Emergency Dermatology

Question 1

What does the essential management for dermatological emergencies consist of?

Answer 1

Full supportive care
Withdrawal of precipitant agents
Manage complications
Specific treatment

Question 2

What dermatological conditions can be life threatening?

Answer 2

Urticaria, anaphylaxis and angioedema
Erythema nodosum
Erythema multiforme
Toxic epidermal necrolysis
Stevens-Johnson syndrome
Acute meningoccaemia
Erythroderma
Eczema herpeticum
Necrotising fasciitis

Question 3

What can cause anaphylaxis?

Answer 3

Food - nuts, seeds, shellfish
Drugs - ACE-Inhibitors, NSAIDS, Morphine etc
Insect bites
Contact - latex
Viral/parasitic infections
Autoimmune
Hereditary

Question 4

How does urticaria present?

Answer 4

Swelling involving the superficial dermis

Itchy wheals

Question 5

How does angioedema present?

Answer 5

Deeper swelling involving dermis and subcutaneous tissue

Swelling of lips and tongue

Question 6

How does anaphylaxis present?

Answer 6

Bronchospasms
Facial and laryngeal oedema
Hypotension

Question 7

How is urticaria managed?

Answer 7

Antihistamines

Corticosteroids if severe

Question 8

How is angioedema managed?

Answer 8

Corticosteroids

Question 9

How is anaphylaxis managed?

Answer 9

Adrenaline - 0.5mg IM (repeat every 5 mins)
Corticosteroids - 200mg IV hydrocortisone
Antihistamines - 10mg IV Chlorphenamine

Question 10

What are some complications of angioedema and anaphylaxis?

Answer 10

Asphyxia
Cardiac arrest
Death

Question 11

What is erythema nodosum?

Answer 11

Hypersensitivity response to a variety of stimuli

Question 12

What causes erythema nodosum?

Answer 12

Group A Beta Haemolytic strep
Primary tuberculosis
Pregnancy
Malignancy
Sarcoidosis
IBD
Chlamydia
Leprosy

Question 13

How does erythema nodosum present?

Answer 13

Discrete tender nodules which may become confluent

Appear for 1-2 weeks then leave bruise like discolouration as resolve

Mostly shins

No ulceration, atrophy or scarring

Question 14

How is erythema nodosum managed?

Answer 14

Treat the cause

Question 15

What is erythema multiforme?

Answer 15

Acute self limiting inflammatory condition

Target lesions are seen on the back of the hands/feet before spreading to the torso

Question 16

What precipitates erythema multiforme?

Answer 16

Mostly herpes simplex virus

Also caused by other infections and drugs

Question 17

What is Stevens-Johnson syndrome (SJS)?

Answer 17

Mucocutaneous necrosis with at least 2 mucosal sites involved

Associated with drugs and infections

Question 18

What distinguishes Stevens-Johnson syndrome from erythema multiforme?

Answer 18

Extensive epithelial necrosis with few inflammatory cells

Question 19

What is toxic epidermal necrosis (TEN)?

Answer 19

Extensive skin and mucosal necrosis associated with systemic toxicity

Question 20

How is toxic epidermal necrosis different from Stevens-Johnson Syndrome?

Answer 20

Full thickness epidermal necrosis with subepidermal detachment is seen on histopathology

Question 21

How are SJS, TEN and erythema multiforme managed?

Answer 21

Full supportive care to maintain haemodynamic equilibrium

Question 22

What are the main complications of SJS and TEN?

Answer 22

SJS 5-12% mortality
TEN >30% mortality

Mortality often due to sepsis, electrolyte imbalance or multiple system organ failure

Question 23

What is acute meningococcaemia?

Answer 23

A serious communicable infection transmitted via respiratory secretions

Question 24

What causes acute meningococcaemia?

Answer 24

Neisseria Meningitides

Question 25

How does acute meningococcaemia present?

Answer 25

Meningitis features - headache, fever, neck stiffness, photophobia Septicaemia - hypotension, fever, myalgia Rash - non blanching purpuric rash on trunk and extremities

Question 26

What precedes a meningococcal rash and how can it progress?

Answer 26

Preceded - blanching maculopapular rash Progress - ecchymoses, haemorrhagic bullae and tissue necrosis

Question 27

How is acute meningococcaemia managed?

Answer 27

Antibiotics - benpen | Prohylactic antibiotics for close contacts - Rifampicin ideally within 14 days of exposure

Question 28

What are the complications of acute meningococcaemia?

Answer 28

Septicaemic shock DIC Multi-organ failure Death

Question 29

What is erythroderma?

Answer 29

Exfoliative dermatitis involving at least 90% of the skin surface

Question 30

What causes erythroderma?

Answer 30

Previous skin disease - eczema, psoriasis Lymphoma Drugs - sulphonamides, gold, sulphonylureas. penicillin Idiopathic

Question 31

How does erythroderma present?

Answer 31

Inflamed, oedematous scaly skin | Systemically unwell - lymphadenopathy and malaise

Question 32

How is erythroderma managed?

Answer 32

Treat underlying cause Emollients and wet-wraps - maintain skin moisture Topical steroids - inflammation

Question 33

What are the complications of erythroderma?

Answer 33

``` Secondary infection Fluid loss Electrolyte imbalance Hypothermia High-output cardiac failure Capillary leak syndrome ```

Question 34

What is the prognosis for erythroderma?

Answer 34

Depends on underlying cause | 20-40% mortality

Question 35

What is eczema herpeticum?

Answer 35

Severe primary infection of the skin by herpes simplex virus 1 or 2

Question 36

How does eczema herpeticum present?

Answer 36

Commonly patients have atopic eczema Extensive crusted papules, blisters and erosions Systemically unwell with fever and malaise

Question 37

How is eczema herpeticum managed?

Answer 37

Antivirals - IV Aciclovir | Antibioitcs for bacterial secondary infection

Question 38

What are the complications of eczema herpeticum?

Answer 38

Herpes hepatitis Encephalitis DIC Death (rare)

Question 39

What is necrotising fasciitis?

Answer 39

Rapidly spreading infection of the deep fascia with secondary necrosis

Question 40

What causes necrotising fasciitis?

Answer 40

Group A haemolytic strep | Mix of anaerobic and aerobic bacteria

Question 41

What are some risk factors for necrotising fasciitis?

Answer 41

Abdominal surgery Diabetes Malignancy

Question 42

How does necrotising fasciitis present?

Answer 42

Severe pain Erythematous, blistering necrotic skin Systemically unwell - fever and tachycardia Crepitus - subcutaneous emphysema

Question 43

What can be seen on X-Ray with necrotising fasciitis?

Answer 43

Soft tissue gas

Question 44

How is necrotising fasciitis managed?

Answer 44

Extensive surgical debridement | IV antibiotics

Question 45

What is the prognosis for necrotising fasciitis?

Answer 45

Upto 76% mortality