Things that make you go ughhh….
Adult Dermatology
Heather Patterson PGY-2
Feb 22, 2007
Objectives
• Learn key features of toxic rashes seen in
adults.
• Win the container of homemade chocolate chip
cookies!
Describe:
• Small solid elevation
<1cm
PAPULE
Describe:
• Palpable mass > 1cm
NODULE
Describe:
• Elevated disc shaped
lesion
PLAQUE
Describe:
• Flat area of
discolouration
MACULE
Describe:
• Fluid filled area <0.5cm
VESSICLE
Describe:
• Fluid filled area >0.5cm
BULLAE
Describe:
• Area of dermal edema,
raised, erythematous
URTICARIA
Describe:
• Denuded area where
epidermis is lost
EROSION
Describe:
• Denuded area where
dermis is lost
ULCER
Describe the rash.
Rocky Mountain Spotted Fever
Etiology?
• Rickettsia rickettsee – found in Rocky Mountain
wood tick saliva
How many hours does the tick need to feed for
innoculation?
• 6 hours
Rocky Mountain Spotted Fever
• Clinical Presentation
–
–
–
–
–
Day 2-14 after bite
Sudden onset fever (>38.3) and rigors
Nausea/vomiting, anorexia
Headache, myalgias
Rash
Rocky Mountain Spotted Fever
How does the rash present on day 2-4 post onset fever?
• 2-6 mm blanchable pink macules starting on wrists
and ankles
• Spreads cetripetally and includes palms and soles
Rocky Mountain Spotted Fever
How does the rash present on day 5-6 post onset fever?
• Non-blanchable petechial rash
• Local edema surrounding petechie
Rocky Mountain Spotted Fever
• Labs:
–
–
–
–
Bands
Thrombocytopenia
↑Na
↑ Transaminases
Rocky Mountain Spotted Fever
Treatment? Duration?
• Doxycycline
– 100mg po bid
– 2.2 mg/kg for kids
• Chloramphenicol
– In pregnancy
• Treat for 3 days after afebrile OR min of 5-7 days
Rocky Mountain Spotted Fever
• Mortality:
– Untreated >30%
– Treated 3-7%
Describe the rash.
Meningococcemia
• Etiology
– N. meningitidis
– Droplet spread
• Clinical Presentation
– Myalgias, malaise, sudden onset fever
– +/- signs of meningitis
– Rash
Meningococcemia
How does the rash present early?
• Non specific erythematous lesions that look viral
Meningococcemia
Classic appearance?
• Irregular borders, small
• Pupura are painful and slightly raised
• Usually on trunk and ext. but can be anywhere
Meningococcemia
Treatment?
• Ceftriaxone and Vanco until isolated
• Pen G 250 000U/kg/day divided q12h
Prophylaxis?
• Rifampin 600mg q12h (5-10 mg/kg)
• Cipro 500mg IM x1
• Ceftriaxone 250mg IM x1 (125mg for kids)
Meningococcemia
What is the mortality with this rash?
• 40%
Describe the rash.
EM
Classic Rash?
• Target lesions
• Progression: Macules  Papules Central Vessicles
EM - distribution
EM
Mucous membrane involvement?
• EM – Minor: little to none
• EM Major: always
Erythema Multiforme
Etiology?
• Drugs
• Infection
– Herpes simplex
– Mycoplasma
• Idiopathic (>50%)
Erythema Multiforme
• Pathophysiology
– Perivascular mononuclear infiltrate
– Dermal edema
– Secondary epidermal changes
EM
• EM Minor:
–
–
–
–
Classic target lesions usually on face and extremities
Vessicles but no bullae
Little to no MM involvement
Recurrent episodes associated with Herpes simplex
EM
• EM Major
– Target lesions more generalized
– Bullae and + Nicholsky sign
– Extensive MM involvement and systemic features:
• Conjunctivitis/corneal ulcers, uveitis
• Cheilitis, stomatitis, GI erosions, resp tract erosions
• Vulvitis, balanitis
– May progress to SJS/TEN
– Most often a drug reaction
Describe the rash.
SJS/TEN
Name 3 causes of this rash.
• Drugs, infection (mycoplasma, viral), vaccination,
chemicals
Name 3 drug /classes that can cause this
rash.
• Sulfa
• Anticonvulsants
• NSAIDs – oxicams
• Allopurinol
SJS/TEN
• Pathophysiology
– Cytotoxic immune reaction against keratinocytes
– Leads to vasculitis of superficial dermis and epidermal
necrosis
SJS/TEN
• Most consider this a spectrum of disease:
– EM major  SJS  TEN
• May start with classic target lesions of EM
BUT
about 50% of SJS/TEN do not have target lesions
SJS/TEN
What %BSA is involved in SJS?
• <10%
What %BSA is involved in TEN
• >30%
SJS/TEN
• Clinical Presentation
– Onset within 1-3 weeks of first exposure to antigen
(repeat exposure has faster onset, ie days)
– 2-3 day prodrome prior to rash:
• Cough, sore throat
• Myalgias, malaise, headache
• Anorexia
• Fever
• Skin burning, itching, tenderness
• Conjunctival burning, itchiness
SJS/TEN
Prodromal Rash?
• PAINFUL, WARM
• Mobilliform with diffuse erythema
SJS/TEN
How does the rash present early?
• Discrete dark red macules with crinkled surface
• Enlarge and eventually coalesce
SJS/TEN
How does the rash appear late?
• Raised FLACCID blisters
• Confluent and necrotic with epidermis sloughing in
sheets leaving red dermis exposed
SJS/TEN
What is Nicholsky’s sign?
• Firm sliding pressure causes blistering/sloughing of
normal appearing skin.
SJS/TEN
Mucous membrane involvement?
• Yes in 92-100% of cases
• 85% have conjunctival lesions
SJS/TEN
• Other findings/complications:
– Fever >38
– Heme:
• Anemia
• Neutropenia (coreltates with poor prognosis)
– GI, Resp
• Epithelial erosions
– Renal
• ATN, ARF
– Sepsis
SJS/TEN
Treatment in ED?
• Supportive
• Clean saline soaked gauze bandages
• Avoid silver sulfadiazine
• Fluids
– fluid replacement required for 3 degree thermal burn of
similar BSA
SJS/TEN
Treatment outside ED?
• High dose steroids
• Cyclosporin/cyclophosphamide
• Plasmaphoresis/IVIG
• NAC
• Erythromycin for eye involvement
SJS/TEN
Mortality?
• SJS – 5%
• TEN – 30%
Describe the rash.
Staph Scalded Skin Syndrome
• Pathophysiology
– Staph exfoliative toxin targets zona granulosa
– Causes intraepidermal splitting leading to bullae
formation
• Clinical Presentation
– Seen in kids AND immunocompromised, alcholics, CRF,
malignancy
– Often have primary infection
– Fever, malaise
– Skin tenderness in flexural areas prior to sloughing
SSSS
How does the rash present early?
• Macular sandpaper rash with erythema
• Deeper coloured erythema with skin tenderness in
flexural areas
SSSS
How does the rash present 24-48h post pain?
• FLACCID bullae in erythem
regions
• Bullae coalesce and rupture
leaving erythem base
• Looks like wet tissue paper
• Palms, soles, MM spared
SSSS
Positive Nicholsky’s sign?
MM involvement?
• Yes BUT only on erythematous skin
• No MM involvement or very mild inflammation
SSSS
Treatment in ED?
• Supportive
• Clean saline soaked gauze bandages
• May require ABx
–
–
–
–
Clox
1st gen cephalosporin
Vanco for MRSA
Macrolide
SSSS
Mortality ?
• Kids – 3%
• Healthy adults – up to 50%
• Adults with comorbidities – up to 100%
Describe the rash.
Staph TSS
Classic appearance?
• Fine erythematous macular sandpaper rash – looks
like scarlet fever
• Extensive generalized non pitting edema
• +MM involvement
Staph TSS
What is the most common underlying cause of
this rash?
• Tampons
Name 2 other causes.
• Surgical wounds with abscess
• Burns
• Ulcers
• Insect bites
• Contraceptive devices
Staph TSS
• Pathophysiology
– Production of endotoxin during bacterial replication
– Act as superantigen to T cells leading to massive cytokine
release
Staph TSS – diagnostic criteria
1.
2.
3.
4.
Fever ≥ 38.9
Rash
Hypotension or orthostatic hypotension
Involvement of 3 of the following
1.
2.
3.
4.
5.
6.
7.
GI – vomiting and diarrhea
Muscular – severe myalgias or CK 2x normal
MM involvement
Renal – Cr or BUN 2x normal or pyuria
Hepatic – bili, transaminases 2x normal
CNS – confusion, headache, seizure, no focality
Heme – thrombocytopenia plts < 100
Staph TSS – diagnostic criteria
5. Desquamation 1-2 weeks post onset illness
6. Evidence against alternative diagnosis
Staph TSS
Treatment in ED?
• ABCs
• May require – pressors/ionotropes
• ++ Fluid resuscitation
• ABx
– Cloxacillin, naficillin
– Clinda
– Vanco if MRSA
• Find and treat source
– Remove tampon, drain abscess etc
Describe the rash.
Pemphigus Vulgaris
• Pathophysiology
– Autoimmune disease
– Loss of cell to cell adhesion in the epidermis due to
antibody binding to surface glycoproteins
Pemphigus Vulgaris
• Presentation:
– Oral and MM involvement – painful bullae with
ulceration
– May complain of epistaxis, hoarseness, dysphagia,
wt loss
– Gums and vermillion boarders are common
locations
– Cutaneous lesions
– General malaise
Pemphigus Vulgaris
Mucosal Lesions?
• Fragile bullous lesions
• Become non healing painful ulcers
Pemphigus Vulgaris
Classic Appearance?
• FLACCID fragile bullae found on
normal looking skin in a random
pattern
– But commonly seen on face, scalp
and upper trunk
• Become non healing painful ulcers
Pemphigus Vulgaris
Nicholsky sign?
• Positive
Pemphigus Vulgaris
Treatment in ED?
• Supportive, analgesia, wound care
• Prednisone 2-3mg/kg/day
– Treat until no new blisters are forming AND negative
Nicholsky sign
• Consult Dermatology
• Immune modulators
– Derm
Describe the rash.
Bullous Pemphigoid
• Pathophysiology
– Most common autoimmune blistering disease
– Antibody to basement membrane leads to complement
deposition and subepidermal blister formation
• Epidemiology
– Most often seen in the elderly and men
Bullous Pemphigoid
Classic Appearance?
• TENSE bullae with
preference for:
– Lower abdo, inner thighs, groin,
flexor surfaces of extrem.
• On normal or
erythematous skin
• 66% with erythem or
urticarial lesions prior to
bullae
• Severe pruritis
Bullous Pemphigoid
Nicholsky sign?
• Negative
Pemphigoid
• MM involvment?
– In 30% of patients
Pemphigoid
Treatment in ED?
• Supportive
• Wound care
• Prednisone 0.5mg/kg/day
AND
Clobetasone proprionate 40g/d divided bid
(or other high potency topical steriod)
• Consult Dermatology
Bullous Pemphigoid
Mortality
?
• 25-40%
– Most common causes: secondary sepsis or physiological
stress leading to MI
Varicella Zoster
What is Hutchison’s sign?
• Involvement of the nasociliary nerve – lesions on the
tip of the nose.
What is the concern with this
distribution?
• Involvement of the eye
• Conjunctivitis, Corneal inflammation and scarring
• Uveitis, iritis
Varicella Zoster Ophthalmicus
Treatment in ED?
• Acyclovir 800mg 5x daily x7-10days
OR
• Famciclovir 500mg tid x 7days
• Consider IV if severe
• Referral to ophtho within 24h
Conclusion
• Hopefully you have learned key features of several
emergent rashes seen in adults!