Dermatological Emergencies

Question 1

What are some functions of the skin?

Answer 1

Mechanical barrier to infection
Temperature regulation
Fluid and electrolyte balance
Vitamin D synthesis
Sensation

Question 2

What is the definition of acute skin failure?

Answer 2

A loss of normal temperature control, an inability to prevent excessive fluid, electrolyte and protein loss, as well as the loss of its normal barrier function

Question 3

What is a potential consequence of acute skin failure with regard to systemic circulation?

Answer 3

It can cause peripheral vasodilation and may rarely lead to cardiac failure

Question 4

What are some general consequences of acute skin failure?

Answer 4

Increased fluid loss
Protein loss
Poor temperature regulation
Infection

Question 5

What is erythroderma?

Answer 5

Reddening of the skin - a descriptive term rather than a diagnosis - it is any inflammatory skin disease affecting more than 90% of the body surface area

Question 6

Give some common causes of erythroderma

Answer 6

Psoriasis
Eczema
Most classes of drugs
Cutaneous lymphomas

Question 7

What is a common, mild skin manifestation caused by adverse drug reaction?

Answer 7

Drug exanthems

Question 8

What are some severe skin manifestations of drug reactions?

Answer 8

Erythroderma

Stevens Johnson Syndrome

Question 9

What is another name for Stevens Johnson Syndrome? What are these conditions?

Answer 9

Toxic Epidermal Necrosis
2 conditions which from part of the same rare spectrum which cause fever, malaise, arthralgia and ulceration of mucous membranes, in particular the mouth

Question 10

What is the most common cause of Stevens Johnson Syndrome?

Answer 10

It is usually secondary to drugs and can be delayed in onset
Antibiotics
NSAIDs
Anticonvulsants

Question 11

What are the clinical features of Stevens Johnson Syndrome?

Answer 11

Fever
Malaise
Arthralgia
Rash -'target lesions', blisters
Severe mouth lacerations with a greyish white membrane and haemorrhagic crusting
Red painful eyes

Question 12

What kind of skin lesions can be seen in Stevens Johnson Syndrome?

Answer 12

Macropapular rash
Targetoid rash
Greyish white memraned mucal ulceration

Question 13

How can Toxic Epidermal Necrosis sometimes differ from Stevens Johnson Syndrome?

Answer 13

Often presents with a prodromal febrile illness

Its rash rapidly becomes confluent and sloughing off of large areas of the epidermis ‘desquamation’ occur

Question 14

What clinical sign may be positive in Toxic Epidermal Necrosis?

Answer 14

Nikolsky’s sign

Question 15

What are the management principles for TEN?

Answer 15

Identify and remove culprit drug!
Supportive Therapy
Specific therapies might include high dose steroids, IV immunoglobulins, anti-TNF therapy, ciclosporin

Question 16

Give some long term complications that occur as a result of TEN

Answer 16

Pigmentary skin changes
Skin scarring
Genital scarring
Joint contractures
Nail loss/hair loss
Eye disease and blindness

Question 17

What is DRESS syndrome?

Answer 17

Drug Reaction with Eosinophilia and Systemic Symptoms

Question 18

What is the mortality rate for DRESS syndrome?

Answer 18

Up to 10%

Question 19

What are the clinical features of DRESS syndrome?

Answer 19

Fever
Rash - multiform, erythrodermic, blistering, pustular
BLOOD EOSINOPHILIA
Lymphadenopathy

Question 20

What are some systemic consequences of DRESS syndrome?

Answer 20

Liver dysfunction
Renal dysfunction
Haematological - eosinophilia, thrombocytopaenia, anaemia
Rarely - GI, cardiac or resp involvement

Question 21

What is the management for DRESS syndrome?

Answer 21

Withdraw offending drug - often Allopurinol, anticovulsants, NSAIDs or antibiotics
Genral skin care, emollients, dressings
Supportive care if skin failure
High dose corticosteroids in severe cases

Question 22

What type of skin condition is pemphigus?

Answer 22

A blistering disorder

Question 23

What is the basic pathophysiology of pemphigus?

Answer 23

Autoimmune disorder where IgG antibodies against desmosomes in the epidermis are produced, leading to a loss of cell adhesion and splitting of the epidermis which causes blistering which are very fragile

Question 24

What type of hisopathological technique can be used to identify pemphigus?

Answer 24

Immunoflourescence

Question 25

What are the clinical features of pemphigus?

Answer 25

Skin - flaccid blisters which rupture very easily - intact blisters may not be seen! Commonly affects face, axxilae and groin Nikolsky's sign may be positive Commonly affects mucous membranes, ill defined erosions in the mouth aooear and can also affect the eyes, nose and genital areas

Question 26

What is pemphigoid?

Answer 26

An antibody mediated disease which affects the dermo-epidermal junction. Deeper than pemphigus, the intact epidermis fomrs the root of the blister

Question 27

Visually, what is the main difference between pemphigus and pemphigoid? Why?

Answer 27

Pemphigus if far more superficial, the blisters will likely be burst and affecting the epidermis. Intact blisters may not be seen and if present will be flaccid and highly fragile Pemphigoid is deeper and blisters are usually tense and intact Pemphigus affects the epidermis whereas pemphigoid affects the dermo-epidermal junction and is therefore less superficial

Question 28

Which differing age groups do pemphigus vs pemphigoid usually affect?

Answer 28

Pemphigus usually affects middle aged patients | Pemphigoid affects the elderly in the main

Question 29

Are pemphigus and pemphigoid common?

Answer 29

Pemphigus is uncommon | Pemphigoid is common

Question 30

What are the treatments for pemphigus and pemphigoid?

Answer 30

Pemphigus must be treated with systemic steroids Pemphigoid may be treatable with topical steroids or systemis ones if severe DO NOT ASSUME THAT BECAUSE PEMHIGOID IS DEEPER THAN PEMPHIGUS IT IS MORE DANGEROUS

Question 31

Outline pustular psoriasis

Answer 31

Generalised erythema followed by clusters of tiny pustules Develops rapidly and the patent may be extremely unwell Patient may not have a history of chronic plaque psoriasis

Question 32

What are the clinical signs which often accompany pustular psoriasis?

Answer 32

Fever - often without infection Malaise Tachycardia Increased WCC

Question 33

What is the treatment for pustular psoriasis?

Answer 33

Admit, preferably to a dermatology ward Blood cultures and treat for any superimposed infections Emollients Avoid topical steroids! Consider systemic treatments e,g, retinoids, methotrexate, biologics

Question 34

What is eczema herpeticum?

Answer 34

A disseminated herpes virus infection on the back of atopic eczema, more common in children. Multiple small vesicles develop, initially overlying eczematous skin and them becoming disseminated

Question 35

Which strand of herpes simplex virus most commonly caused eczema herpeticum?

Answer 35

HS-1

Question 36

What is the treatment for eczema herpeticum?

Answer 36

Send a swab for viral culture Treat with systemic antivirals e.g. aciclovir 200mg 5x/day Consider superimposed bacterial infection Try to avoid topical steroids Ophthalmology input in eye involvement

Question 37

What is staphylococcal scalded skin syndrome?

Answer 37

A condition which starts with a staphylococcal infection e.g. impetigo, throat, nose, mouth The staph produces a toxin which causes splitting of the epidermis and widespread desquamation More common in children but can occur in immunocompromised adults

Question 38

What are the clinical features of SSSS?

Answer 38

Preeceding staph infection - may be subclinical Diffuse erythmatous rash with skin tenderness More prominent in flexures Blistering and desquamation follows May occur at the site of minor trauma

Question 39

What is the treatment for SSSS?

Answer 39

Antibiotics - good idea to cover staph and strep Topical antibiotic preparations e.g. Bactroban Wound care Fluid rehab (Most children are not too systemically unwell)

Question 40

What are the basic principles of management of skin failure which broadly apply regardless of the cause?

Answer 40

Good fluid and electrolyte balance Temperature regulation Emollients Anticipate and treat infection