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Flashcards in Acute & Emergency Dermatology Deck (39)
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1

Name consequences cause by the failure of skin functions

• Mechanical barrier to infection -> sepsis
• Temperature regulation -> hypo and hyperthermia
• Fluid and electrolyte balance ->
1. Protein and fluid loss
2. Renal impairment and vasodilation

2

What is erythroderma?

A descriptive term rather than a diagnosis

Any inflammatory skin disease affecting >90% of total skin surface

Usually effects older people

3

What are different causes of erythroderma?

• Psoriasis
• Eczema
• Drugs
• Cutaneous Lymphoma
• Hereditary disorders (presents as neonates with genetic defect in skin formation)
• Unknown

4

What is a drug that causes erythroderma "red man syndrome"?

Vancomycin

5

What are the principles of management for erythronderms?

• Remove any offending drugs
• Careful fluid balance (don't want to push into cardiac failure)
• Good nutrition (loss of protein)
• Temperature regulation (minimise fluid loss)
• Emollients - 50:50 liquid paraffin:White soft paraffin (acts as an artificial barrier)
• Anticipate and treat infection
• Oral and eye care
• Disease specific therapy; treat underlying cause

6

Describe drug reactions

• Can occurs to any drug
• Commonly 1-2 weeks after drug
• Mild: morbilliform exanthem
• Severe: erythroderma, Stevens Johnson Syndrome/Toxic epidermal necrolysis, DRESS

7

What occurs in Stevens Johnson Syndrome (SJS) and Toxic Epidermal necrolysis (TEN)?

Loss of epidermis on top of dermis (erosions)

8

What differentiates Stevens Johnson Syndrome (SJS) and Toxic Epidermal necrolysis (TEN)?

Severity of the two conditions

• If surface of epidermal detachment < 30% --> SJS
• Overlap 20-30%
• TEN -> 30%

9

What drugs can cause Stevens Johnson Syndrome (SJS) and Toxic Epidermal necrolysis (TEN)?

• Antibiotics
• Anticonvulsants
• Allopurinol (used for gout)
• NSAIDs

10

What are the clinical features of SJS?

• Fever, malaise, arthralgia
• Rash
- Maculopapular, target lesions (dusky centre with red outline), blisters
- Erosions covering <10% of skin surface
• Mouth ulceration
- Greyish white membrane
- Haemorrhagic crusting
• Ulceration of other mucous membranes

11

What are the clinical features of Toxic Epidermal Necrolysis (TEN)?

• Profromal febrile illness
• Ulceration of mucous membranes
• Rash
- Macular, purpuric (small vessel bleed) or blistering
- Sloughing off of large areas of epidermis > 30%
- Nikolsky's sign - removal of epidermis when rubbed

12

How is the severity of SJS/TEN determined?

SCORTEN

13

Describe SCORTEN

One point given for each positive:
• Age >40
• Malignancy
• Heart rate >120
• Initial epidermal detachment >10%
• Serum urea >10
• Serum glucose >14
• Serum bicarbonate <20

14

Using the SCORTEN score, how is prognosis determined?

0-1 - > 3.2%
2 - 12.1%
3 - 35.3%
4 - 58.3%
> 5 - > 90%

15

What are the long term complications of SJS/TEN?

• Pigmentary skin changes (as melanocytes found in epidermis)
• Scarring
• Eye disease and blindness
• Nail and hair loss
• Joint contactures

16

What is the management for SJS/TEN?

• Identify and stop causative drugs asap
• Supportive therapy

17

What is erythema multiforme?

Hypersensitivty reaction usually triggered by infection

Usually by a virus (herpes) and this is how it is differentiated from TEN

18

What occurs in erythema multiforme?

Abrupt onset of up to 100s of lesions over 24 hours
• Distal -> proximal
• Palms and soles
• Mucosal surfaces (EM major)
• Evolve over 72 hours - pink macule, become elevated and may blister

19

What is the treatment of erythema multiforme?

• Self living and resolves over 2 weeks
• Symptomatic and treat underlying cause

20

What occurs in DRESS?

• Onset 2-8 weeks after drug exposure
• Fever and widespread rash
• Eosinophilia and deranged liver function
• Lymphadenopathy
+/- other organ involvement

21

What is the treatment of DRESS?

• Stop causative drug
• Symptomatic and supportive
• Systemic steroid
• +/- immunosuppression or immunoglobulins

22

What is pemphigus?

• Antibodies targeted at desmosomes (between keratinocytes, causing separation)
• Skin – flaccid blisters, rupture very easily
• Intact blisters may not be seen
• Common sites – face, axillae, groins
• Nikolsky’s sign may be +ve

23

What are the clinical features of pemphigus?

• Commonly affects mucous membranes
• Ill defined erosions in mouth
• Can also affect eyes, nose and genital areas

24

Describe the pathology of pemphigus

Take biopsy
• Immunoflourescence - stain with antibodies, which shows attachment of antigen to keratinocytes
• Histopathology - shows detachment between keratinocytes

25

What is pemphigoid?

• Antibodies directed at dermo-epidermal junction
• Intact epidermis forms roof of blister
• Blisters are usually tense and intact

26

What are the differences between pemphigus and pemphigoid?

Pemphigus:
• Middle age
• Blisters fragile - may not be seen intact
• Treat with systemic steroid, dress erosions and support

Pemphigoid:
• Elderly
• Blisters often intact and tense
• Topical steroid if localised; systemic required if diffuse

27

What are the features of erythrodermic psoriasis and pustular psoriasis?

• Can occur without history of psoriasis
• Common causes: infection, sudden withdrawal of steroids
• Rapid development of generalised erythema +/- clusters of pustules
• Fever, elevated WCC

28

What is used to treat erythrodermic psoriasis and pustular psoriasis?

Systemic therapy

29

What are the clinical features of eczema herpeticum?

Monomorphic blisters (all look similar) and “punched out” erosions

Generally painful, not itchy
Fever and lethargy

30

What is the treatment of eczema herpeticum?

Aciclovir

• Mild topical steroid if required
• Treat secondary infection
• Ophthalmology input if peri-ocular disease
• In adults consider underlying immunocompromise