Emergency Dermatology

1. ED Dermatology

2. Aims
 Review terminology of skin conditions
 Identify common non-serious ED presentations
 Discuss serious but rare skin disorders

4. Definitions
 Macule
Impalpable coloured lesion
<1cm, circumscribed alteration
of skin colour
 Patch
Impalpable coloured lesion
>1cm.

5.  Papule
Palpable lump <1cm
diameter.
 Nodule
Palpable lump >1cm.

6.  Vesicle
Palpable fluid filled
lesion <1cm.
 Bulla
Palpable fluid-filled
lesion >1cm

7.  Petechiae
red, non blanching
spots <5mm
 Purpura
red, non blanching
spots >5mm

8.  Plaque = Palpable
disc shaped lesion
 Wheal = Area of
dermal oedema

9. Descriptive Terms
 Annular : Ring shaped, hollow centre
 Arcuate : Curved
 Circinate : Circular
 Confluent : Lesions that run together
 Discoid : Circular without hollow centre
 Eczematous : Inflammed and crusted
 Keratotic: Thickened
 Lichenified: Thickened and roughed with accentuated
skin markings
 Zosteriform : Nerve distribution

10. History
 How long
 Had it before
 Is it worsening / anything improving it
 Distribution ie palms / plantar / face / mucosal membranes
 How did it start / evolve
 Itch
 Social changes eg diet / work / cleaning
 Meds & allergies
 Cutaneous manifestations of systemic disorders eg sore joints & past medical
history
 Family history
 Travel
 Contacts
 Viral symptoms or fevers

11. ?

12. Urticaria

13. Urticaria
 Physical triggers / drugs / foods / stings / viral/ atopy / blood
products / temperature...
 Wheals, smooth with a red flare with some clearing leaving
annular pattern & scratch marks. Dermatographism
 Acute / Recurrent / Chronic
 Investigation
FBC / WCC / Eosinophils / Challenges
Complement levels with angiooedema
 Management
Remove cause / anti-histamines / steroids

14. ?

15. Eczema
 Flexural Distribution
 Itch ++ / Scratch marks, hyper or hypopigmented lesions
 Age related stages
 Atopic vs Contact
 Can be vesicular
 Treatment
 Emollients ++
 Treat infected skin
 Moist dressings
 Avoid triggers
 Antihistamines for itch
 Topical / systemic steroids
 Increase sunlight exposure / Phototherapy
 Immunomodulators / Immunosupressants : Cyclosporin / Azathioprine /
Tacrolimus /

16. ?

17. Psoriasis
 Itch / Pain / Decreased movement / FHx
 Extensor Distribution – well demarcated salmon pink silvery scales. Red surface on
removal / capillary bleeding (Auspitz sign)/ new lesions at site of trauma (Koebner’s
Phenomenon)
 Plaque / Guttate / Erythrodermic / Pustular variants / Inverse
 Triggers – Stress, Strep, HIV, Trauma, Drugs (Lithium + BetaBlockers Especially)
 Psoriatic Arthritis
 Treatment – topical v’s systemic : Systemic if failed topical / repeated admissions /
extensive plaques in elderly / severe arthropathy / generalised pustular or
erythrodermic psoriasis
 Emollients ++ / Keratolytic agents
 Topical Steroids.
 Coal Tar.
 Dithranol.
 Vitamin D3
 Retinoids – topical or oral.
 Phototherapy / Photochemotherapy (& methotrexate)
 Immunosuppressant's – Methotrexate, Cyclosporin, Mycophenalate
 Infliximab / CD4 monoclonal antibodies

18. ?

19. ?

20. VZV
 Varicella / Chicken Pox – Respiratory droplets. Infectious for 2 days prior to
lesions. Ends when crusts
 Rash head / trunk /
 Simultaneous presence of rash at different stages. Macule / Papule / Vesicle /
Pustule / Crusts
 A/w headache / malaise / anorexia / cough / coryza and sore throat / low grade
fever
 Rx symptomatic. Antivirals in certain cases / Secondary infection risk
 Shingles
 Dermatomal distribution & enlarged draining node
 Presents as pain, malaise, fever, rash in same distribution several days later
 Dx Clinical but can do smears or titres or isolation of virus in blisters
 Mx – antivirals / pain relief / IV antivirals if immunocompromised / IFN
 Complications : Corneal ulcers / Gangrene of affected area / Phrenic Nerve palsy
/ Meningoencephalitis / Ramsay Hunt syndrome / Neuralgia / Disseminated
zoster
 NB if AIDS – major CNS effects/

21. ?

22. ?

23. HSV
 Pain / Itch / Vesicles / Sore mouth / Gum swelling /
Mouth ulcers
 Small vesicles & lymph nodes
 Complications –
 Erythema Multiforme / Encephalitis / Keratitis /
Whitlow / Disseminated infection if
immunocompromised / Visceral involvement /
Neonatal / Meningitis
 Rx topical / oral / IV antivirals

24. ?

25. Impetigo
 Group A beta haemolytic Strep or Staph aureus
 Contagious
 Vesicles to honey coloured crusted lesions. Painless. Face
or extremities
 Local adenopathy / Generally afebrile
 Rx topical / oral antiobiotics
 Generally resolves 7-10/7
 Complications – Osteomyelitis / Septic Arthritis / Sepsis /
Pneumonia / Endocarditis
 Post strep glomerulonephritis / Scalded skin syndrome

26. ?

28. Erythema Multiforme
 Hypersensitivity reaction, polymorphous skin eruption
 Target Lesions
 Symmetric eruption red round macules, oedematous papules, target
lesions (x3 concentric areas of colour change) dorsum hands and
forearms
 Central dusky area due to keratinocyte necrosis.
 Can be vesicular and painful.
 Minor generally self limiting
 Etiology
 HSV
 Immunologic disorders – IBD / SLE / graft v’s host
 Mycoplasma, TB, Histoplasmosis.
 Drugs: Sulphonamides. Barbiturates. Penicillin. Phenytoin. NSAIDS.
Allopurinol.
 Malignancy
 Idiopathic
 Mx – Minor consider antivirals if HSV / symptomatic

29. ?

30. Erythema Nodosum
 Painful nodules, poorly defined. +++ tender
 Hx – fever / painful nodules/ arthralgias / sore throat / drugs / Cough
 Aetiology:
 Strep / TB / Yersinia / Leprosy / Coccidioidomycosis / Histoplasmosis
 Sarcoid
 SLE
 Behcets
 IBD
 Drugs – Sulphonamides / OCP
 Management
 Definitive dx – wedge biopsy
 CXR
 ASOT / Throat Swabs.
 Symptomatic
• Self–limiting - 3-6 weeks
• NSAIDS
• Elevation
• Compression Stockings.

31. ?

32. Koplik’s Spots / Measles
 Primary infection respiratory epithelium - droplets
 Highly contagious
 Fever / Coryza / Koplik spots 2-3 days into prodrome
precedes rash (14 days). Maculopapular, lasts 5-7/7
may desquamate
 Clinical diagnosis of Measles wrong in 50% of cases
 Probably requires serology for confirmation /
leucopaenia / lymphopaenia
 Complications: Superimposed bacterial infection.
Encephalitis. SSPE

33. ?

34. Slapped Cheek Syndrome
 Fifth Disease “Erythema infectiosum”
 Parvovirus B19
 Respiratory droplets
 Viral prodrome, slapped cheek, perioral pallor, later
extremities with palms and soles spared. Laced
appearance
 Antipyretics and antihistamines
 Generally benign. Rare aplastic crisis. In utero a/w
hydrops foetalis

36. Hand, Foot + Mouth
 Usually Coxsackie A or Enterovirus
 Usually children, very infectious, incubation 3
days then fever malaise and rash / painful oral
lesions
 Treatment supportive

38. Kawasaki’s disease
 Usually < 5 yo, early phase of prolonged fever,
irritability, and involvement of mucous
membranes (conjunctivitis and mouth). Hands
and feet red and swollen early, later may have
desquamating maculopapular rash
 Association with cardiac abnormalities...
 Treatment with IV Immunoglobulin

39. ?


40. Pityriasis Rosea
 Presumed viral.
 ?HHV 7.
 Christmas tree distribution.
 Self limiting over 6-12 weeks.
 Herald patch often mistaken for
ringworm.

41. ?

42. Scabies
 Sarcoptes scabiei
 Intense itch
 Permethrin or Malathion
 Applied at bedtime to whole body from chin
to soles.
 Treat all close contacts even if
asymptomatic.
 Wash all towels, clothes worn in last week
and bedlinen
 Vacuum house and furniture!
 Itch can persist for 6 weeks even after
successful treatment due to dead mites in skin.

43. ?

44. Melanoma
 Asymmetrical
 Border irregular
 Colour Variegated
 Diameter >5mm
 Evolution / Elevation

45. So far...
 Reviewed terminology
 Common, but usually not serious/life threatening
conditions

46. Serious conditions with
blistering / skin loss
 Erythema Multiforme major / SJS
 Pemphigus
 Pemphigoid
 TENS
 SSS
 ( Kawasaki’s )

47. ?

48. Erythema Multiforme Major
 Stevens Johnson Syndrome
 Symmetric erythematous macules, head and neck and lower
body
 Progresses to bullae, skin necrosis and denudation, at least
x2 mucosal surfaces involved
 Widespread rash involving up to 10% BSA skin sloughing /
blistering.
 Treatment:
 Prompt drug withdrawal.
 Admission / supportive care / general burns care.

49. ?

50. Toxic Epidermal Necrolysis
 Widespread rash like sunburn initially >30% TBSA with later
necrosis and sloughing. +ve Nikolsky sign
 Large mucous membrane involvement.
 Remove causative agent & manage as severe burns (ICU /
Burns unit)
 Mostly thought to be drug related
 Debates re plasmapheresis / IG / Steroids etc, nil proven
 Complications: High mortality / NB Ophthalmology
involvement and regular eye irrigation

51. ?

52. Pemphigus
 Autoimmune
 Blisters in mouth followed by on skin.
 Diagnosis by biopsy – IgG in epidermis, disruption of connections
intercellular
 3 Types:
 Vulgaris – begins in mouth 50% cases
 Foliaceous – may be drug induced
• Least severe.
• Often mistaken for eczema
 Paraneoplastic.
• NHL most common
 Mx: Barrier nursing / antibx / IV fluids / systemic steroids +/-
immunosuppressants (azathioprine / cyclophosphamide / methotrexate /
gold / dapsone /ciclosporin)

53. ?

54. Pemphigoid
 More common than pemphigus
 Generally benign
 Also Autoimmune
 Affects older age group
 Affects deeper layer in skin – tense flexural areas
 Subepidermal / eosinophil rich with IgG and C3
deposited in basement membrane
 Treatment same as Pemphigus – steroids +/-
immunosupressants
 Variants
 Gestational
 Mucous membrane (Cicatricial)

55. ?

56. Scalded Skin Syndrome
 Syndrome of acute exfoliation of the skin typically following an
erythematous cellulitis. Severity varies from a few blisters to a
severe exfoliation affecting almost the entire body, but doesn’t
involve mucous membranes as in TENS
.
 Staph aureus with epidermolytic exotoxins (A+B).
 Nikolsky’s sign -separation of skin with gentle pressure.
 Treatment.
 Antibiotics, supportive care.

57. ?

60. Purpuric Rash
 Petechiae <5mm.
 Purpura >5mm.
 Causes:
 Drugs: Steroids / Gold / Anticoagulants
 Senile
 Trauma
• Coughing / vomiting / direct.
 Infection
• Meningococcal, Cellulitis, Viral.
 Vasculitic
• E.g. HSP / Wegners / PAN
 Thrombocytopenia
• ITP / TTP / Leukaemia / DIC.

61. Red flags
 Unwell patient
 Other serious comorbidity, eg immunodeficiency
 Large area of skin
 Mucosal or ocular involvement
 Specific conditions with serious complications
eg Kawasaki

62. If any doubts d/w senior colleague / dermatologist
Remember you can easily send them an image of
a rash ! (in hours)
 A good reference website:
http://dermnetnz.org/doctors/