Nicholas Satterfield MD
Emergency Medicine PGY2
Henry Ford Hospital
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Define dermatologic terms
Discuss the approach to dermatologic
complaints
Discuss dermatologic diseases with high
morbidity and mortality
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Flat lesions
◦ Macule (< 0.5 cm)
◦ Patch (> 0.5 cm)
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Elevated Lesions
◦ Papule (Up to 0.5 cm)
◦ Plaque (Greater than 0.5 cm)
◦ Nodule ( Papule but deeper, involves dermis and
sometimes subcutaneous tissue)
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Fluid Filled
◦ Vesicles (Up to 0.5 cm)
◦ Bullae (Greater than 0.5 cm)
◦ Pustules (Vesicle but with pus)
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Blood derived (From leakage of capillaries)
◦ Petechiae (Less than 0.5 cm)
◦ Purpura (Greater than 0.5 cm)
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Erosion (loss of epidermis)
Excoriation (itching leading to loss of
epidermis)
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Ulceration (Loss of epidermis and dermis)
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Crusting (Collection of dried serum and
cellular debris)
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Lichenification (Thickened epidermis)
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Atrophy (Thinning of epidermis or dermis)
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Scaling (Shedding excess dead epidermal
cells by keratinization and shedding)
Secondary
Syphillis,
Anthrax
Early
Meningoc
occemia,
RMSF,
TSS, EM,
SLE, viral
exanthem
Lyme
Meningococc
emia, RMSF,
HSP,
Vasculitis,
SLE, ITP, TTP,
rubella, EBV,
Endocarditis
Necrotizing
fasciitis, TSS,
STSS, SSSS,
Kawasaki, EM,
hypersensitivi
ty reactions,
cellulitis, viral
exanthem
EM,
StevensJohnson,
TEN,
Pemphigus
vulgaris,
varicella
zoster, HSV,
necrotizing
fasciitis
(late)
Bacterial
folliculitis,
gonorrhea
, cellulitis
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Timing and progression
Location
Changes over time
Travel
PMH
Occupation
Medications
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Fevers (Rocky mountain spotted fever, toxic shock
syndrome, Stevens-Johnson syndrome, toxic
epidermal necrolysis, Kawasaki Disease)
Very Young (Meningococcemia, Kawasaki disease)
Elderly (Meningococcemia, pemphigus vulgaris,
meningococcemia, toxic epidermal necrolysis,
Stevens-Johnson syndrome)
Toxic Appearing (Necrotizing fascitis,
meningococcemia, toxic epidermal necrolysis,
Stevens-Johnson syndrome, toxic shock syndrome,
rocky mountain spotted fever)
Immunocompromised (Meningococcemia, herpes
zoster, necrotizing fascitis)
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Diffuse Erythroderma (Staphyloccocal scalded skin
syndrome, toxic shock syndrome, streptococcal toxic
shock syndrome
Petechiae/Purpura (Meningococcemia, necrotizing
fascitis, vasculitis, DOC, rocky mountain spotted
fever)
Mucosa/Oral Lesions (Erythema multiforme major,
toxic epidermal necrolysis, Stevens-Johnson
syndrome, pemphigus vulagaris)
Severe pain or tenderness (Necrotizing fascitis)
Recent new drug use (Erythema multiforme, toxic
epidermal necrolysis, Stevens-Johnson Syndrome
Arthralgias (Rocky mountain spotted fever, viral
illness)
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Pathology
◦ Acute inflammatory condition leading to
maculopapular rash
◦ Believed to be due to immune complex deposition
◦ Has multiple etiologies
 Infectious (HSV or mycoplasm most common)
 Drugs (Penicillins, sulfonamides, dilantin, barbituates)
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Prodrome of malaise, fever, arthralgia
Dusky red papules with sudden appearance that
as they enlarge the central area pecomes cyanotic
and dusty
Tend to develop on palm, soles, extensor
surfaces (knees and elbows)
If due to drug reaction it tends to appear
Lesions may develop for 2-4 weeks then resolve
in 1-2 weeks
Rarely can have a recurrent form or persistent
form that is usually from HSV infection
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Major includes one area of mucosal
involvement
◦ Most common is oral (up to 70%) erythema,
erosions or bullae
◦ Can also have ocular bullae, pseudomembranes and
purulent discharge (10-20%) which can lead to
keratitis conjunctival scarring and visual
impairment
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If you suspect drug reaction stop the drug
Supportive (NSAIDS, antihistamines)
Kenalog (triamcinolone) 0.1% cream for non face and
genitals
Hydrocortisone 1% cream for face and genitals
Lidex (fluocinonide) 0.05% gel for oral lesions
Magic mouth wash (2% viscous lidocaine, benadryl
and maalox)
Steroids?
◦ Rosens suggests to use if on trunk, EM Major and
immunosuppressed
◦ If so start at 40-60 mg/daily with 2-3 week taper
Dermatology referral
Optho referral: topical steroids and antibiotics
SJS
TEN
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Pathology
◦ Altered drug metabolism and immune complex
mediated reaction
◦ Etiology
 Medications
 Infection (Mycoplasma pneumonia, CMV)
◦ Risk Factors
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HIV
Genetics
Malignancy?
SLE
◦ Presentation
 Prodrome of myalgias, fevers, cough, sore throat
 Lesions begin around face and trunk with some
extremity involvement
 Erythematous macules and papules that start to have skin
sloughing
 Nikolsky sign
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Stomatitis (erosive)
Conjunctivitis
Esophagitis
Respiratory Failure
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Primarily due to electrolyte abnormalities and
infection
Vision loss
Vaginal stenosis
Organ failure secondary to septic shock
SCORTEN
180 mg/dl
250 mg/dl
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IDENTIFICATION
PROPER DISPOSITION: SCORTEN greater or
equal to 2 should go to burn unit
Stop the suspected drug
Steroids
◦ No consensus
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IVIG, plasmapheresis, Anti-TNF, cyclosporine
◦ Small studies, not recommended
EM Minor
EM Major
SJS
TEN
Epidermal
detachment
No
No
Yes
Yes
Mucosal
Involvement
No
Yes
Yes
Yes
Most
Common
etiology
Infectious
Infectious
Drug
Drug
Degree of
epidermal
detachment
%BSA
0
0
<10%
>30%
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IgG against keratinocytes
Presentation
◦ Elderly with oral erosions, vesicles and bullae for
weeks to months
◦ Then get skin vesicles and bullae
◦ Slow progressive disease
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Treat with steroids (1 mg/kg/day)
Admit if signs of infection or toxicity
Outpatient Dermatology follow up
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Neisseria meningitidis infection that includes
bacteremia with CNS
Risk factors
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Crowded environments
Complement deficiencies
Asplenic patients
Protein C and S deficiencies
Usually occur in ages 6 months to 1 year and
young adults (usually less than 20)
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Often first appears to be viral URI
Get petechiae starting at wrist and ankles that
spread and become papules
Meningitis symptoms
Quickly become septic: multiorgan failure and
DIC
Can get hemorrhagic destruction of adrenal
glands (Waterhouse-Friderichsen syndrome)
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Get blood cultures and punch biopsy
(significantly more sensitive than CSF gram stain)
Treat with ceftriaxone 2 g q12
If still concerned for Rocky mountain spotted
fever add doxycycline
For severe penicillin allergies use IV
chloramphenicol 4g per day
Close contacts (day care personnel, people
sharing housing, ED who are in contact with oral
secretions or someone who has been in contact
for 4 hours over the past week get prophylaxis
◦ Cipro 500 mg once
◦ Rifampin 600 mg BID for two days
◦ Single dose IM ceftriaxone 250 mg (pregnancy)
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Immune mediated destruction of platelets
Usually idiopathic
Secondary causes
◦ HIV, HCV
◦ SLE
◦ CLL
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Petechia and purpura usually in dependent
areas
Significant bleed in approximately 10%:
Usually GI rarely ICH
CBC and coags show isolated
thrombocytopenia
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ICH or GI bleed and plt<30,000
◦ Platelets
◦ IVIG (1g/kg)
◦ Steroids(methylprednisone 1 g/d for 3 days)
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Bleeding or new diagnosis and plt <30,000
◦ Steroids (methylprednisone 1g/d for 3 days)
◦ IVIG (1g/kg) only if bleeding
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Plt 20,000 to 30,000 with no bleeding:
observation
Pediatrics
◦ Only treat if significant bleeding
◦ Most cases self resolve in less than 3 months
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Microangiopathic hemolytic anemia
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Microangiopathic Hemolytic Anemia (SOB,
fatigue, chest pain)
Thrombocytopenia (bleeding)
Fever
Renal insufficiency
Neurologic finding (headache, confusion,
dizziness, stroke, coma)
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Anemia
Thrombocytopenia
Evidence of hemolytic
◦ Schistocytes
◦ Elevated LDH and billirubin
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ADAMTS13 assay
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Admit
Plasma exchange
◦ Needs to be started early
◦ If high clinical suspicion get started before all labs
are back
◦ Get hematology involved early
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Steroids: 125 mg methylprednisone IV Q6-12
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Staph aureus
◦ Local infection causing shock due to toxins
◦ Enterotoxin and toxic shock syndrome toxin
◦ Toxins are super antigens that directly activate T
cells at MHC without the need for antigen
presenting cells
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Group A Strep
◦ Local infection post surgical or after trauma
◦ Very painful and tender area of infection
◦ Bacteremia leads to sepsis
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Like any other infection
Find your source
Source control
Antibiotics (clindamycin and
vancomycin/zosyn/carbapenem)
Fluid resuscitation
Ionotropic support if needed