Things that make you go ughhh…. Adult Dermatology Heather Patterson PGY-2 Feb 22, 2007

1. Things that make you go ughhh….Adult DermatologyHeather Patterson PGY-2Feb 22, 2007

2. Objectives • Learn key features of toxic rashes seen in adults. • Win the container of homemade chocolate chip cookies!

3. Describe: • Small solid elevation <1cm • PAPULE

4. Describe: • Palpable mass > 1cm • NODULE

5. Describe: • Elevated disc shaped lesion • PLAQUE

6. Describe: • Flat area of discolouration • MACULE

7. Describe: • Fluid filled area <0.5cm • VESSICLE

8. Describe: • Fluid filled area >0.5cm • BULLAE

9. Describe: • Area of dermal edema, raised, erythematous • URTICARIA

10. Describe: • Denuded area where epidermis is lost • EROSION

11. Describe: • Denuded area where dermis is lost • ULCER

13. Describe the rash.

14. 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

15. Rocky Mountain Spotted Fever • Clinical Presentation • Day 2-14 after bite • Sudden onset fever (>38.3) and rigors • Nausea/vomiting, anorexia • Headache, myalgias • Rash

16. 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

17. Rocky Mountain Spotted Fever How does the rash present on day 5-6 post onset fever? • Non-blanchable petechial rash • Local edema surrounding petechie

18. Rocky Mountain Spotted Fever • Labs: • Bands • Thrombocytopenia • ↑Na • ↑ Transaminases

19. Rocky Mountain Spotted Fever • Doxycycline • 100mg po bid • 2.2 mg/kg for kids • Chloramphenicol • In pregnancy Treatment? Duration? • Treat for 3 days after afebrile OR min of 5-7 days

20. Rocky Mountain Spotted Fever • Mortality: • Untreated >30% • Treated 3-7%

22. Describe the rash.

23. Meningococcemia • Clinical Presentation • Myalgias, malaise, sudden onset fever • +/- signs of meningitis • Rash • Etiology • N. meningitidis • Droplet spread

24. Meningococcemia How does the rash present early? • Non specific erythematous lesions that look viral

25. Meningococcemia Classic appearance? • Irregular borders, small • Pupura are painful and slightly raised • Usually on trunk and ext. but can be anywhere

26. Meningococcemia • Ceftriaxone and Vanco until isolated • Pen G 250 000U/kg/day divided q12h Treatment? Prophylaxis? • Rifampin 600mg q12h (5-10 mg/kg) • Cipro 500mg IM x1 • Ceftriaxone 250mg IM x1 (125mg for kids)

27. Meningococcemia • 40% What is the mortality with this rash?

29. Describe the rash.

30. EM Classic Rash? • Target lesions • Progression: Macules  Papules Central Vessicles

31. EM - distribution

32. EM Mucous membrane involvement? • EM – Minor: little to none • EM Major: always

33. Erythema Multiforme • Drugs • Infection • Herpes simplex • Mycoplasma • Idiopathic (>50%) Etiology?

34. Erythema Multiforme • Pathophysiology • Perivascular mononuclear infiltrate • Dermal edema • Secondary epidermal changes

35. 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

36. 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

38. Describe the rash.

39. 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

40. SJS/TEN • Pathophysiology • Cytotoxic immune reaction against keratinocytes • Leads to vasculitis of superficial dermis and epidermal necrosis

41. 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

42. SJS/TEN What %BSA is involved in SJS? • <10% What %BSA is involved in TEN • >30%

43. 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

44. SJS/TEN Prodromal Rash? • PAINFUL, WARM • Mobilliform with diffuse erythema

45. SJS/TEN How does the rash present early? • Discrete dark red macules with crinkled surface • Enlarge and eventually coalesce

46. SJS/TEN How does the rash appear late? • Raised FLACCID blisters • Confluent and necrotic with epidermis sloughing in sheets leaving red dermis exposed

47. SJS/TEN What is Nicholsky’s sign? • Firm sliding pressure causes blistering/sloughing of normal appearing skin.

48. SJS/TEN Mucous membrane involvement? • Yes in 92-100% of cases • 85% have conjunctival lesions

49. SJS/TEN • Other findings/complications: • Fever >38 • Heme: • Anemia • Neutropenia (coreltates with poor prognosis) • GI, Resp • Epithelial erosions • Renal • ATN, ARF • Sepsis

50. SJS/TEN • Supportive • Clean saline soaked gauze bandages • Avoid silver sulfadiazine • Fluids • fluid replacement required for 3 degree thermal burn of similar BSA Treatment in ED?