Download - DERMATOLOGY - Emergency Medicine
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DERMATOLOGY
Alison Ruiz PA-C
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Molluscum Contagiosum • Pox virus • Spreads by direct skin
contact – Especially in kids – In adults usually spread
with sexual contact. • Well circumscribed, small
erythemaotus paupules with a small central indentation – Central indentation
resolves as lesions progress
• No treatment required in healthy individuals
• Can use Imiquimod cream 5% (same as used for HPV in the genital skin
• In children, freezing, curettage, topical cantharidin
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Erythema Infectiosum • Fifth’s disease • Occurs in spring in children
– 5-15 yrs of age usually • Human parvovirus B19 • Abrupt onset of fiery red
rash on cheeks – Slapped cheek appearance – Closely grouped tiny papules
on erythematous base • 1-2 days later
– erythematous maculopapular rash on trunk and limbs
• Fevers, malaise, headache, Sorethroat, cough, coryza, nausea, vomiting, diarrhea and myalgia
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Case Presentation
• 25 y/o M PMH Seizure Disorder recently diagnosed presents to the ED with fevers for the 4 days and URI symptoms.
• He noticed a rash for the past 72 hours to his chest and back. Rash initially itchy but now it it more painful, warm and “cracking”
• Pt feels weak, has not been eating. Fever max 103.5. States he was placed on Keppra after recent diagnosis of seizure disorder.
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History
• PMH – Seizures
• PSH – None
• Meds – Keppra
• Allergies – none
• FH – Noncontributory
• SH: – smoker 5 cigaretteres
per day for 5 years – Alcohol 4 drinks per
week
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Physical Exam • HEENT: PERRL, EOMi • Neck supple. No nuccal
rigidity • Lungs: CTA bilat. No
W/R/R • CV RRR s1s2 • Abd: soft NT ND NABS. • Skin: see picture • Back: see picture • Ext: small maculopapular
lesions on thighs and lower legs bilat.
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Differential Diagnosis
• ??????
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What labs do you want to send?
• CBC • BMG • LACTIC ACID • BLOOD CULTURES • URINALYSIS • URINE CULTURE • CXR
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LAB RESULTS
• CBC – WBC: 20.4 (H) – RBC: 3.33 (L) – HEMOGLOBIN: 11.4 (L) – HCT: 28.6 (L) – MCV: 85.7 – MCH: 28.2 – MCHC: 32.9 – RDW: 16.5 (H) – PLATELET COUNT: 199
• BMG – GLUCOSE: 102 (H) – SODIUM: 140 – POTASSIUM: 3.5 – CHLORIDE: 109 (H) – CO2: 26 – BUN: 22 – CREATININE: 1.1 – CALCIUM: 8.2 (L)
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LAB RESULTS
• Lactic Acid – LACTIC ACID: 3.6
• CXR – WNL
• BLOOD CULTURES PENDING
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URINALYSIS • COLOR: YELLOW • APPEARANCE: CLEAR • SPECIFIC GRAVITY: 1.019 • PH: 6.0 • PROTEIN: NEGATIVE • GLUCOSE: NEGATIVE • BILIRUBIN, URINE: NEGATIVE • NITRITE: NEGATIVE • KETONES: NEGATIVE • BLOOD: NEGATIVE • UROBILINOGEN: 1.0 • LEUKOCYTE ESTERASE: NEGATIVE • SQUAMOUS EPI: 3 • HYALINE CASTS: 0 • BACTERIA: NEGATIVE • WBC, URINE: 1 • RBC: 2
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48 hours later….
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What is the most likely Diagnosis?
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Erythema Multiforme
• ACUTE INFLAMMATORY DISEASE
• Range – Papular eruption of the
skin (EM minor) to severe multisystem illness (EM major) with
• Vesiculobullous lesions and erosions of the mucous membranes known as Stevens-Johnson syndrome
• Characterized by epidermal detachment
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Epidermal Detachment EM Minor • No epidermal detachment
Stevens-Johnson Syndrome • <10% epidermal
detachment
Overlapping SJS and TEN • 10-30% epidermal
detachment
TEN • >30% epidermal
detachment
The more epidermal detachment, the higher
risk of death
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Erythema Multiforme
• Affects all ages – Incidence highest 20-40
yrs
• 2:1 Males:Females • Occurs in fall and spring • Symptoms
– Malaise, fevers, myalgias, arthalgias
– Pruritus or burning from skin lesions
• Precipitating Factors – Infections
• Mycoplasma • HSV
– Drugs • Antibiotics • Anticonvulsants
– Malignancies – Unknown cause in 50%
of cases
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Erythema Multiforme Lesions
Maculopapular lesions Target or Iris lesion
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Management
• Hospitalize • Steroids used for localized disease and prove
sympotmatic relief • Systemic analgesics and antihistamines for
symptom relief • Ocular involvement requires optho consult
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Toxic Epidermal Necrolysis
• Explosive dermatosis – Tender erythema, bullae
formation and exfoliation.
• Found in all age groups • Males=Females • Medications are most
common cause – Sulfa, PCN,
anticonvulsants, oxicam, NSAIDS
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TEN
• 25%-35% mortality • Presentation
– 1-2 wk prodrome of malaise, arthalgias, fevers, anorexia
– Skin tenderness, erythema which starts with the eyes, nose, mouth and genitalia
– Nikolsky sign • Management
– Hospitalization in ICU, optimally a burn unit
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Nikolsky Sign
• Slippage of the th epidermis from the dermis when slight tangential or rubbing pressure is applied to the skin.
• Seen in bullous disorders, TEN and staphlyoccocal scalded skin syndrome
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Differential Diagnosis
Pemphigus
Pemphigoid
Erythema Multiforme
Exfoliative erythemoderma
Toxic Shock Syndrome
Scalded Skin Syndrome
Kawasaki’s disease in children
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?????
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Erythema Nodosum
Inflammatory eruption of the SQ fat.
• Fungal, bacterial, parasitic, viral, pharmacologic, sarcoidosis, inflammatory bowel disease, pregnancy, behcet syndrome, leukemia and lymphoma, idiopathic
Causes
• Tender, warm, ill-defined erythematous nodules
Clinical features
• Bed rest, leg elevation, NSAIDS • Treat underlying cause
Treatment
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?????
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Urticaria • Wheal • Why do we get them?
– Allergic – Idiopathic
• ID swelling in respiratory tract – Look for lip, mouth throat
swelling and listen to lungs • Treatment
– Steroids – Benadryl
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?????
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Pemphigus Vulgaris • Autoimmune
– Autoantibodies against part of the epidermal layer
• Primary lesions – bullae or vesicles
• Affects head, trunk, mucous membranes first
• Then blisters rupture & become painful and denuded
• Decreased fluid intake, accelerated protein, fluid and electrolyte loss through the involved skin – Leads to hypovolemia and
electrolyte disturbances • Admit • Aggressive fluid and
electrolyte administration • Steroids and
immunosuppressives to prevent death
• +/- plasmapheresis and IV immunglobulin
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??????
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• Diffuse infection • Caused by toxins produced by serotypes A and
B from Staph – Causes the exfoliative presentation
• Fevers, malaise, irritability and tenderness over the skin
• Most are <2 yrs old and almost all are <6 yrs old
Staphylcoccal Scalded Skin Syndrome (SSSS)
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Treatment of SSSS
• Diffuse Disease – Admit
• Use burn unit if disease is extensive
– IV fluids – IV antibiotics
• Localized Disease – Outpt therapy with f/u
• Nafcillin IV • Pencillin G IV • AugmentinPO • Cefazolin IV • Cephalexin PO • If suspect MRSA, then
include Clindamycin, bactrim or Vancomycin
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Case Presentation
• 7 y/o M c/o with rash and ST. Pt has had ST for 3 days. Developed fevers 2 days ago. Fever max 102.1. Pt vomited once. Drinking less because of throat pain. Rash started today. Mom unable to see the pediatrician.
• Using motrin for fevers • Kids at school are sick but mom is not sure
with what.
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History
• PMH: none • Peds Vacc UTD • PSH: none • Meds: Motrin • Allergies: NKDA
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Physical Exam • Vitals; 100.5 po, R: 20, HR 90, BP 101/50, Pulse ox 100% • Alert and oriented times 3 NAD. Pt is quiet but looks well
hydrated. • HEENT: PERRL EOMi • TMs clear bilat without bulging or erythema • OP: erythema, exudate. Enlarged tonsils. Uvula midline.
No petechiae • Neck: anterior cervical LAD • Lungs; CTA bilat. No W/R/R • CV RRR s1s2 • Abd: soft NT ND NABS. No HSM • Skin: see picture
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Oropharynx
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What to do next?
• What labs/imaging do you want?
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Differential diagnosis
• Strep throat • Scarlet fever • Viral exanthems • Pharyngeal abscess
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Diagnosis:
• Rapid strep: positive • STREP + RASH=?????
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Scarlet Fever • Affects children • Group A B-hemolytic
strep • Fever, ST, HAs, vomiting,
abd pain • Exanthem 1-2 days later
– Sandpaper rash • Strawberry Tongue • Treatment:
– Pen VK – Amoxocilin – Macrolides for PCN allergy
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?????
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Contact Dermatitis • Can be caused by
allergens • More commonly caused
by irritants – Detergents, soaps,
chemicals, cold air • May be chronic exposures
or isolated accidental exposure
• Severe reactions can lead to necrosis and ulceration
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Atopic Dermatitis AKA Eczema
• Atopic Triad – Dermatitis, Asthma, Hay
fever • Presentation
– Affects hands, feet antecubital and popliteal fossae, postt neck wrist and ankles
– Erythematous, pruritic, scaly patches
– Chronic atopic dermatitis • Hyperpigmentation,
lichenifications and fissuring
• Remove offending agents – antihistamines,
antibiotics and anti-itch creams (cause secondary allergy)
– Lubricate: petroleum jelly, thick ointments
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Psoriasis
• Palms and soles are common – Also affects elbows, knees, scalp, umbilicus and
gluteal cleft • May need biopsy to diagnosis • Treatment
– High or ultrahigh potency topical corticosteroids such as fluocinonide, clobetasol propionate or betamethason dipropionate ointment
– Topical lubricants
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Sebaceous Cyst
Blockage of the duct of the sebaceous gland leads to a glandular cyst
Can exist for long period of time without becoming infected
If bacterial invasion abscess formation
Erythematous, tender, fluctuant
I&D abscess (attempt to remove capsule as well)
Will help avoid recollection
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REFERENCES
• Tintanilli 1599-1669, 912, 916, 1023