Lecture Overview Dermatology Review 2020 EMRAM In-Service ◼ Terminology Review ◼ Describe the key features and a typical Julie Parks Bortel MD, FACEP dermatologic presentation for each condition ◼ Case review of common and important rashes 1 2 Approach to rashes Terminology ◼ Determine how the rash started and evolved ◼ Note the distribution, pattern, and configuration ◼ Excoriation – linear ◼ Fissure - linear cracks mucous membrane involvement erosion in skin surface palm/sole involvement ◼ Is it pruritic or painful ◼ Any prodromal symptoms 3 4 Terminology Terminology ◼ Macular –Flat and ◼ Patch – Flat and ◼ Papule – Raised ◼ Plaque – Raised <1cm >1cm <1cm >1cm 5 6 1 Terminology Terminology ◼ Vesicle - Blister <1cm ◼ Bullae - Blister >1cm ◼ Nodule – Dermal or ◼ Tumor – Dermal or subcutaneous lesion subcutaneous lesion <2 cm >2cm 7 8 Terminology Terminology ◼ Pustule – vesicle with Scale - visible layers of ◼ Erosion – Loss of part ◼ Ulcer – Dermis or purulent fluid stratum corneum or all of the epidermis deeper getting shed from the skin 9 10 Terminology Terminology ◼ Telangiectasia - small, blanching surface capillaries ◼ Purpura – non- ◼ Petechiae -- non- blanching purple blanching purple spots discoloration > 2mm < 2mm in diameter 11 12 2 Terminology Dermatitis ◼ Wheal -- transient, edematous papule or plaque with peripheral erythema 13 14 Rash #1 Dermatitis aka Eczema ◼ A 9 month old boy ◼ Inflammation of the epidermis with a history of ◼ Group of skin conditions that includes: asthma is brought in by his mother for an Atopic dermatitis itchy red rash Allergic contact dermatitis Irritant contact dermatitis Stasis dermatitis ◼ Exact cause is often unknown 15 16 Atopic Dermatitis Atopic Dermatitis ◼ A type of dermatitis with a hereditary component ◼ Atopic triad – asthma, eczema, allergies ◼ Common in developing countries ◼ Variety of symptoms – erythema, edema, vesiculation, flaking, weeping, & itching ◼ Treatment aimed at decreasing inflammation 17 18 3 Atopic Dermatitis Atopic Dermatitis ◼ Diagnosis is made by having three or ◼ Major Features more major features and three or more Pruritis minor features Typical morphology and distribution ◼ Flexural lichenification in adults ◼ Facial and extensor involvement in kids Dermatitis – chronic or relapsing Personal or Family History of atopy 19 20 Minor Features Atopic Dermatitis ◼ Cataracts ◼ Elevated IgE ◼ NOT caused by a true allergic reaction ◼ Chelitis ◼ White dermographism ◼ Results from defective cell mediated ◼ Recurrent conjunctivitis ◼ Wool intolerance immunity reactions brought on by ◼ Facial pallor/erythema ◼ Xerosis environmental stress ◼ Food intolerance ◼ Infections – Staph, ◼ Hand dermatitis herpes ◼ May have a primary T-cell defect ◼ Ichthyosis 21 22 Atopic Dermatitis Atopic Dermatitis ◼ Highest incidence in children ◼ Two Subgroups ◼ Clinical Features 1. Patients with asthma and enhanced IgE Starts with itching producing potential 2. Patients without asthma or enhanced IgE The scratching creates the patterns of the disease ◼ More than 50% of kids with atopic dermatitis develop asthma by the age of 13 Initially there is acute inflammation followed by slow resolution and replacement with dry, scaly skin (Ichthyosis/xerosis) 23 24 4 Atopic Dermatitis 3 Phases of Atopic Dermatitis ◼ Acute ◼ Infantile Phase (2mo-2yrs) Bright red swollen plaques Affects cheeks, perioral area, scalp, ears, Often linear vesicles trunk (spares diaper area), tops of feet, and ◼ Chronic Intense itching elbows Inflamed area is ◼ Subacute thickened Lesions often exudative Various patterns of Parallel skin markings erythema and scale Commonly involved Mild to moderate areas are easy to itching reach Indistinct borders 25 26 Atopic Dermatitis Phases Atopic Dermatitis Phases ◼ Childhood Phase (2-12 yrs) ◼ Adult Phase (12-adult) Flexural involvement Flexural involvement is common Scratching and chronicity leads to Hand dermatitis may be only manifestation lichenification Upper lid dermatitis is also common Associated findings include dry skin, ichthyosis vulgaris, and keratosis pilaris 27 28 Atopic Dermatitis Complications Atopic Dermatitis Treatment ◼ Skin lesions frequently colonized with staph and secondary infections are common ◼ Topical Steroids ◼ Increased susceptibility to viral infections ◼ Oral Antibiotics for secondary infection ◼ Inflammation can lead to pigmentation ◼ Burrow’s Solution changes ◼ Lubricant to restore skin barrier ◼ In children with moderate-severe disease ◼ Eliminate aggravating factors may also have emotional/behavioral ◼ Control Pruritis problems ◼ Short course of oral steroids if needed 29 30 5 Rash #2 Allergic Contact Dermatitis ◼ 35 y.o. male was outside yesterday mowing his lawn and trimming bushes ◼ Delayed hypersensitivity reaction now presents to the ER for an intensely ◼ It affects a limited number of people after itchy rash. they have been exposed to an antigenic substance ◼ Reactions develop acutely in 6-72 hours 31 32 Allergic Contact Dermatitis Poison Ivy/Oak/Sumac ◼ Examples ◼ Requires prior sensitization Poison Ivy/oak/sumac ◼ Caused by the antigen Urushiol Glue ◼ Rash occurs between 6-72 hours after Insecticides exposure Acrylics ◼ Lasts 2 days – 3 weeks Latex ◼ Rupturing the vesicles does not spread the Nickel rash Neomycin ◼ Highly characteristic linear lesions 33 34 Poison Ivy Poison Oak 35 36 6 Poison Sumac Treatment ◼ Mild Calamine lotion Benadryl Topical Steroid ◼ Moderate – Severe Aveeno bath Oral Benadryl Systemic steroids 37 38 Rash #3 Irritant Contact Dermatitis ◼ 40 y.o. construction worker who has been on a job repaving I-75 presents with an ◼ Caused by exposure to environmental itchy rash. He reports that it improved substances over vacation but now seems worse ◼ Level of irritation is related to duration of exposure and concentration of substance ◼ Gradual onset ◼ Borders correspond to the pattern of the offending agent and often assist in the diagnosis 39 40 Contact Dermatitis Irritant Contact Dermatits ◼ Shampoos/soaps ◼ Fuels/lubricants/cement ◼ Pineapple juice ◼ Alcohols, alkalies, grease 41 42 7 Rash #4 Diaper Dermatitis ◼ A mom presents to the ER with her 4 month old for a rash. She reports that she ◼ Candida – beefy red plaques with well noticed it while changing the diaper and defined edges the child was screaming while being wiped ◼ Irritant/Contact so she came in for evaluation. 43 44 Dyshidrotic Dermatitis Rash #5 ◼ A 77y.o. male with a history of HTN, DM, ◼ Itchy 1-2mm blisters on the palms of the CAD, & CHF comes in for a rash that has hands or soles of the feet been progressively more noticeable for the ◼ Take ~3wks to heal last 6 years but it was on his mind and he ◼ Often recur couldn’t sleep so he came in for evaluation at 3am. ◼ Cause is unknown 45 46 Stasis Dermatitis Rash #6 ◼ 30 y.o. female presents for a bump on the ◼ Skin changes in the back of her neck which started to leak a legs that occur from cheesy material prompting her insufficient venous return leading blood presentation to the E.R. to pool ◼ Pooling blood increases pressure in the capillaries and fluid leaks into the tissue 47 48 8 Epidermal Inclusion Cyst Epidermal Inclusion Cyst ◼ Solitary lesion that usually occurs on the face/neck/scalp/upper trunk ◼ May occasionally become inflamed, tender, and have foul-smelling drainage ◼ Mobile dermal to subcutaneous nodule 49 50 Epidermal Inclusion Cyst Rash #7 ◼ Treatment – non-emergent unless ◼ 25 y.o. female presents with a red scaly inflamed prominent itchy rash on the scalp ◼ If inflamed I&D may be helpful ◼ May inject steroids ◼ Keflex if indicated ◼ PCP can excise after inflammation improves 51 52 Psoriasis Psoriasis Subtypes ◼ Abnormal immune reaction to skin cells ◼ Plaque – red patches with white scales ◼ Causes acceleration of the growth cycle of cells ◼ Guttate - small droplike papules ◼ Salmon colored plaques and papules that are ◼ Pustular – presents with small non- well-circumscribed infectious pus filled blisters. Often on ◼ Most commonly on extensor surfaces such palms and soles as the knees and elbows ◼ Treatment: topical, phototherapy, & immune ◼ Inverse – Red patches in skin folds modulators ◼ Erythroderma – near to total body psoriasis 53 54 9 Psoriasis Psoriasis 55 56 Rash #8 ◼ Mom presents to the ER with her 4 month old infant complaining of a greasy yellow rash on her baby’s head 57 58 Seborrheic Dermatitis Seborrheic Dermatitis ◼ Common chronic inflammatory dermatitis ◼ Characteristic distribution Infants – vertex of scalp, diaper area, skin folds Adults – scalp, eyebrows, nasolabial folds, paranasal skin, around the ears, presternal skin and upper back 59 60 10 Seborrheic Dermatitis Treatment Cradle Cap ◼ Shampoos to decrease dandruff ◼ Low dose steroid creams – when ◼ neonatal seborrheic dermatitis – greasy, yellow rash necessary ◼ Uncertain of cause ? Related to eczema Fungal Overactive sebaceous glands ◼ Treatment Many home remedies – Vegetable oil, Baking soda, herbal washes Shampoo, Tar, Steroids, Ketoconazole 61 62 Maculopapular Rash #9 Rashes ◼ A 22 y.o. male presents to the EC complaining of an intensley painful red rash. Yesterday he was out on a boat all day partying at jobbienooner. 63 64 Sunburn Rash #10 ◼ Acute inflammatory reaction in ◼ Treatment response to UV A & B rays Cool soaks or OTC cooling ◼ Erythema peaks at 12-24 hours agents ◼ A 7 y.o. male presents to the ER for an ◼ In severe cases, can lead to 2nd Anti-prostaglandins – ASA or degree burns NSAIDS itchy rash after playing outside on a hot ◼ Are there any photosensitizing Steroids medications?