5/20/2020 Let’s Hash out the Drug Rash Part 2 Heartland National TB Center of Excellence Presented by Nurse Consultants: Iris Barrera, Catalina Navarro, Marybel Monreal Webcast January 30, 2020 1 Iris Barrera, RN has the following disclosures to make: •No conflict of interests •No relevant financial relationships with any commercial companies pertaining to this educational activity 2 1 5/20/2020 Catalina Navarro, RN, BSN has the following disclosures to make: •No conflict of interests •No relevant financial relationships with any commercial companies pertaining to this educational activity 3 Marybel Monreal, BSN, RN has the following disclosures to make: •No conflict of interests •No relevant financial relationships with any commercial companies pertaining to this educational activity 4 2 5/20/2020 Describe the characteristics of 3 Describe common types of skin lesions. Goal: Utilize current foundational knowledge to aid Utilize dermatological terminology to Utilize patients appropriately describe skin lesions. experiencing drug rash. List List two rash identification resources. 5 But did you ask Public Health! 6 3 5/20/2020 PHYSICAL ASSESSMENT RECAP: THE COMPONENTS GATHERING OF EPISODE SPECIFIC OF A RASH INFORMATION (HISTORY.) ASSESSMENT INCLUDE: OBTAINING LABORATORY AND OTHER DATA. 7 Physical Assessment Observe the Location: Texture: Color: Red Purple patient’s reaction Arms Legs Torso Raised Flat Scaly Blanching for: Face Hands Feet Pustules Sloughing Size: Distribution: Inspect Oral Warm to the touch Pinpoint Small Diffuse Localized Mucosa Large 8 4 5/20/2020 https://patient.info/doctor/common‐childhood‐rashes# Adapted by Dr Adrian M Bonsall, from the Pediatric Handbook 6th Ed. Royal Children's Hospital, Melbourne. 9 What other Questions to ask the Are you allergic to any Any other known medication or patient: medicines? allergies? Food? remedies have you been taking? When did you first Have you been using a Any changes in your Is it: Itchy or painful? notice the reaction? different detergent? lifestyle? Gathering episode specific information 10 5 5/20/2020 How long after your dose of Drug Rash medication did the rash • Typical symptoms include redness, bumps, blisters, hives, itching, and occur (minutes, hours, days) sometimes peeling, or pain. • Every drug a person takes may have to be stopped to figure out which one is causing the rash. Has this happened before • Most drug rashes resolve once the with this medication drug is stopped, mild reactions may be treated with creams to decrease (increasing sensitivity) symptoms but serious reactions may require treatment with drugs such as epinephrine (given by injection), diphenhydramine, and/or a corticosteroid to prevent complications. Have you taken anything for the rash 11 Reference Materials • Have a visual aid available to guide your assessment and documentation For image SEARCH KEYWORD: Rash terms with pictures • Dermatology Resource: UpToDate 12 6 5/20/2020 Common Lesion Types Macules: Flat, nonpalpable lesions usually < 10 mm in diameter. Macules represent a change in color and are not raised or depressed compared to the skin surface. A patch is a large macule. Examples include freckles, flat moles, and some allergic drug eruptions Macules 13 Common Lesion Types Papules Elevated lesions usually < 10 mm in diameter that can be felt or palpated. Examples include nevi, warts, insect bites, some lesions of acne. Papules 14 7 5/20/2020 Common Lesion Types The term maculopapular is often loosely and improperly used to describe many red rashes; because this term is nonspecific and easily misused, it should be avoided. • Remember a macule is <10mm …the pictured reactions is much bigger. • Additional terms should be used • Confluent: flowing or coming *Maculopapular together also : run together. 15 Common Lesion Types • Hives AKA Urticaria AKA Wheals: • Circumscribed, raised, erythematous plaques, often with central pallor. • Lesions may be round, oval, or serpiginous( wavy margin) in shape and vary in size from less than 10mm to several centimeters in diameter. They are intensely itchy • Individual lesions are transient, usually appearing and enlarging over the course of minutes to hours and then disappearing within 24 hours. Lesions may coalesce (come together) as they Hives aka Urticaria aka enlarge. Wheals 16 8 5/20/2020 Polling Question What dermatological term best describes these non‐raised blanching erythematous skin lesions? A. Macules B. Papules C. Hives D. Maculopapular rash 17 Polling Question What dermatological term best describes these non‐raised blanching erythematous skin lesions? A. Macules B. Papules C. Hives D. Maculopapular rash 18 9 5/20/2020 Macules are flat, nonpalpable lesions usually < 10 mm in diameter. Macules represent a change in color and are not raised or depressed compared to the skin surface. Pictured is a Blanching erythematous macular rash in a patient with measles. Rationale 19 Polling Question What dermatological term best describes these raised skin lesions? A. Macules B. Papules C. Hives D. Maculopapular rash 20 10 5/20/2020 Polling Question What dermatological term best describes these raised skin lesions? A. Macules B. Papules C. Hives D. Maculopapular rash 21 Papules are elevated lesions usually < 10 mm in diameter that can be felt or palpated. Pictured are multiple hyperpigmented papules present on the face of a patient with dermatosis papulosa nigra. Rationale 22 11 5/20/2020 Polling Question What dermatological term best describes these well circumscribed, erythematous plaques that are intensely itchy? A. Macules B. Papules C. Hives D. Maculopapular rash 23 Polling Question What dermatological term best describes these well circumscribed, erythematous plaques that are intensely itchy? A. Macules B. Papules C. Hives D. Maculopapular rash 24 12 5/20/2020 Hives are circumscribed, raised, erythematous plaques, often associated with central pallor and are intensely itchy. Pictured is a urticarial drug eruption in a patient taking Moxifloxacin. Rationale 25 Summary of Common Lesions portion • A thorough physical assessment utilizing appropriate dermatological terms is critical to assisting physician recommendations and patient safety. • The term maculopapular is commonly misused and should be avoided. • Additional terms like confluent can better describe the reaction’s macular and/or papular presentation. • Remember: macules are flat discolorations and papules are elevated lesions; neither are larger than 10mm. 26 13 5/20/2020 Not all Rashes are Drug Rashes 27 “Nurse, I have a rash and I think it’s because of the medicine!” 28 14 5/20/2020 Objectives 1 Define atypical drug rashes 2 Define why some rashes are not drug rashes 3 Test your knowledge / self‐check 29 • Started anti TB therapy 3 weeks ago • Multiple erythematous papules primarily on wrist and fingers • Symptoms started 3 days ago • Itching worse at night Is this a drug rash? 30 15 5/20/2020 • Started anti TB therapy 3 weeks ago • Multiple erythematous papules primarily on wrist and fingers • Symptoms started 3 days ago • Itching worse at night Is this a drug rash? No 31 Scabies • Infestation of the skin by the burrowing mite Sarcoptes scabie • Transmitted through direct and prolonged skin‐to‐skin contact (family members or sexual partners) • Manifests as intense eruption of pruritic papules with characteristic distribution • Common sites: fingers, wrists, axillae, areolae, and genetalia 32 16 5/20/2020 Classic Scabies Burrrows Crusted Scabies • Multiple small, erythematous • Burrows are characteristic • Poorly defined, erythematous papules, often excoriated but often not visible patches that quickly develop prominent thick scale crust • Severe pruritis, worse at night • Thin, gray, red, or brown lines • Seen more in older adults or • Diffuse distribution • 2 to 15 mm in diameter immunocompromised • Back relatively free of persons involvement • Develop on scalp, hands, and • Young children & infants: feet, although any skin area palms, soles, and fingers can be affected 33 If you suspect scabies • Ask if itching is worse at night? • Ask if itching is widespread o Usually not found on the head (unless infant or young child) • Are there other household members with similar symptoms? 34 17 5/20/2020 Miliaria / • Transient cutaneious disorder caused by occlusion or Heat Rash inflammation of the eccrine sweat duct • Sweating leads to miliaria: o Hot and humid environments, physical activity, febrile illness, Miliaria/ occlusion of the skin • Can affect infants, children, and adults Heat Rash o Neonates more susceptible • Miliaria has been reported in patients treated with medications that influence the sympathetic or cholinergic systems o α‐sympathomimetic drugs: clonidine, opiates, β‐blockers 35 Crystallina Rubra Profunda • Common in neonates, usually • Erythematous papules 2 to 4 mm • Erythematous skin‐colored, firm on head neck, and upper trunk • May be papulovesicular or pustular papules 1 to 4 mm • Superficial clear vesicles 1 to 2 • Itching or stinging worsened by • Blockage deep within sweat duct that mm in diameter sweating occurs after repeated episodes of rubra • No inflammation • Common in infants in skin folds of • Common in adults, usually on trunk but • In adults common on trunk neck, axilla, or groin can be on extremities • Asymptomatic • Anhidorosis, or absence of • Can cause anhidrosis sweating, can occur in affected area • Compensatory hyperhidrosis in nonaffected area –can lead to inefficient thermoregulation 36 18 5/20/2020 Chronic inflammatory skin disease