotreInoin; anIandroGens • SystemiC immunomodulators – CyClosporine, methotrexate,
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